Michael Weinmann | Search PubMed

PubMed2003

Everyone dies.

It's not unusual to be dispatched to one problem and discover something completely different when you arrive. Patients and family members will tell dispatch what they feel is the problem, and dispatch, without the benefit of being on scene, can only pass along the complaint as it was given to them. Upon arrival back at base, the attending paramedic in this case was asking himself questions like, "What if I had done this differently?" and "Did I miss something?" At the conclusion of every patient interaction, there is an opportunity for EMS to review its actions and [table: see text] change its approach to similar cases in the future. The benefit of public-safety agencies providing service in nonemergent situations is the opportunity to "practice" for true crisis incidents. This case, however, did not present many opportunities to improve care or change the outcome. The paramedic's assessment identified the need for the patient to be transported immediately. Immediate packaging of the patient, intubation and pacing were performed on scene--you known this crew was moving. The ED physician concurred that this was a "load and go" situation. The crew is to be commended for taking charge of a critical situation and performing in an expeditious manner. Oxygen, pacing, i.v. and meds were all given in a timely fashion. Unfortunately, this patient's cancer had progressed to a critical point, and the patient was not going to survive even with optimal care. This EMS crew unfortunately walked into an end-of-life event. Despite their best efforts (a total on-scene time of seven minutes and a five-minute transport) and performing every function flawlessly, this patient still died. This patient was given excellent medical service, but perhaps more important, at his critical moment, was in the presence of people who cared. One of the first things we learn in EMS is that people die. Sometimes our job is simply to provide comfort, relieve suffering and communicate with the survivors. Since all humans must die, it is just as important for us to service their needs at that moment in time. From there, we move on to the next call.

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PubMed2003

Hot on the inside.

When a disease process becomes life-threatening, it is termed to be malignant. Hyperthermia is a heat illness that arises from one of two basic causes: 1) the body's normal thermoregulatory mechanisms are overwhelmed by the environment (an exogenous heat load) or, more commonly, by excessive exercise in a moderate-to-extreme environment (an endogenous heat load); or 2) failure of the thermoregulatory mechanisms, such as those encountered in the elderly or debilitated patient. Either cause can lead to heat illnesses such as heat cramps, heat exhaustion or heatstroke. Heat cramps are brief, intermittent and often severe muscular cramps that frequently occur in muscles fatigued by heavy work or exercise. They are believed to be caused by a rapid change in the extracellular fluid osmolarity resulting from sodium and water loss. Heat exhaustion is a more severe form of heat illness characterized by minor changes in mental status (poor judgment, irritability), dizziness, nausea and headache. In severe cases, the patient may have an altered LOC. Just as with heat cramps, profuse sweating is present. Removing the patient from the hot environment and administering fluids will usually result in a rapid recovery. [table: see text] Left untreated, heat exhaustion may progress to heatstroke. Heatstroke results when there is a complete collapse of thermoregulatory mechanisms. This will lead to a rise in body core temperature in excess of 105.8 degrees F (41 degrees C), which will produce multisystem tissue damage and physiological collapse. Severe cases can cause death. The patient in this case had an axillary temperature taken and recorded at 101.4 degrees F. Typically, axillary temperatures are one degree cooler than oral temperatures, which are one degree cooler than core temperatures. This patient, then, had a core temperature of 103 degrees F or higher. There are two types of heatstroke: classic and exertional. Classic heatstroke occurs during periods of sustained high ambient temperatures and humidity. Exertional heatstroke more often occurs in athletes, military personnel and people who work strenuosly in the environment. In these situations, endogenous heat accumulates more rapidly than the body can dissipate it in the environment. Although sweating is usually absent in the classic form of heatstroke, 50% of exertional heatstroke cases have persistent sweating as a result of catecholamine release. The presence of sweating does not preclude the diagnosis of heatstroke, and cessation of sweating is not the cause of it. As the illness progresses, peripheral vasodilation occurs, resulting in hypotension and shunting. As internal temperatures rise, myocardial contractility begins to decrease, manifested by bradycardia and irritability of the myocardium. No matter the age group, the presence of hypotension and decreased cardiac output indicates a poor prognosis for the patient.

Emergency Treatment↗