The More You Think You Know, the More You Have to Learn

by Joe Moore

The More You Think You Know, the More You Have to Learn

We are paged to the medical center for a 60 year old female.  She had arrived at the medical center with severe abdominal pain, diarrhea, lower left back pain, and a fever.  She had a history of high blood pressure, but had not taken her medication for three days.  The patient had been treated at the medical center for the loss of fluids or dehydration caused by the illness.  She had already received 1000 milliliters of D5LR, a combination of sugar water with electrolytes, and 1000 milliliters of normal saline.  She had already received the IV medications of Toradol, the liquid motrin, and Phenerghan, the prevention drug for vomiting.  The BIEMS paramedic assisted the patient to the BIEMS ambulance cot.  The patient’s list of medications was quite long, and we were instructed to take the list and the drug bag with us.  We transported the patient by local airline with two EMS persons accompanying the patient.  The patient was turned over to the Charlevoix EMS crew at the Charlevoix Airport for the final leg of the trip to Charlevoix Hospital. 

One of my student’s stepfather arrived at the medical center by personal vehicle and called 911 for BIEMS to be dispatched to that location.  He was a 53 year old male who was having difficulty breathing which started early in the morning.  He waited, so as not to get everyone up too early, until a little after six in the morning to drive himself in to the medical center and then have us paged.  Upon BIEMS arrival at the medical center, the patient denied any chest pain.  His complaint was difficulty breathing.  When I tried to check his pulse, I got what we learned in paramedic school as the condition called, “Pulse too fast to count.”  When hooked up to the cardiac monitor in the ambulance, his heart rate was up to 180 beats per minute which does not allow the heart to fill and is certainly not conducive to good circulation.  An IV was administered in his right AC and oxygen was also administered at 15 liters per minute by non-rebreather mask.  We were already enroute to the local airport with the treatments indicated being completed while enroute.  As we began to load the patient into the aircraft, the supraventricular tachycardia (SVT) converted itself without any intervention from BIEMS. 
Although we would like to take credit for this successful change in the patient’s condition, we truly provided only supportive care to the patient.  The patient’s skin color, temperature, and moisture improved to pink, warm, and dry, and the patient continued in normal sinus rhythm throughout the flight.  Upon arrival at the Charlevoix Airport, the patient was taken off the cardiac monitor and care was transferred to the Limited Advanced crew of Charlevoix EMS for further transport to the hospital.  The patient had remained completely stable throughout the entire twenty minute flight.  He was checked over at the hospital and returned to the island that same day.  Sometimes, there is nothing that EMS or the hospital can do to help the patient, other than providing an atmosphere conducive to self repair.  We would like to think that the IV and the oxygen contributed to his recovery, but we will never know unless or until this same condition hits this same patient again on Beaver Island with the same crew.  To this day, I don’t think that my student in my classroom in my health class this year knows anything about this encounter that I had with her stepfather.  She will never find out about it from me.

Another Twofer with the Same Patient

BIEMS was paged to an address on Gull Harbor on the north end of Beaver Island at close to nine in the morning for an 85 year old male patient who was having chest pain.  He gave the pain a score of 1 on the 0-10 scale.  He had pain when he inhaled, but was describing the pain as more like an intermittent ache.  He had become nauseous after eating breakfast.  His history revealed that he had had two previous heart attacks and two previous bypass operations.  He had had a little chest pain yesterday, but was lightheaded in the shower and during breakfast this morning.  His blood pressure showed orthostatic changes, (changes from lying to sitting or standing), in his blood pressure from a BP of 130 when lying or sitting to a BP of 110 when standing.  The assessment revealed some dry crackles on the right chest and a heart murmur.  We started an IV of normal saline, and then we transported the patient without further event to the medical center.  Per the PA at the medical center, we gave the patient a 200 milliliter bolus of fluid fairly quickly to rehydrate him, and then we set the drip rate of the IV to 150 milliliters per hour.  At this point we turned the patient over to the medical center PA, as we were told that our services were no longer needed.  We were told that the patient did not need to be transported further.  We left the patient and parked the ambulance in the garage attached to the medical center.

At close to twelve-thirty, we were paged back to the medical center for the same 85 year old male, who was still having weakness and dizziness upon standing, even after being treated with fluids for the orthostatic, (positional), changes in his blood pressure.  He had received sufficient fluids that “should have taken care of his problem.”  The patient did not look or act like he had received any treatment   The patient’s vital signs were normal except his blood pressure was much higher than when we had previously arrived at his residence.  His blood pressure now was running in the 180/80’s with a pulse of 64, and respirations of 18.  He stated that he was “doing fine,” as we began a head to toe assessment to check for any changes.  His breath sounds were clear on both sides.  He denied any pain or pressure at this time.  The oximeter readings varied from 98-100% throughout the transport.  The patient was accompanied by a BIEMS paramedic and EMT from the medical center, in the aircraft, in the Charlevoix ambulance, and in the Charlevoix Hospital ER where report was given to the ER nurse.  The patient’s 12-lead EKG had never been normal from our first meeting the patient at around 9:00 a.m.  The physician’s comment to us before we left the patient and the ER was, “Very interesting.”

When the medical center is closed and a patient can’t get in touch with a health center provider, BIEMS is paged to the medical center to assist the patient.  We were paged to the medical center again at ten at night for an 81 year old female, another church member and friend.  I had spent a lot of time helping this woman get her computer to work in addition to attending church with her.  She had arrived at the medical center by personal vehicle.  Upon arrival at the medical center, she had complained of shortness of breath, chest pain 6/10 on the ten scale.  Her vital signs were pulse in the eighties, respirations of twenty-four, and at blood pressure of 140/80.  She was lightheaded and complained also of numbness to her left arm.  These are classic signs, for an older woman, of a heart attack.  We started an IV after checking lung sounds, and we gave the patient one nitroglycerin tablet under her tongue.  Her blood pressure did not go down with the nitro administration, but the pain decreased from a 6 to a 4 on the ten scale, which is another classic sign.  A knees-to-nose exam was done to check for any other problems with nothing else found.  The patient had already taken two regular aspirin to try to alleviate the pain.  The PA arrived just as we gave another nitro under the tongue.  The PA gave the patient what is known as the “GI Cocktail.”  Based upon the patient’s wishes, we contacted medical control for permission to take the patient down to Munson Medical Center where her physician was on staff.  We got permission and contacted the ER at Munson.  We got orders for 4 milligrams of morphine slow IV push followed by a nitroglycerin drip starting at five micrograms per minute titrated for pain relief as long as the blood pressure maintained at least at 100.  I mixed the 50 milligrams of nitroglycerin into a bottle of 250 milliliters of D5W, set the IV pump at 2 cc’s per hour.  We monitored the patient thoughout the procedures ordered.  The 12-lead EKG revealed Normal Sinus Rhythm with “non-specific T-wave abnormality.”  I did not know what that meant for sure, but I got the word “abnormality” from the printout. 

We moved the patient onto our cot and hooked her up to our BIEMS equipment.  Her oximetry reading was 100% on four liters of oxygen.  The patient’s husband stated, “Her color is good now, not like before.”  The patient received another 4 milligrams of morphine for the pain, and the pain shortly thereafter decreased to 1 on the ten scale.  We were being successful at relieving the patient’s pain with the morphine and the nitro drip.  While the external pain isn’t really what we were wanting to accomplish, it indicated that the heart was not working so hard to pump the blood.  Within two hours and fifteen minutes, we had the patient transported to the township airport and ready to be turned over to the Northflight crew.  When the patient was turned over to the Northflight crew, she was completely pain free.  All eight responders were bidding farewell to the patient and her husband as the patient was loaded and transported to Traverse City Airport and then on to Munson Medical Center.

BIEMS had always had an ambulance stand by for the home games for the Beaver Island Community School’s soccer games.  Since the number of students on the island is so small, the student’s have three basic sports:  soccer, basketball, and volleyball.  On this particular September evening at about seven p.m., we were on stand by, and we were needed.  One of our students had collided with another player while attempting to get the ball.  The 16 year old female was complaining of pain in the right knee on the outside with pain radiating down to her ankle on the outside.  Two EMS providers, who were her English and mathematics teachers, responded onto the field when requested by the Beaver Island coach.  We splinted the knee using an ACE wrap, put on an ice pack, and then applied kling gauze over the top to hold it in place.  We made a seat and back out of our interlocked arms and carried the patient off the field to the awaiting ambulance.  She was then transported to the medical center.  The patient told us, “The other player kicked me in the outside of my right knee.”    It is one thing to work on a stranger, but it is quite another thing to work on one of your students, and then it is quite a bit more stressful to work in full view of your entire community that has come out to cheer on the local soccer team.  We did our best to make the patient comfortable until the medical center provider arrived.

At the end of the year 2003, we had lost four paramedics or were in the process of losing them.  Two had left to continue their careers.  One had left to get a paying job.  The last one had left when his PA wife was leaving her position.  This left just one paramedic on the island at this time.  That paramedic was me.  I’m still here on the island, and right now I am still the only off-season paramedic.  During this year of 2003, we had only 66 calls for service with twenty of these runs requiring advanced life support due to medical conditions and only six runs that required spinal immobilization.  Eighteen responses did not require BIEMS to transport the patient off the island.  A major change had taken place with the medical center on the island.  The community had built a new rural health center.  They had hired one Family Nurse Practitioner (FNP) and were searching to a second FNP.  The medical care on Beaver Island had changed, and I believe that it had changed for the better.  Even though I had lost many friends due to these changes, I truly believe that the changes would continue to make a difference for all of the island patients whether (s)he needed emergency care or clinic care.