Bonnie
Urquhart
Gruenberg, CNM, MSN
Artist, Writer
Photographer
Web Design
Certified Nurse Midwife
Bonnie |
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Cheating The Reaper The forty-six year old woman was as limp as yesterday’s lettuce. Her husband had a difficult time holding her upright atop the toilet seat. Her glassy eyes were half-closed, her breathing ragged. She gave no indication that she was aware of our presence, even when I groped unsuccessfully for a peripheral pulse. "She’s unresponsive! Probably hypotensive," I shouted to my partner, Kevin, who had followed me through the doorway shouldering my heart monitor. "We need to lie her flat - lets just carry her out to the stretcher," I decided quickly. As I held a higher certification than Kevin, all patient care decisions were my responsibility. Swiftly, we grasped her as firmly as we had grasped
thousands of previous patients, and carried her to our bed. She didn't flinch, sagging
like a 180-pound beanbag in our arms. Our noses told us that she had released both bowels
and bladder, an ominous sign. Her hair was soaked with sweat. As we worked, I tossed questions at the family members. She had finished breakfast, they told us. Then she began to vomit violently, screaming that she couldn't breathe. She fainted, roused, and fainted again. Her only medical problem was high blood pressure. Aside from a minor sore throat, she felt fine this morning. She took Alieve for the pain. No, she didn't take any other medications, and she wasn't allergic to anything. I sleuthed for clues, and attempted to organize them into a working diagnosis. This woman was dying. We didn't have much time. There are "cookbook" medics, and there are thinking medics. The cookbook medic knows all of the protocols and algorithms, and reacts like a progression of falling dominos. This would be sensible if medicine were absolute and unbending, but it isn't. A thinking medic knows the protocols, but continues to probe for the reason behind the symptoms, looking for inconsistencies and possibilities. Her lungs were clear, her breathing was adequate. After we positioned her for shock and started her on 100% oxygen, she began to awaken. She was aware of our ministrations, but remained too ill to speak. "I can’t find a blood pressure." Kevin pulled the stethoscope out of his ears in frustration after his third attempt. I suspected as much from her lack of peripheral pulses. I pulled up her shirt and studied her skin under the bright lights. Not red, not pale, not blotchy, no hives. Her skin was somewhat pink and subtly mottled, but this could have been normal for her. The real question was, what was causing this woman to go into shock? The clues were ambiguous. Her history didn't include diabetes or seizures, and neither condition was likely to present with hypotension. Stroke? Doubt it. Allergic reaction to Alieve? Maybe, but her family insisted that she had never reacted to the drug before, and there were no obvious signs of allergy like wheezing, edema, or hives. Maybe she aspirated her vomit? No, her lungs were clear. Cardiac? She was getting close to the cardiac age group, and the dyspnea, vomiting, diaphoresis all could point to that diagnosis. My heart monitor showed an uncomplicated sinus tachycardia, but this unsophisticated three-lead machine did not provide enough data to allow me to diagnose a heart attack. Warm, pink skin was not usually seen in a cardiac case, but more importantly, my gut instinct said it wasn’t her heart. Medic hunches bubble to the surface from underground wellsprings of knowledge, reservoirs filled by the experience of handling countless patients and learning from each one. Often, these hunches are our most reliable sources of information. My intuition kept pulling me back to the possibility of an anaphylactic reaction to Alieve. The woman was dying. I had to act. If I treated her for anaphylaxis, and it turned out to be an atypical presentation of cardiogenic shock, I would kill her. If I treated her for cardiac, and it was really an allergic reaction, I would kill her. If I did nothing, she would die. If I radioed our medical director for advice and instructions, the time delay would kill her. I was not going to let a 46 year old mother die because of my indecisiveness. I acted. "Spike me a saline, and get me a large bore IV catheter, " I instructed my partner. We had to get that blood pressure up. Aggressively following the anaphylaxis protocol, I swiftly inserted a garden hose of an IV catheter into her left arm, and bolused her with fluid. Sirens wailing, we started enroute to the hospital. Somehow remaining upright through Kevin’s high-speed turns, I injected her left deltoid with diphenhydramine, and emptied a small syringe of epinephrine under the skin of her right shoulder. Beneath the oxygen mask, our patient moaned at the jab of the needles. I spoke to her in a monologue as I worked, attempting to make her ordeal less frightening. "I think you had an allergic reaction to Alieve. I’m pouring fluid into your veins to raise your blood pressure. That first shot was Benadryl. That’s gonna make you very sleepy. The second shot was epinephrine - that will make you feel like you just drank a whole pot of coffee. I know it sounds impossible to feel sleepy and hyper at the same, but in a few minutes you’ll understand what I mean." The fluid infused into her vasculature - two hundred cc’s., three hundred. She had a radial pulse now. Her blood pressure climbed to 80/50, then 100/60 -- almost acceptable! As we wheeled her into the hospital, she was alert enough to supply brief answers to questions. After we transferred her to the hospital bed, her blood pressure climbed to a healthy 110/60. She was trembling like an unbalanced washing machine, which I reassured her was just the epinephrine doing its job. But the doctor attacked me like an irate pit bull. "Epi? You gave her epi and Benadryl? Why on earth did you do that? Where do you see anaphylaxis? She isn't wheezing! I see no urticaria or edema! She has a decent blood pressure!" I looked up from my oxygen bottle. "She was dying." I answered honestly. "I had only minutes to assess the situation and act. My gut instincts said it was anaphylaxis, and that is what I treated for." The doctor threw a gaze of disgust in my direction, then wielded his stethoscope and auscultated the woman’s lungs, muttering about the evils of inappropriate epinephrine under his breath. He studied her skin for blotches or hives, and added a few more barbs about the dosage I had administered. I slunk out of the room inconspicuously. Had I performed inappropriately? Had I harmed the patient? It is easy for the emergency room physicians to second-guess the care paramedics give in the field. Everything is clearer retrospectively. They have lab tests, sophisticated equipment, many more years of schooling, and plenty of extra hands to help them make a working diagnosis. We frequently have poor lighting, incomplete medical histories, hysterical family members, third floor carry-downs, and combative patients complicating our task. Most ER doctors have never had to medicate or intubate in a vehicle rapidly bouncing down a dark highway, or start an IV in an car that is on its roof and half-submerged in a river. Yet paramedics are expected to be perfect, all the time, and suffer the consequences if we are not. Guilt and remorse stand ready to malignantly erode our confidence if we berate ourselves over a bad outcome. Part of being a successful paramedic is to make peace with these pressures, and learn to forgive ourselves (and others) for not being perfect. We must learn from each call, then move forward to the next one. I filed my paperwork, then darted off, lights and sirens, to a motor vehicle accident on the highway. After that, we were en route to a seizure, then a finger amputation. We were unable to return to that hospital until the end of our shift. I slunk humbly towards a knot of emergency room physicians, and, heavy with dread, asked how our patient of that morning had fared. But the doctor was smiling now. "It was anaphylaxis! The medications you gave stabilized her. After she felt better, she told us told us the whole story. Last year, she took Alieve and developed hives. I have no idea why she took it again, but she did. I told her it damn near killed her! She’s up in the ICU, but she should do just fine." I beamed, pleased by both the patient’s recovery and the unspoken acknowledgment that I had done well in diagnosing the problem. Not all of our calls are dramatic, but as long as we are treating people with compassion, our work has meaning. In my work as a paramedic, I touch the lives of others, whether through a heroic save or through gentle kindness. I am grateful for the opportunity to make a positive impact on the world, one life at a time.
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