I was drinking my coffee and wondering if the paramedic student we had riding with us would bring on the “curse of the observer”. Which would be OK as a quiet shift would be nice for a change. Alas, it was not to be. We were sent to a call for an anaphylactic reaction. I’ve written about this before and I’m generally skeptical given that we are dispatched to a large number of these calls and they are rarely as advertised. In fact, most of the time, we are canceled by the BLS crew because it’s a lesser problem.

So, we started off in the direction of the call, anticipating that we’d get an update from the BLS guys and could continue on with our pursuit of whatever it was we were doing to while away the time. We got the update, but it was not what I expected. It was a little bit garbled, but we thought we heard something about an epi pen. My partner and I were a bit perplexed as we continued on to the call. When we arrived the crew was just putting the patient into the back of the ambulance. We grabbed our gear and our student and walked on over to get a look at the patient.

We found a man in his late 40s who was very ill. Not only did he have practically practically no blood pressure, but his face and lips were swollen up like a balloon, he was having some difficulty catching his breath, and he had pain from the waist down. The last one concerned us a bit because it’s not one of the usual complaints with an allergic reaction.

The story we got was that the patient had eaten some fried rice with shrimp. This, despite his knowing that he had an allergy to shellfish. The story was a bit weird because he was in an apartment with a bunch of people, including a woman that wasn’t his wife. When the EMTs arrived, the woman was more concerned, in fact totally concerned, with getting money from the patient for the food that was doing it’s best to kill him. No one could tell the crew anything about the patient, including his name. Nor did they care about anything but getting the sick man out of their apartment and not involving the police. And getting their money, of course. The milk of human kindness.

The patient could speak to us, but not very much. Yes indeed he was allergic to shellfish, but he claimed that he didn’t know there was any shrimp in the rice he ate. Not that it mattered because there was in fact shrimp in the rice. Or maybe it was that there had been cross contamination, who knew? Not that it mattered in the least, because he was as sick as hell.

We quickly came up with a treatment plan which involved an IV, fluid, Benadryl and maybe more Epinephrine. We discussed Albuterol, but despite his trouble breathing, his lungs were clear. We placed the patient on the monitor, which told us absolutely nothing about the patient that we didn’t already know.

Now it was the student’s turn to do her thing. She’s a good EMT, she’ll make a good medic, but she was nervous. I know that I was that nervous too at one time, but it’s so far in the dim past that I can’t remember it. She got the IV, but made a mess doing it with blood staining the sheet. Not that the patient noticed, he was too busy trying to stay alive. The Benadryl went on board and we discussed using Albuterol, but he didn’t have bronchospasm so we decided to hold off. Did I happen to mention that his blood pressure was 80/p? Fluid was in order, but unseen by me or my partner the student had only started a 20 gauge IV. A bit small to give fluid, but that’s what they teach in paramedic school and it’s reinforced by clinicals in the hospital. For some reason, which never made much sense to me, they always want students to start small gauge IVs. Not a fatal mistake, but one that I’d have to mention later on after the call. We usually spend a bit of time quizzing a student about the medication he or she is going to give, but this time we just made sure that she had the right drug, right amount, the drug wasn’t expired (a formality, but it’s good to check), and so on. She quickly gave the Benadryl, but it didn’t seem to help all that much. We opened the fluid wide and it started to slowly flow in.

We discussed more Epinephrine, but with his heart rate already in the 140s, we thought it might do more harm than help. Epinephrine is not a benign drug, not that any drugs are completely without risk.

We decided it was a good idea to call the hospital and let them know we were coming in. Which of course is when the radio in the BLS truck decided to stop working. After a bit of fiddling we went to the back up radio and I gave the hospital a notification which included the lack of BP, tachycardia, angioedema, and our efforts to treat the patient. I also, which I rarely do, suggested that we start in one of the resuscitation rooms. Which they the doctor on the other end of the radio thought was a good idea.

We brought the patient in and were greeted by a larger than normal group of people. Apparently something I had said had prompted the response, but I didn’t think that I had said anything out of the ordinary. After a quick exam, the doctors, or one of them decided that the patient needed to be intubated immediately. While the resident was trying to do that one of the nurses, seeing where this might be going, stat paged anesthesia. A whole troop of anesthesiologists (or is it a herd?) came down carrying every piece of specialized airway equipment they had. None of which the anesthesia fellow needed to intubate the patient.

At last report, the patient was doing just OK.

That was enough excitement for one night, but we weren’t done yet. We were sent to what seemed like a typical chest pain call. The patient had an extensive cardiac history for a younger (late 40s) patient, including cardiac stents. We started doing our exam, again with the student taking the lead. The student told us the BP, which was pretty high. She didn’t mention the pulse rate, but I think that was because she thought I had already taken the pulse, which I hadn’t. Imagine my surprise when I turned on the monitor and saw a heart rate in excess of 200 beat per minute. Ooo, not good. I ran off a strip and handed it to the student who correctly identified the rhythm as Atrial Fibrillation. We asked the student and the patient about a history of irregular heart beats, but they both denied it. New onset AF, that’s pretty exciting for a paramedic student. Well, it was pretty exciting for me too, if truth be told.

Looking at the patient’s medication list, we saw that she was treated for hypertension with Atenolol, which for my non medical readers is a beta blocker. Beta blockers are used to lower blood pressure and sometimes control heart rate. Again for my non medical readers, there are essentially two types of drugs that are used to control cardiac rates. One is the aforementioned beta blockers, the other is the calcium channel blockers. The general rule is that if a patient is on one class of drugs for any reason, we don’t give the patient the other class of drugs. The theory being that bad things can happen if you mix the two and both work at the same time. In fact, a while back we had a patient that had taken both types of drugs (his wife’s) in an attempt to treat his high blood pressure. He almost killed himself, so we knew that the danger was there.

Once again our student was tasked with starting the IV and administering the medication. We quickly ran her through the dose, indications, contraindications, route, potential side effects, and other information about the medication. She was a little bit shaky about it, not because she’s not smart (she is), but because of the way her program is constructed. They do didactic and field at the same time and they haven’t covered all of the drugs yet. Not the way I’d do it, but what do I know? Anyway, we explained to her about the drug, what to watch for, and the importance of running a strip on the monitor while giving the drug. She did all of this pretty well, given that this was her first day on an ALS ambulance. Drug given, patient monitored, no improvement. So, we repeated the drug, same routine, no improvement.

When we got to the hospital, the doctors, being doctors, decided that the rule about not crossing drugs could be safely violated. That’s what they go to medical school for, to make those kind of decisions. They gave a calcium channel blocker which didn’t kill the patient and did fix the problem in the short run.

I was pretty happy with the performance of the student. She has a pretty good grasp of the concepts and a considerable amount of BLS experience, which I’ve always felt is important to being a good paramedic. I think she’ll be a good paramedic when all is said and done. I’d like to think I might have a small part in that process.

I just don’t know if I can stand all that many exciting calls!