Over the weekend I had a chance to work with a good friend from medic school. He picked up the open spot on my tours, and we spent the weekend saving the Bronx one "diff breather" at a time. My usual partner went to New Mexico for vacation, and the shifts were up for grabs. 27X-ray, tour 3, operates from 1800 - 0600. Two of my permanent shifts are Saturday/Sunday. On average, we run 5-7 jobs in a tour. Not bad. For some ungodly reason, my friend decided to bring the black cloud with him. To say the least, we got hammered. Both tours. We had some very legitimate calls. APE(Acute Pulmonary Edema), COPD exacerbation, tight asthmatics, and a grand finisher the respiratory arrest, witnessed by yours truly.
0430 hours, the radio sounds "27X" for the assignment. Our KDT reads "aided is a male with difficulty breathing, history of asthma." Okay. Another asthma. I wonder sometimes, how many people are actually walking around the Bronx with this reversible airway disease... This category of patients alone could keep NYC EMS afloat without question. We arrive the presumed location and enter the building. The fresh smell of cigarettes and weed immediately flood your nares. It smells like an all day every day affair for the residents living in this apartment complex, given the strength of the odor and lovely yellow nicotine stained walls. A wonderful environment for an asthmatic. We make our way through the second hand smog, and give the old "knock-knock, EMS." A nervous looking man, the roommate, opens the door and leads us in. (actually it was just myself that could get in.) There, in front of the door was a strategically placed pull out bed, allowing the door to open mayyybe a foot. enough for me to get my cardiac monitor and drug bag in. directly behind the door, I can hear the "wheezes." I peek in and see a black male, in obvious distress. This guy is getting out 1-2 word dyspnea and visible central cyanosis, an obvious sign of poor oxygenation.
Finally, my partner makes it in, and busts open the drug bag, understanding the severity of this guy's situation. I am administering the first combivent treatment (Albuterol and Ipratropium) by nebulizer, and have moved on to estableshing IV access. I grab a 20 gauge needle and bam. Blood flashes in the chamber. I'm in. I push steriods and attach the IV drip set, which has 2 grams of Magneseum Sulfate added to help relax the smooth muscles in hopes of reducing the bronchioles from spasming. No relief is observed. I looked to my partner and told him to draw up the Epinephrine, because our patient was obviously headed towards what you would call "impending respiratory failure." After a second combivent, and Epi in the syringe on stanby, our patient seems to be getting some wind in his sails. Wonderful! Let's move! Our patient stands up to pivot around the door and into our stairchair. He grabs my shoulders. The words "Bro, Imma fall out" are heard in a raspy, almost breathless undertone. His eyes roll back and he collapses into the chair. My partner grabs the bottom of the chair and I'm at the top. We bolt for the ambulance. With the equipment strapped to our backs we head for the flight of 13 steps to the door. Before our descent, I hit our patient with the Epinephrine in the muscle of his left shoulder(IM injecttion), and we head down. We lose the IV line in our haste, on the exit handle of the door leading to the street. Our patient is now bleeding everywhere from where the IV catheter was, and is breathing agonally. Things are getting intense. People are everywhere out on the street, wathcing like little kids peering in the window of a pet store. We are the focus of attention. We get him on the stretcher and a woman decides to come to the back of the ambulance and get involved. She says "bro, you ok?" "He ok, right?" "Yo, you crackas know CPR??, cause he dead!" I love the medical education that random street dwellers posess. It's very comforting.
We are in the bus. My partner (let's call him CC) CC has closed the doors to rid of the "street doctors" and he gets on the phone with medical control for sedation orders. I call for a FNDY conditions boss and a BLS (basic life support) unit to drive us. I'm assisting ventilations with a bag valve mask device, as the patient is no longer able to breathe on his own. CC placed him on the cardiac monitor. He has a heart rhythm and is oxygenating relativley well wit my ventilations. CC has gained IV access again, and we got our orders granted from the doctor to sedate the patient and intubate him. Now, there is a funny thing that happens with asthmatics. If you attempt to pass the endotracheal tube through the trachea and miss, you can cause the airway to spamsm and close off completely, a natural mechanism of the body to protect the airway. So to put it plainly, in less words, you basically get one shot. You had better visualize the vocal cords, and pass the tube quick if you want your patient to live. The conditions boss is on scene now, and standing at the back doors of our ambulance. BLS has arrived and is in the drivers seat, ready to go at our command. We push Etomidate and follow up with 10mg of Valium. Once the patient demonstrates jaw laxity, you can assume the gag reflex is no longer present, and your patient is sedated. He is infact sedated, and I open the airway with my laryngascope in my left hand, and the ET tube in my right. I visualize the cords perfectly, and pass the tube. I'm in. I inflate the cuff (a little balloon at the end of the tube). There is condensation in the tube, and CC hears good lung sounds. We attatch capnography and we see a reading. Great! I attach a Bite Block, and we have secured the airway. BLS is blasting to the hospital, and I'm bagging (breathing for the patient). CC calls for a follow up 5mg of Valium to keep sedation active, and we pull into the ER bay. A team of doctors and residents awaiting our arrival get a full report and reconfirm all our interventions that were done for the patient. It's now around 0520 hours in the morning. Close to the end of our shift. We restock and head back to our hospital base, 20 blocks from the hospital we brought our patient to.
