Flights - A Pain in My Heart

Welcome to the fifth case in our Air Care and Mobile Care Flight Orientation Curriculum! 

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 trauma, penetrating trauma, STEMI, 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.


By Displaced (Own work) [Public domain], via Wikimedia Commons

By Displaced (Own work) [Public domain], via Wikimedia Commons

You are the Pod doc overnight on a particularly quiet Sunday night.  You have been looking for an excuse to leave the pod and do anything other than treat abdominal pain for the past several hours when the tones drop.  You thank whatever celestial being you believe in and grab the blood and run out of the department full of glee.  In route to the helipad you are told it is a Code STEMI.  At this point, even that seems more interesting than sitting in C Pod.

You buckle into the helicopter and take a quick flight to the outside hospital.  You grab a set of gloves and unload the cot carefully and walk inside.

The physician is nowhere to be found, but the nurse states that the patient presented to outside hospital with chest pain.  They have performed an EKG and found a STEMI.  They gave the patient an aspirin and him on a heparin drip.  They have arranged for a cardiac catheter at their sister facility.  They did give a nitro with mild relief of the patient’s pain.  The patient has been stable during his time in the ED.  In your initial discussion with the patient, you learn that he had a drug eluting stent placed a few weeks ago and has been non-compliant with his Plavix because he “forgets to take his medicine” sometimes.

 Physical Exam

  • Vitals: P: 85, BP: 140/75, RR: 18, O2 Sat: 98% 2L NC, Glucose: 102  
  • General: alert, oriented and in mild distress
  • Cardiovascular: NSR, no m/r/g
  • Pulm: clear to auscultation bilaterally
  • Abdomen: soft, NT, ND
  • Musculoskeletal: moves all 4 extremities with full and equal strength
  • Neuro: alert and oriented, answers all questions appropriately.

Past Medical History

  • HTN – ACE, Ca Channel Blocker
  • HLD – statin
  • CAD – Plavix for stent placed 2 weeks ago
  • DM - glyburide

Interventions Prior to Arrival:

  • ASA 324mg
  • Nitro SL with mild relief
  • IV with heparin gtt
  • Morphine for pain

Questions*

What can you do to help facilitate the movement of the patient from the outside hospital to the cot (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?

As you move the patient to the cot he has a ventricular fibrillation arrest.  What are your priorities for management of the patient?  What if he arrests in the helicopter, what interventions do you need to perform and who performs them?

You have performed good quality ACLS at the outside hospital.  The patient is still in cardiac arrest.  What other resources do you have at the hospital to try to save this patients life beyond ACLS?

What do you do if you have ROSC but the patient’s blood pressure is 60/30 and the referring facility wants you to leave immediately?

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