I have a new preceptee again, and while we have been busy, most of our ALS calls – even our good ones — have been routine – CVA/TIA, chest pain, asthma, dislocated shoulder, allergic reaction, pneumonia, nausea and vomiting. Lots of IV, 02, monitor with the basic drugs – NTG, Aspirin, albuterol, solumedrol, benadryl, zofran, morphine. I think the CVA that was really just a TIA was the only one we went lights and sirens to the hospital on. These calls are all good for getting into a routine, but as always, we need the knee buckling calls – the shooting to the head, the respiratory arrest, the tombstone ST MI. Last week we get called for the patient not responding. Sounds like it has a possibility to be a code, but when we get the update – lethargic and low blood pressure, I think not. “Visiting nurse call,” I say. “Gotta be.” Whenever we go to a private home and the EMD update includes a blood pressure, it usually means there is a visiting nurse on scene, and if there is a visiting nurse, then it usually isn’t too bad of an emergency. After all the visiting nurse came by on a schedule. The patient or their family didn’t call. The seventy eight year old woman is sitting up in bed. Her hands are cold and she says she doesn’t feel too well, and hasn’t been for a couple days. The visiting nurse asks my preceptee what he gets for a blood pressure. He says he can’t hear anything – that we will try again in the truck. The patient has thick edemadous arms, plus a left side mastectomy keeps us from using that arm. We carry the patient out in the stair chair and then once out in the ambulance with the heat on, we try again for the blood pressure. Can’t hear anything. We go to the monitor’s automatic cuff and are pleased to see 90/60. At least that’s something. When my preceptee puts her on the monitor, the story starts to come clearer. Her heart rate is 34. The rhythm is a little funky – definitely not a third degree block, but not a sinus brady either. The ECG print out calls it a junctional rhythm. We put her on oxygen and start to the hospital. She denies any pain, just reiterates how weak she has been feeling. Neither of us can get an IV – I try twice and can’t even draw blood. Can’t see a vein, can’t feel one. Try by anatomy, but nothing. When I touch the jugular vein in her neck, she says, don’t put an IV in my neck. Just looking, I say. Her heart rate is staying steady at 34. Her end tidal CO2 is also trending steady at 28/29. Not too bad considering. We aren’t even going lights and sirens. This is after all a visiting nurse call. The patient may have been in this rhythm for a couple days. Maybe it is an electrolyte imbalance. If we get an IV, we can try some atropine, but that may not work. We could also try dopamine or pacing(I’m not buying our monitor’s BP). But we are after all only ten minutes from the hospital now. I touch the patient’s neck again, she again shakes her head. Don’t even think about it. We try another pressure. Can’t hear anything. The machine comes up 150/110. I don’t trust that. We check it again by electronic cuff 138/78. Don’t believe that either. Still, even though we can’t hear or feel a pulse, the machine, for what it is worth, has read some kind of pressure three times. She’s stable enough, I tell my preceptee. Let the hospital put in a central line if they have to. But even as I’m saying that, still I’m thinking here’s a chance for him to get an EJ or maybe even better, we just got the EZY-IO. I’ve never used it before. I might just pull rank and pull that baby out and drill her right in the leg. With IV access, we can really play. But I say nothing. Her rate stays at 34. Her ETCO2 at 29. She’s 78 years old. No sense in getting her all riled up by jabbing her neck or pulling out the power drill. We just take her on in with supportive care. “She’s really sick,” the doctor says, looking at her. “You have access?” No, sorry. He tells the nurse to get the IV try. He sees me shaking my head, and then adds, “and bring a central line kit in here just in case.” They can’t get an IV line. They do get a pressure. 50 is all the nurse can hear, doing it manually. Their electronic cuff can’t get a reading. They hook her up to the standby pacer, and open up the central line kit. After two tries, they finally gain access. The atropine bumps her up to 40. The dopamine gets her pressure to 70. When we come back later we learn she is intubated and up in the ICU – likely dying of sepsis, multi-organ failure, including an infarct that started after she’d been in the ER awhile. I’ve written about this before in Practice. When you have a preceptee you always weigh the educational experience for him. You get him an EJ or an IO, and you push atropine and dopamine, it makes for a good story, something for him to boast about to the other preceptees – all hoping for the bad one. I feel a little bit of a failure – I certainly could have justified the aggressive treatment. But on the other hand. We didn’t overly traumatize her, we kept her calm, got her to the hospital – a higher level of care. Some days, you lean one way, some days you lean another. I’m hoping that the lesson, if there is one, is you do what you can with what you have to work with on each particular call according to the texture of the call. I don’t mean to teach him that on this particular call less is better than more or that more is better than less — just that, on each call, you need to have that debate within yourself. Either way, she’s probably going to die.