KISS

Here’s a story:

 

We get dispatched to a patient’s residence for an unresponsive female. Upon our arrival an elderly female was found in her bed responsive only to deep painful stimuli, breathing at 32 per minute with white liquid oozing from her mouth, her lung sounds are congested with equal chest rise and fall, pulse at 115, oxygen saturation at 93% on room air, glucose at 180 via fingerstick, sinus tachycardia on the monitor, no ectopy noted, 12 lead revealed sinus tach, no ectopy or ST elevation noted. Blood pressure is normal at 122/78. Eyes are equal and reactive. Patient is cool and diaphoretic. No family is at location, no other information is known. We suction the patient and place her on high flow oxygen. IV is established. Some medication bottles are found but they are empty and they are from Mexico. 

 

I would like to attempt CPAP but I know that with the patient vomiting I can’t risk it, there is too much risk of aspiration. In the ambulance I consider RSI (Rapid sequence intubation or induction). I could establish the ET tube and then protect that airway from any chance of aspiration. The hospital is only 10 minutes away and when I try to open the airway and use an oral airway the patient gags, she’s coughing when she vomits, she’s still guarding her airway. I suction some more and with oxygen her saturation level goes up to 98, her pulse lowers to normal sinus rhythm. 

 

In the back of my head I still think about RSI, the dosages are not hard and the patient doesn’t appear to be anatomically complicated. 

 

I arrive and the doctor begins to work the patient up. I leave as the patient is being taken to CT. A few days later we arrive and talk to the nurse and while she doesn’t know the outcome or diagnosis she does say that approximately 8 hours after we left her she was sedated and they intubated her. Also it was difficult and a few people attempted before she was successfully intubated. 

 

Let me begin with I am not afraid of RSI when it is necessary. I have had to RSI someone that was shot in the face with a rifle and I knew without a doubt that was the only treatment that would save that man’s life. His transport time was also over 20 minutes. He had been shot in the face and the shock was making him attack us. He lived after air medics transported him to the nearest trauma center sedated and intubated. 

 The reason I am brining this first story up is sometimes we want to do more than is necessary. We may be thinking of the patient’s best interest, but we may not remember that our first rule should always be not to do any further harm. We have a lot of equipment on some of our rigs. I recently remembered this while reading a blog post on The EMS patient Perspective: http://emspatientperspective.com/2012/03/22/its-the-basics-stupid/ . I remembered that sometimes we can do more by sticking to the basics. I could have gone further with the RSI, but I was able to maintain oxygenation and protect the airway with basic oxygen administration and suctioning. The patient still had adequate chest rise and fall. 

How many of us have heard of situations where medics go above and beyond not because they had to for the sake of the patient, but because they could go above and beyond. How many times are BLS interventions minimized but in reality, how many times do they save patient’s lives? Keep it simple stupid. KISS. But how many of us truly remember this?

 

Any thoughts? What do you all think? Do too many paramedics jump to advanced skills before all the basic bases are covered? Let me know. 

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