call FUBAR #1

I wish I'd started writing this while I was actually working on my training. Of course, it's the calls that I screwed up on that stick with me, and it's easy to forget the ones that went well. I figure, though, that as long as I can learn from them and not make the same mistake twice I'm okay. RevMedic reminded me frequently that mistakes like this are the reason it is called "practicing" medicine, because we constantly learn and grow with each experience.

It had been a fairly slow day for The Rev and I early in my training. The call came in as cx pn, the address way out in the boonies- took us over 10 minutes to get there, even going c-3. We find a man lying on his bed, barely responsive; a single firefighter has responded and a family member stands by, says his only previous hx is chronic pn, but he'd been in to the clinic for a long-lasting cold a few days before. I ask him the standard OPQRST, but he's unable to answer; I ask him to point out where the pn is, and his hand moves to his right side, hovering over the lower part of his ribcage. I ask him if it gets worse when he breathes in or out. No answer. Lung sounds are clear. No fever. SPO2 is around 90 on the O2 that FD has placed. BP isn't great, but isn't alarmingly low, either. 12 lead shows a controlled A-fib. CBG is fine. My mind is racing. I'm thinking pneumonia with that "long-lasting cold," but all I've got is my gut to go on. The Rev mentions the man's slightly puffy legs; considers furosemide. . .but that just doesn't sit right with me for some reason. RevMedic's searching the house for meds, finds an awful lot of empty methadone bottles. Of course! Pupils are constricted but not pinpoint, but I'm so relieved to find something to treat that my awareness goes out the window. I dig for an IV, can't get one. The Rev gets one in the hand, finally, and I push 0.5 mg of Narcan, standard for this company and most others, although things were a tad different during my internship. SPO2 rises a gratifying percentage. We're in the process of figuring out how to move this short, stout man from his bed to the gurney when I hear a noise. It doesn't register, at first-- I'm so focused on the task at hand-- until The Rev taps me on the shoulder. "Your patient is snoring." He hands me an NPA. And as I lube it and push it into the patient's nose with absolutely no response, the jumble of puzzle pieces that had been falling into place rearrange themselves. This can't be. . .if his SPO2 is rising, his mentation should be improving. If the call wasn't FUBAR before this, it's definitely heading in that direction now, and at an alarming speed. I revert back to my internship, where a full 2mg of Narcan submentally (yes, submentally) injected was the norm, and push the remaining meds. My patient crumps. So much for Narcan being a relatively innocuous drug. We move him with no grace or fanfare to the gurney, strap him in, and wheel him out to the bus. The firefighter says he'd come with us but he's the only one covering his district today. We head out c-3. Halfway in, my patient starts frothing. It is thick, and yellow, and not at all attractive. I knock on the partition, tell The Rev we need to intubate. He pulls over, heads into the back. I try to open my patient's mouth with the standard finger pry and his teeth snap shut, narrowly missing my thumb. I try again, and his jaw is clamped so tight I probably couldn't get it open with a hammer and a prybar. I am not at all impressed with my performance from this point on. I completely blanked on my sux dosage, almost forgot the Versed, and missed both tube attempts. I am sweating and close to crying, because I still cannot figure out what is wrong with this patient. Rev gets him tubed and on the vent, and we continue on. My radio report is remarkably coherent. My mind is not. The ambulance looks like a war zone. My pt starts frothing up the tube. I'm scrabbling through suction caths, the vent is beeping, and now he's bucking the tube. The vec falls out of my hand and goes skittering under the gurney. I go to get the vent on the portable O2 and realize it's empty. ER staff pulls out the gurney, they get him into a room, they take over. The Rev and I clean up. My written report finished, we head back home. Two days later, our physician advisor skins us upside and down. He insists this pt needed Lasix. I do not concur. We check with the ICU, discover the patient had an atypical pneumonia, had almost developed ARDS. Pt received 2 L of fluid in the ER, another 2 in the ICU. Lasix would have been catastrophic.
The list of things I learned from this call numbers in the hundreds. Seriously. I do not push Narcan lightly now, particularly if the patient has an underlying pulmonary condition. I spent much time afterwards fondling various suction catheters, blades, and laryngoscopes, staring at the vent, going over in my head dosages, techniques, indications and contraindications. I read everything I could about naloxone, chronic pain, and types of pneumonia. The Rev taught me a way to prepare meds for an RSI that would prevent vials and syringes from slipping out of my butterfingers. My chart had been shoddily written, with some important things left out- the fact that our pt had trismus, and needed RSI instead of a basic intubation, the fact that the other medic unit was on another call, and could not assist, the fact that the FD had only one available person and was unable to ride along. A glaring typo in the vec dosage.
I forget, sometimes, that every new medic goes through a crisis of faith/education/whatever. But most new medics have something that I missed- that initial feeling of being unstoppable, the paragod factor that allows them the illusion of self-confidence while they build up the real thing. Self-doubt and perfectionism can both be crippling, and in my time, I've had scads of both.