Should We? (When is a patient too unstable to transfer?)
How unstable of a patient should an EMS crew take on an interfacility transport? What criteria should we be looking at to determine if a patient is appropriate for a transfer? How much risk is too much risk?
My phone is ringing. I have no idea what time it is other than the middle of the night. My wife looks at me, shaking her head and mouths “you’re not…are you?” I mouth back, “maybe,” and give her a shrug. We both know it’s work calling, asking me to come in and we both know that I am going to say yes. I’m half-awake at best during the phone conversation, getting bits and pieces of the story. There is something about a really sick patient that OD’ed a few hours ago and is on a vent and flights are grounded. I tell them I will be there soon.
An hour later I am in the ED regretting answering my phone and asking myself why I say yes to these kinds of things.
The patient is a metabolic nightmare having arrested once for EMS on the way to the ED and three more times over the past two hours in the ED. They’re intubated and on a ventilator with both epinephrine and levophed infusing plus a bicarb infusion. A quick glance at the monitor shows that the blood pressure is simply not enough, not even close to a decent MAP. The pulse ox cannot get a reading. No one really knows much about the patient other than they took some pills in a suicide attempt.
The chaos, the exhaustion, the fuzziness in my head, it all feels familiar. I know I must begin to make sense of this situation; to sort through the noise and piece together a plan - or at least get everyone to make a go / no-go decision here. The patient is no longer a human being with hopes and dreams and ideas and a life outside of the emergency department – they exist now as just chemistry, HVAC and plumbing problems; an equation to be balanced, a group of systems that need to be fixed, and a problem for me to solve.
I also know I must be cautious here, I know that people will follow anything that is presented confidently in these situations, even if it is dead wrong.
“What is the pH?” I ask. “Well, we are not really sure,” the ED staff says. “But you got a gas, right? What do you mean you… aren’t… sure?” I ask, trying not to sound like a dick. “The ABG only reads as low as 6.5. The patient currently reads as “low” which means they are below that.” The nurse tells me. That cannot be right, can it? How is this patient still alive? I try and do math in my head, what the hell kind of minute volume should I shoot for here? 240ml x 90kg =what? Wait, the vent is currently set at what? 12 respirations a minute and vT of 380? This guy is about six feet tall. That’s not enough tidal volume is it? The BP is 52/17 in spite of the 20mcg/min of epi and 35mcg/min of levophed going and getting three and a half liters of IV fluids.
There is no way I think going to the full 240ml/kg is a good idea with that blood pressure. I regret saying yes to this train wreck, but it is too late to just walk out and go back to bed. We turn up the respiratory rate on the vent to some arbitrary number, I think it was 22/minute. The pulse ox still refuses to read anything. The PaO2 is around 80 despite an fio2 of 1.0. I mumble something about I guess when you don’t perfuse your lungs that is kind of what happens. I briefly start to think about if this is a left shift or right shift on the oxyhemoglobin curve and then realize I don’t have the brain power at that moment to devote to things like and I can’t really get more oxygen than 1.0 in there anyway – I sure as hell am not going to add in any more PEEP. Maybe if we get the pH back into the survivable range, I can think about it then. I am not sure anything we do at this point matters.
“We’ve also given the patient three liters of normal saline and a ton of bicarb,” the nurse tells me. I struggle a tiny bit to keep my emotions in check when I ask, “You guys didn’t want to use LR?” They tell me that they had some concerns about the potassium (at 5.7) and that because LR has potassium in it they did not want to give any more, but they did give insulin and dextrose for this. In the unlikely event we ever correct the acidosis (spoiler – we won’t) this patient is going to have a potassium so low that it might be a negative number. This will be an educational opportunity for later I remind myself. We aren’t thrilled with taking him the two hours through the mountains to the level one hospital in his current state. The level IV hospital we’re at is running out of bicarb. They do not want to “code” this patient all night, they are tired and out of resources and have been at this for a few hours already, frankly they are over it and I get it. They talk about parking the patient upstairs in the ICU on comfort measures but there is some hesitancy about it, they are clearly uncomfortable with this plan. No one can find any family or advance directives. The ethics get sticky. While the state does have some provisions for proxy decision making, no one seems to want to fully commit to letting this patient die. Everyone is hoping someone else will make the decision. My partner expresses some concerns that the patient being too unstable to transport. I can’t say she is wrong. I explain that I see three possible outcomes: 1. The patient stays here and is 100% dead. 2. We transport the patient and there is a high likelihood they die during transport and a slim chance they live long enough to get to the receiving hospital. 3. The patient survives transport but will almost certainly die in the next day or two at the receiving, but there is a slight, slight, like one in a million chance (rough estimate) the patient could live if they get to a legitimate ICU with intensivists and the ability to dialyze an incredibly unstable patient. I think we should give them the slightest chance over certain death, but I know most likely we are only changing the location and time of death. The doctor asks us “Will you take this patient?” I explain my thought process behind it, and he agrees with giving the patient a chance, even if the odds are astronomical.
“One more thing, the patient has a temperature of 87 f,” they tell me as we are about to load them up. How the hell am I going to keep this patient warm I ask them? I think this might be the deal breaker for the transport. “You can take our bear-hugger.” The nurse says. I have no idea if that is what it is really named, but it is a machine that blows hot air into a blanket and around the patient. The doctor adds in that we can put warm bags of IV fluid on his groin. I think they would have given me anything I wanted at this point to get the patient out of there. “Let’s just get them on our gurney and see if they survive that move and go from there.” I say to my partners. Surprisingly enough we make it out to the ambulance and eventually start transporting.
The first 20 minutes of the transport are a flurry of activity- untangling lines, changing the vent settings, titrating epi and hanging more levophed because the patient has already received 250ml of it, getting air out of IV lines, and realizing that at no point has there been any analgesia or sedation. After twenty minutes all the tasks are done and for the first time in hours the patient has a decent BP. I consider telling my partner that see, things aren’t that bad and that we are going to make it to the receiving hospital, that all it took was some tweaking of dials and managing hemodynamics and some critical care shit and that this is no big deal.
I think this is called hubris.
The patient has some spontaneous movement and some tears coming from their eyes. It is unlikely they are aware, as they are almost certainly brain dead at this point from the four other times they arrested but we discuss a very low dose ketamine infusion to start with. We start infusing 0.3mg/kg hour hoping it is just enough to take the edge off. We start the ketamine. I consider getting out my book and doing some reading. I crack open an energy drink and sit back to survey the excellent work I have done. Within two minutes of thinking about how we had stabilized this patient things begin to change on the cardiac monitor.
“Oh, uh….hey, take a look at this. What would you say this rhythm is?”The patient is in some kind of rhythm and I can’t name it. It might be a slow atrial fib or some kind of agonal, irregular junctional rhythm; I don’t spend the mental energy to figure it out – I don’t care what it is. There is a pulse, it is slow, but it is there. Naming the rhythm is not going to change the treatment.
Honestly, I did not remember atropine but I think we were clearly past that point anyway and had I thought about it I would have dismissed instantly. I hit the pace button and start escalating the power. Within ninety seconds the milliamps are maxed out at 200mA we cannot get capture. I am not surprised. I do not think more epi is going to help at this point. I don’t think anything is going to help at this point. We get ready because we know what comes next. We pull over as the patient loses pulses for the fifth and final time that evening.
The LUCAS pumps a steady stream of brown liquid out of the patient’s mouth at this point. I put all our personal belongings on the high ground of the bench seat. We know this is an exercise in futility, but we go through the motions. We disconnect the vent and attach a BVM, we give drugs every few minutes, but we know how this end. I call the sending physician. He mentions going to look something up in the care notes. I tell him that I am only presenting two options here – we can bring the patient back to them or I can call the coroner. He does not seem interested in having this patient come back and we stop the resuscitation.
We move to the front of the ambulance (thank god for the crew cab) and make small talk for the hour it takes the coroner to get to us. It is easy to forget there is a dead guy in the back of the ambulance.
The Eastern horizon beginning to glow as we help the coroner zip the patient in a body bag. I can only imagine what the early morning commuters thought as they passed an ambulance on the side of the road putting a body bag in a van in the middle of nowhere.
Should we have ever left the hospital with this patient? I think most EMS providers would have declined this transfer. This patient was in no way stable and I think it would be very reasonable to say no to this. The patient was almost certainly going to die and probably was going to die in our ambulance. Many EMS providers have a strong aversion to a patient coming from a hospital dying in their ambulance. I think at times there is a potential benefit that outweighs the risks, and this was one of those cases. Maybe I am too cavalier in my attitudes about patients dying in the back of my ambulance?
What would you have done in this situation?