Flights - Un-Break My Heart

Welcome to the second case in our Air Care and Mobile Care Flight Orientation Curriculum for 2016!

Every few weeks throughout the spring and early summer, there will be a series of posts and cases published to help spur some thought and discussion on the management of the critically ill patients we take care of in the pre-hospital environment.  These virtual flights will be used to highlight some key considerations in the management of blunt poly-trauma, severe TBI, penetrating trauma, STEMI, acute neurologic emergencies, and several other common disease processes seen on Air Care.

Comments will be open for 2 weeks after which time, a post containing expert commentary and curated commentary from the community will be published to reinforce the key learning points brought up in discussion.


It is early October and you are the flight doc in C-pod on a brisk but clear Saturday morning. The day starts out with several challenging patients with vague complaints and has just begun to ramp up in volume when a patient rolls into your pod by EMS, restrained face-down to the cot, covered in feces and urine, screaming about hearing voices. You begin to take report from EMS when, as if by divine intervention, the tones drop and you are dispatched for an inter-facility transfer. You gleefully (almost too gleefully…) give a brief patient sign-out to your staff, grab the blood cooler, and head to the roof.

You scan the horizon from your seat in the back of the EC145 and admire the bright oranges and deep reds of the changing early-fall foliage that paints the rolling hills along the Ohio River Valley as your aircraft quickly follows the winding course of the river. You receive a page that says that you will be responding to an outlying hospital for a "Code STEMI”.  A follow-up page informs your team that the patient is “Alert, not intubated, 280 lbs, a 63 y/o M, and on two drips”. You land at the hospital, unload the stretcher and equipment with your flight nurse, and walk into the ED.

You are unable to find the referring physician, but the nurse at the bedside of your patient informs you that he presented to the OSH with 2 hours of chest pain that began while he was working on repairing his barn. He initially thought that it was heartburn and jaw pain from a “rotten tooth”, but his wife made him come to the ED for evaluation. He has a 50 pack year smoking history, hypertension, and hyperlipidemia as well as DMII that is controlled by Metformin. She hands you the following EKG:


The OSH staff has administered a heparin bolus and started him on a heparin drip. They also gave the patient a full dose aspirin and 2 sublingual nitroglycerine tablets. He suddenly became markedly hypotensive and they have just finished hanging a dopamine drip. They have arranged for a cardiac catheterization at their sister facility on the outskirts of Cincinnati and ask if you have any further questions.

Physical Exam

Vitals: P: 62, BP: 86/54, RR: 16, O2 Sat: 95% on 2L NC, FSBG 220
General: The patient is somewhat pale and diaphoretic, but alert and oriented, and in good spirits
Cardiovascular: No murmurs, rubs, or gallops. NSR on the monitor
Pulmonary: Clear to auscultation bilaterally
Abdomen: Obese, but soft and non-tender
Musculoskeletal: Moves all four extremities with full and equal strength
Neurologic: GCS 15, No obvious neurologic deficits  


Past Medical History: HTN, HLD, DMII
Past Surgical History: None
Medications: Metformin, Lisinopril, Hydrochlorothiazide, Simvastatin
Allergies: None

Interventions PTA

  • Aspirin 324 mg chewable
  • Sublingual Nitroglycerine X 2 without relief in symptoms
  • Heparin bolus and drip, now running
  • Dopamine drip, now running

Questions

*To help facilitate discussion, when commenting please precede your answer to a particular question with Q1, Q2, etc.

Q1: What are your thoughts at the beginning of this patient encounter and what are your first actions at the bedside of this patient? What can you do to help more rapidly facilitate the movement of the patient to your cot and into the aircraft?  What responsibilities are yours and what are the nurses? Do you have assigned roles? What times are you responsible for knowing and documenting in Golden Hour?

Q2: Just after takeoff, the patient turns to your partner and says “I don’t feel so well…” and promptly goes into a ventricular fibrillation arrest. What are your priorities for the management of the patient? What interventions do you need to perform and who performs them? And, how does this differ inside the back of the helicopter when compared with a code in the ED?

Q3: The patient is still in cardiac arrest as you are landing at the receiving cath-capable hospital helipad and you and your partner are still valiantly trying to resuscitate the patient. What are your next steps? Is there anyone that you would consider calling? Do your destination plans change at all?

Q4: Now, instead of making it to the aircraft, the patient arrests as you are moving him onto your cot while still at the referring hospital. You perform good quality CPR and ACLS at the outside hospital for ~10 minutes, but the patient is still in cardiac arrest. What other interventions could you consider? Would you consider still transporting the patient in this state?