As these stories often seem to begin, I was working overtime at another station when this call went down. We were responding to a call for an unknown medical with an unknown age patient. What else is new? En route we got an update that the patients wife was calling because her husband had fallen in the other room but was behind the door, blocking it, so she couldn't get in. She stated that he was making snoring sounds earlier but now wasn't making any noise at all.
Yeah. That's not good.
On arrival we were met by a surprisingly calm older woman who relayed that same story to us again. I asked when this had occurred and she said at noon. It was now 12:25! Not sure why she waited so long to call but it didn't matter now.
The next thing she said was that it was really "crowded" in the house. As we entered we realized what an understatement that was. It was a full on hoarder house with a strong smell of cat urine, even through our P-100 masks. A couple cats bounded out of the way as we went in. My firefighter was ahead of me and had the large airway bag on his back and the cardiac monitor in his hand. I was carrying the drug box and trying in vain to catch all the things he was knocking over as he tried to maneuver through the debris field and stacked towers of god knows what. I told him just to ditch the gear if he could find a spot because it wasn't going to make it through.
We reached the door and it was indeed blocked. Whether strictly by the patient or by an avalanche of possessions and garbage, we didn't know. We asked the wife if there was window to that room and she said yes and told us to follow her. She was still very calm and slow as she led us through the back of the house and outside. We found the window but it was locked and while the firefighter attempted to jimmy it loose I went back around the outside of the house to enter the front door again and see about forcing the bedroom door and get access to the patient.
My firefighter apparently had the same idea and abandoned the window but wound his way back through the house and was already pushing his way into the room when I got there. He was able to squeeze in and lift the patient enough that we could push the door open.
The patient then basically flopped half way out of the room landing at my feet. A quick check for pulse and breathing revealed what was already very obvious, that he was dead. He had a large purple shiner around one eye from a previous fall and just didn't look healthy...on top of being dead that is.
My captain asked if I wanted to work this call right there and I responded with an emphatic no. There was no room at all and it was awful everywhere. So, I grabbed his wrists and the firefighter grabbed his ankles and we worked our way through the mess to the front lawn. Outside, out of the corner of my eye, I saw an ambulance employee standing there; the first bit of good news. My captain said we should set him down in the shade to work and I said we should carry him straight to the gurney. I then realized that the guy on the lawn was an EMS supervisor and that the transport ambulance wasn't there yet. He had heard the call come in and was close by and thought it sounded serious. He was right and it turned out to be good news anyway because he was able to help out with initial treatment and speed things up.
Out on the lawn I did another pulse check and a check for rigor or lividity or any sign that would let us pronounce him dead and not have to work up this obviously futile resuscitation attempt. No such luck. So we put the automated cpr device on him and began rescue breathing with a bag valve mask. The supervisor applied the cardiac monitor while I made a long shot IV attempt. I had the sup set up for an IO in case the IV attempt failed, which it did. He was able to get an IO established in the humerus so we were good to go. Our first rhythm check showed the patient was in asystole, as expected.
The protocol for an asystolic arrest is to give three rounds of epinephrine, each ten minutes apart, and if no change after 30-40 minutes we can pronounce death in the field and discontinue resuscitation efforts. It was clear this was the route the call was going. I administered the first round of epi as the ambulance arrived and took over managing the patients airway and dropping in an et tube.
We all agreed that this was pretty much going to be a three rounds and out call and there were no other treatments to add to the protocol we were working with. I did ask one of the medics to check a blood sugar for me just to rule it out. Turns out his sugar was very high, in the 400s, despite us being told he was not diabetic. This didn't change the course of treatment though may have been indicative of a metabolic reason for the arrest.
At the next rhythm check there was some electrical activity on the heart monitor but no pulse (pulseless electrical activity or PEA). Still no change in treatment and that can often happen as a side effect of the medications we were giving. We call them Epi beats. They say with enough epi you can get electical activity from a rock. After ten minutes I administered the second dose of Epi. It's always an odd part of the code when the machine is doing most of the work, all procedures are in place, and you have ten minutes until you can give the next drug. It seems like an eternity of standing around doing nothing. I went ahead and drew up the next dose of Epi for when the ten minutes was up.
But...
After another two minutes of cpr we paused for the next rhythm and pulse check. To all of our surprise, the medic said, "I've got a pulse."
What?!?
The monitor confirmed a consistent sinus rhythm tracking with the pulse he was feeling. The patient still was not breathing on his own so the rescue breathing continued as we slid him onto a tarp and moved him to the gurney to head to the hospital.
I jumped on board as a rider and took over rescue breathing. A reassessment of vitals showed a strong regular pulse, a more than sufficient blood pressure, and (probably due to the amount of fluid we'd given through the IO) a blood sugar now in the high 200s. It was about a ten minute ride to the hospital during which there was nothing to do but monitor the patient and breathe for him. The ambulance medic and I both marveled at the turn of events and how neither of us thought this call was going in this direction at any point.
The patient was delivered to the ER and their staff took over from there. He still had a good blood pressure and pulses but was still not breathing on his own. Based on the 20 plus minute downtime I wouldn't expect him to come out of this neurologically intact and if he does survive he's going back to that hoarder house which is no place to be cared for or to recuperate and get healthy. But, we did our job and executed all of our procedures pretty seamlessly, worked well as a team, and essentially re-animated the dead (for a little while at least).
I doubt I will find out what the ultimate outcome ends up being for this patient and whether his resuscitation will have turned out to be a good thing or a bad thing. But it's always interesting to see the protocols and procedures work as intended and (for good or bad) be able to restart a heart, especially without defibrillation. It certainly changes the tone of the resuscitation in the end as well.
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