Case of the Month: 'Do the Right Thing'


 
 

Paul A. Werfel | | Tuesday, June 26, 2007


What does it really mean for our patients?

"Diligence is the mother of good luck."

ƒ Benjamin Franklin, Poor Richard's Almanack

Have you ever had people tell you to "do the right thing"? We seem to hear it constantly: on television, at work, everywhere. It's truly a staple of popular culture. It seems to have always been simply something to say, like the endless "awesomes" that my teenage daughters now use as an adjective for just about anything from clothing to rock bands.

I first heard the expression when I was working as a paramedic in New York City. Police would ask you to do the right thing, the emergency department (ED) would implore you to do the right thing, and your boss, dispatchers, partners and patients would tell you to do the right thing, too. Now, I'm a program director and an instructor, and my students are asking me to do the right thing. In all candor, it seems to me that the vast majority of the folks asking me to do the right thing mean to do the right thing for them.

But is doing the right thing really a simple result of doing your job? Let's look at this month's case to find out.

Case

You_re working in an affluent New England city with your paramedic partner, and you're dispatched to an elderly male, accidental fall, 264 Greenwich Road. Time out is 19:02.

As you respond to the scene, your mind runs through the possibilities of what you'll be confronted with ƒ perhaps a cardiac arrest, maybe a simple laceration or anything in between.

You arrive to find an 83-year-old male who is confused and lethargic. His family tells you he has been unsteady on his feet for several weeks, and he fell yesterday while walking and hit his head on marble steps. You notice an abrasion on his forehead but no active bleeding; his pupils are equal and reactive to light. Your partner places the patient on 15 L NRB oxygen.

The family tells you they called the patient's doctor after the fall, and he told them to watch for any changes in the patient's level of consciousness. Tonight, they noticed he had an onset of slurred speech, which prompted the 9-1-1 call. You palpate the patient's cervical spine, and the patient denies any tenderness in the cervical area. Just to be cautious, you ask the police officer (also an EMT) to manually immobilize the patient's cervical spine.

The family tells you that he has no significant medical history but takes aspirin and Lipitor. Vital signs are BP 170/90, pulse 100, respiration 20. You start an IV. The ECG reveals sinus tachycardia. (See Figure 1, below.)

SOURCE: ARRHYTHMIA RECOGNITION: THE ART OF INTERPRETATION BY GARCIA AND MILLER, FROM JONES AND BARTLETT



Your partner gets the long board, and the patient is immobilized and made ready for transport. That's when you notice the patient gurgling and making snoring respirations and also observe a marked increase in respiratory effort. You try a jaw thrust maneuver with some success and place a nasal airway. You and your partner hustle the patient out to the ambulance and find that the airway is not patent.

You remove the NPA and try to place an oral airway and ventilate with the BVM. This is minimally successful because the patient has a gag reflex present and clenched teeth. Your partner checks the patient's blood glucose level via dextrose stick; it's 120.

You contact medical control and get an order for rapid sequence induction, and administer 2 mg Versed via IV, with no change. Another 8 mg Versed is given. The patient becomes flaccid and apneic, and the heart rate drops to 24.

The patient is intubated successfully with an 8.0 mm endotracheal (ET) tube; its position is confirmed via breath sounds and capnography, and the ET tube is secured. Your partner ventilates the patient with high-flow oxygen to the BVM. The patient's heart rate comes up to 123, and he pinks up. During the transport he opens and moves both eyes and moves his right leg, but not his left. The repeat vital signs are BP 118/58 and pulse 142, with an assisted respiratory rate of 20.

The rest of the transport is accomplished uneventfully. The ED confirms correct ET tube placement, and you go back into service. Days later, your medical director (an attending physician in the ED) tells you, as Paul Harvey would say, "The Rest of the Story."

It turns out that the patient in fact had a fracture of C1 and C2 in addition to his other medical problems. The medical director credits your cautious approach with saving this patient from potential quadriplegia. Both you and your partner are speechless because neither of you really suspected a cervical injury but were just playing it safe. Your agency is doing a continuing education/call review night the following week, and the director red-tags the PCR as a great case for call review.

Discussion

As we ponder this case, we can see that the crew wasn't asked to do the right thing; they just did it. Their judgment wasn't clouded with preconceived ideas of what the injuries were or were not. The providers were presented with a case that had a good story of a potential injury but not a lot of signs or symptoms to hang one_s hat on. The crew appropriately treated the injuries that could have been there, and not just the ones that they saw.

Remember, knowing the right thing to do is often as easy as doing your job well.

Paul Werfel, NREMT-P, is paramedic program director for the University Medical Center at State University of New York, Stony Brook. Contact him via e-mail atpwerfel@epo.hsc.sunysb.edu.




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