Tuesday, October 20, 2009

My First Kill

They always said that sooner or later, at some point in your medical career, you'd be responsible for causing the death of a patient. Thankfully, my most recent experience doesn't fall into that heading, but perhaps that's up to interpretation.

This past Saturday was an unseasonably cool and rainy day. The first snow of the year had just fallen in the higher elevations, and autumn seemed to have skipped us by in the Northeastern part of the United States completely. It was summer two weeks ago, and now here I am, bundled up in a thick jacket and cradling hot chocolate while sitting in the ambulance, waiting for a call. My partner that day was a nurse/paramedic with about 15 years experience on me, and when we're not doing 911 jobs, we serve as the critical care inter-facility transport unit. I myself have 6 years total EMS experience, with just about a year as a paramedic.

About three hours into the shift that started at 6AM, we're off to a call for new onset seizures. Our system is multi-tiered, and in addition to the Paramedic unit I'm working, every Priority 1 assignment gets a BLS ambulance and the firefighters as first-responders as well. Fire is already in the house when we pull up on scene, but a few moments after the BLS had arrived. When we get upstairs, we find a 62 y/o women tended to by her tall, panicky son, who in my opinion anyway, seemed tweaked up on something. The women is conscious and breathing just fine. My partner starts asking her some questions which she answers without difficulty. She doesn't seem like she had any seizures at all. By talking to some of the family members, it seems that she has a history of asthma and diabetes. She vital signs all check out fine (EKG: ST at 110 bpm, BP: 128/82, Respiration clear at 14-16, BGL: 224 mg/dL). She tells us that she has no pain, but "doesn't feel well." Her son says that she threw up this a couple hours ago this morning, and was in the hospital and discharged for something similar a week or two ago. Other than this, everything else checks out.

In our system, if a patient doesn't need ALS, we routinely release the patient into the care of the BLS and allow them to transport to the hospital. This is what we did in this case. Finding no life-threatening medical problems, or issues that we could care for, we allowed the BLS to take her to the hospital, an eight minute ride away - three minutes farther than the closest hospital. Our field diagnosis was that of either a stomach bug or perhaps the flu.

We return to the station to pick up some supplies and about fifteen minutes from the time we left the patient's home, I get a phone call from the BLS crew.

"Dude! Our patient just arrested in the ER!"

"No!!" I yell into the phone, "That's not possible!"

"Yeah man, they're doing CPR on her right now!"

Out patient died not 30 minutes after I last spoke to her.

I don't know for sure the cause of death, but after we raced up to the ER to find out what was going on, the nurse said she likely had a heart attack. This is something we could have detected. Perhaps not in time to prevent her from going into cardiac arrest, but something we should have known about. We have drugs that could have helped, and we certainly could have treated her.

For the past few days, images from the scene have been replaying themselves in my head. My mind is looped on the assessment we performed on this patient, trying to determine if there was something, anything, that presented itself that would have indicated to us to go a little further and spending more time with this patient - something that would have indicated that we should do an additional test, or look deeper in the patient's situation. I keep coming up dry. Aside from throwing every test we have available to us and looking for an abnormal finding, we performed a prudent exam based on the presentation of the patient. That exam lead us the the field diagnosis that we arrived at.

It's easy to Monday night quarterback these types of calls, and some colleagues of mine have indicated that they would have handled this patient differently, but several others have indicated that they would have probably done the same. It's easy to think about how things would have gone another route, but I continue to arrive at the same conclusion time after time: we didn't miss anything, obvious or subtle.

I'm waiting for the Quality Assurance director to review this call, but I've already approached our medical director and spoken to him about this one. He said that it probably would have been prudent to do a 12-lead EKG or orthostatic vital signs, and I agree, but he seemed sympathetic at least. In the mean time, the images continue to roll around in my head.

1 comment:

medic999 said...

Hi there!
You can always kick yourself when you feel as though you 'missed' something, but in truth in the vast majority of these cases it just comes down to 'sh%t happens!'

In my service, we can 'respond not convey' to patients, which means that I can get on scene, do a full assessment and then tell the patient that they dont need to go to hospital or maybe refer them onto their home doctor. As you can imagine, this makes you very thorough and more than a little bit paranoid. I havent been caught out yet, but I know that it will happen at some point because sometimes, people just deteriorate after you have gone. As long as your report is excellent and documents all of your normal findings then no one can really criticism or cast blame.

However, the one thing that I say to all paramedics is a mantra that I am heard saying over and over again to some people:

'If you are going to do a 4 lead, do a 12!'

I really think we are past the stage of rhythm strips only. Having a rhythm strip does not rule out anything cardiac, as you are not looking at the whole of the heart. If I am leaving anyone at home or are referring onwards and I have even the slightest thoughts aout anything cardiac, they get a 12 lead.

As I said, if you did a rhythm strip, then you were thinking along the lines of a cardiac assessment as well, therefore, just stick another couple of dots on and make yourself watertight!

At the end of the day, in this case, her 12 lead may have been fine and something may have acutely happened on the way to the ER.

Dont beat yourself up about it (easy to say,I know), just move on to the next patient and class it as a learning experience.