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.
Friday, December 28, 2007
Tuesday, December 18, 2007
Your Choice
He was on his way out to the car when he slipped on the ice. We find him on his knees, leaning into the open front seat of his car. He says he isn’t hurt, but he needs help getting up. He is a big man. I’m guessing three hundred pounds of dead weight. It takes three of us to get him up and even then, we just barely do it. He is unsteady on his feet and we lead him carefully back into the house. In the doorway, his knees buckle and we have to slowly lower him to the ground, unable to support his weight. We finally manage to get him up into a chair. I’ve got him in a bear hung from behind, but can barely straighten my legs up from a squat during the lift. My partners are on each leg.
We let him sit a bit to catch his breath. He tells us he has congestive heart failure and it has been a struggle of late. He can barely walk a block on his own. All this weight, the water pills can only do so much, he says. I try to talk him into going to the hospital, but he wants no part of it.
Well, if you are not going, we need at least to see you stand up.
“I understand,” he says. “Just give me a minute, just give me a minute to get my strength.”
The house is cluttered with newspapers and old books. The light shade is heavy with dust and dead insects.
“My mind still thinks I’m young,” he says, “my body is a different story. It doesn't want to work anymore. Just give me a minute here. Just let me rest.”
***
We see him standing by the side of the road, a strong lean man with a long white beard, wearing a baseball cap. He is there most days; hands in his sweatshirt pockets, watching traffic go by. Every once in awhile he gets an inkling to go for a walk, striding mightily along the avenue. Sometimes we hear about it on the radio. Elderly man doesn’t know where he is, talking gibberish. They call us to check him out. His eyes are bright and engaging, his arms muscled and veined. “Pork chops sunny running through only one ninety nine, how about that, Ford Fairlane!” he exclaims, but doesn’t wait for an answer. "Titille lovely yesterday, huh? Googen corn whoosh, Hmm, hmm.”
We take him home.
***
Your mind or your body? What kind of choice is that.
We let him sit a bit to catch his breath. He tells us he has congestive heart failure and it has been a struggle of late. He can barely walk a block on his own. All this weight, the water pills can only do so much, he says. I try to talk him into going to the hospital, but he wants no part of it.
Well, if you are not going, we need at least to see you stand up.
“I understand,” he says. “Just give me a minute, just give me a minute to get my strength.”
The house is cluttered with newspapers and old books. The light shade is heavy with dust and dead insects.
“My mind still thinks I’m young,” he says, “my body is a different story. It doesn't want to work anymore. Just give me a minute here. Just let me rest.”
***
We see him standing by the side of the road, a strong lean man with a long white beard, wearing a baseball cap. He is there most days; hands in his sweatshirt pockets, watching traffic go by. Every once in awhile he gets an inkling to go for a walk, striding mightily along the avenue. Sometimes we hear about it on the radio. Elderly man doesn’t know where he is, talking gibberish. They call us to check him out. His eyes are bright and engaging, his arms muscled and veined. “Pork chops sunny running through only one ninety nine, how about that, Ford Fairlane!” he exclaims, but doesn’t wait for an answer. "Titille lovely yesterday, huh? Googen corn whoosh, Hmm, hmm.”
We take him home.
***
Your mind or your body? What kind of choice is that.
Saturday, December 08, 2007
5 Hour Gap
The call is for a hypoglycemic in the lobby of the nursing home. The nurse tells us the woman sleeping in the chair is an admission from a hospital post cardiac care . They were expecting her five hours earlier, but she has just now showed up in the last ten minutes, apparently by private vehicle (not an ambulance) with her suitcase and altered mental status, but no admission papers. Without the admission papers, they can’t admit her. Since she has a bracelet identifying her as a diabetic, they checked her sugar. It was 38. They have given her some oral glucose, but since she is not admitted, they cannot give her any glucagon. They want us to take her back to the hospital.
I look at the woman. “Gena!” I say.
The woman looks up at me with glazed eyes and smiles, pleased to be recognized, and then she drops back off.
Gena is an old frequent customer. I can’t call her a frequent flyer because we rarely ever transported her – hers was always a treat with dextrose and they she’d refuse transport. I have not seen her for years. She used to work in a local convenience store. A customer would come in and find her unresponsive behind the cash register. How many customers would come in and help themselves to chips and soda before one would call 911, I don’t know. We’d strap a tourniquet around her arm, put in an IV, check her sugar, find it always in the 20-40 range, and give her an amp of D50. She’d wake up, give us a big smile, say, “Hey how’ya doing, what’s going on?” and then refuse to go to the hospital. Sometimes we’d get called to her house in town. Her brother would check on her and find her unresponsive sprawled on the couch in front of the TV. Same deal. Amp of D50. Refusal. Then one day while working in the city, I found her unresponsive in a car in the city’s north end – not a place you’d expect to find a fifty-five year old white woman. I checked her sugar – it was 140. She was still unawake and breathing a little irregularly. I looked at her pupils. Pinpoint. 1.2 mg of narcan. She woke right up with the same old smile. “Hey, how’ya doing. What’s going on?” We took her to the hospital. The next day we were sent lights and sirens to a familar address for the lawnmower crash into a tree, patient unresponsive. We arrived to find a riding lawnmower halfway up a tree and rolled on its side with the driver still in the seat. Gilda, snoring. Blood sugar 35. We disentangled her from the lawn mower. Gave her some D50, but despite her brother’s pleadings, she refused to go to the hospital. “She had a blood sugar problem yesterday, too,” the brother said. “Maybe she should go in and get checked.” “Is that what you told him,” I said to Gilda. She looked at me sheepishly and said nothing.
“I know Gena,” I say to the nurse. “We’ll fix her up.”
“I want her taken back to the hospital. No papers, no admission.”
“Well, let’s just wake her up and find out what’s going on. Maybe she can tell us where the papers are.”
“We already looked in her suitcase.”
The IV line goes in and then the amp of D50, and Gena is much more awake now and giving us that big smile. “Hey how’ya doing? What’s going on?” she says.
“What’s going on with you? How’d you get here? Where are your papers?”
“Papers?” she says, as she looks around trying to figure out just where she is. Then she nods off.
She still seems a little out of it. I recheck her sugar. 215. I look at her closer. Asleep with her mouth open. I open an eyelid. Pinpoint.
I gesture to my partner to get her up on the stretcher. The nurse seems pleased now that we are transporting and there will be no battle over trying to make them take the patient.
“Back to the hospital,” I announce.
In our region we are only allowed to give narcan to a patient if their respirations are less than 8 or they show signs of hypoventilation. Gena is easily stimulated, but she then falls back to sleep midsentence. I put a capnography cannula on her and then dim the lights. Ever the scientist, I am curious what the capnography will reveal. Her initial reading is 50 – a bit on the high side, but her respiratory rate is actually 30, although her respirations are erratic and many of them are shallow interrupted by an occasional larger breath. I nudge her; she opens her eyes and then falls back to sleep. I watch the capnography. While her respiratory rate stays high, her ETCO2 starts to rise. Very steadily – the staircase effect. 52, 54, 55, 56, 57, 58, 59. That qualifies as hypoventilation. I get out the narcan and draw up a small dose. .4mg, which I push slowly into the IV, and then wait. A minute passes. No change. Her ETCO2 is now 60. Her pulse SAT has also dropped to 89. I draw up another .4mg. Just as I am ready to push it, she suddenly opens her eyes, sees the syringe and say, “Hey. What’s going on? What are you injecting me with?”
“Nothing,” I say. “I was just flushing the line so it doesn’t clog. Now that you’re awake, tell me how you got to the nursing home and what happened to your paperwork?”
“I need to go to the nursing home. They’re expecting me.”
The monitor shows her ETCO2 is down to 42. Her SAT up to 98%. Impressive.
“We just came from the nursing home,” I say. “That’s where we picked you up.”
She looks confused.
“Let’s try to start from the beginning,” I say. “You got discharged from the hospital. Who picked you up?”
“Two of my roommates,” she says.
“Where did they take you?”
“We went to my apartment to get my stuff.”
“And then what happened?
“The car wouldn’t start so I got a cab.”
“To the nursing home?”
“Yeah, where’s my suitcase and boxes?”
“Your suitcase is right here. We don’t have any boxes.”
She looks around in a panic.
“I brought them with me.”
“Well, they are either there or they’re in the cab of your friends’ car or at your place. Tell me a little more about what you did at your place.”
“What I did?”
“Yeah, like heroin.”
“I did not.”
“Gena, come one, you can tell me.”
She starts to deny it again, but then she breaks into a smile as she shrugs. “Hey, they offered,” she says, “Who am I to say no?”
“And do you know where the paperwork is?”
“I had it with me. Where are my boxes?”
I tell the story at the hospital. Discharged from the cardiac unit. Shows up at the nursing home five hours later by cab. No papers. Hypoglycemic and with heroin on board. The triage nurse just shakes her head and tells me, “Put her in the hall outside 21.”
I look at the woman. “Gena!” I say.
The woman looks up at me with glazed eyes and smiles, pleased to be recognized, and then she drops back off.
Gena is an old frequent customer. I can’t call her a frequent flyer because we rarely ever transported her – hers was always a treat with dextrose and they she’d refuse transport. I have not seen her for years. She used to work in a local convenience store. A customer would come in and find her unresponsive behind the cash register. How many customers would come in and help themselves to chips and soda before one would call 911, I don’t know. We’d strap a tourniquet around her arm, put in an IV, check her sugar, find it always in the 20-40 range, and give her an amp of D50. She’d wake up, give us a big smile, say, “Hey how’ya doing, what’s going on?” and then refuse to go to the hospital. Sometimes we’d get called to her house in town. Her brother would check on her and find her unresponsive sprawled on the couch in front of the TV. Same deal. Amp of D50. Refusal. Then one day while working in the city, I found her unresponsive in a car in the city’s north end – not a place you’d expect to find a fifty-five year old white woman. I checked her sugar – it was 140. She was still unawake and breathing a little irregularly. I looked at her pupils. Pinpoint. 1.2 mg of narcan. She woke right up with the same old smile. “Hey, how’ya doing. What’s going on?” We took her to the hospital. The next day we were sent lights and sirens to a familar address for the lawnmower crash into a tree, patient unresponsive. We arrived to find a riding lawnmower halfway up a tree and rolled on its side with the driver still in the seat. Gilda, snoring. Blood sugar 35. We disentangled her from the lawn mower. Gave her some D50, but despite her brother’s pleadings, she refused to go to the hospital. “She had a blood sugar problem yesterday, too,” the brother said. “Maybe she should go in and get checked.” “Is that what you told him,” I said to Gilda. She looked at me sheepishly and said nothing.
“I know Gena,” I say to the nurse. “We’ll fix her up.”
“I want her taken back to the hospital. No papers, no admission.”
“Well, let’s just wake her up and find out what’s going on. Maybe she can tell us where the papers are.”
“We already looked in her suitcase.”
The IV line goes in and then the amp of D50, and Gena is much more awake now and giving us that big smile. “Hey how’ya doing? What’s going on?” she says.
“What’s going on with you? How’d you get here? Where are your papers?”
“Papers?” she says, as she looks around trying to figure out just where she is. Then she nods off.
She still seems a little out of it. I recheck her sugar. 215. I look at her closer. Asleep with her mouth open. I open an eyelid. Pinpoint.
I gesture to my partner to get her up on the stretcher. The nurse seems pleased now that we are transporting and there will be no battle over trying to make them take the patient.
“Back to the hospital,” I announce.
In our region we are only allowed to give narcan to a patient if their respirations are less than 8 or they show signs of hypoventilation. Gena is easily stimulated, but she then falls back to sleep midsentence. I put a capnography cannula on her and then dim the lights. Ever the scientist, I am curious what the capnography will reveal. Her initial reading is 50 – a bit on the high side, but her respiratory rate is actually 30, although her respirations are erratic and many of them are shallow interrupted by an occasional larger breath. I nudge her; she opens her eyes and then falls back to sleep. I watch the capnography. While her respiratory rate stays high, her ETCO2 starts to rise. Very steadily – the staircase effect. 52, 54, 55, 56, 57, 58, 59. That qualifies as hypoventilation. I get out the narcan and draw up a small dose. .4mg, which I push slowly into the IV, and then wait. A minute passes. No change. Her ETCO2 is now 60. Her pulse SAT has also dropped to 89. I draw up another .4mg. Just as I am ready to push it, she suddenly opens her eyes, sees the syringe and say, “Hey. What’s going on? What are you injecting me with?”
“Nothing,” I say. “I was just flushing the line so it doesn’t clog. Now that you’re awake, tell me how you got to the nursing home and what happened to your paperwork?”
“I need to go to the nursing home. They’re expecting me.”
The monitor shows her ETCO2 is down to 42. Her SAT up to 98%. Impressive.
“We just came from the nursing home,” I say. “That’s where we picked you up.”
She looks confused.
“Let’s try to start from the beginning,” I say. “You got discharged from the hospital. Who picked you up?”
“Two of my roommates,” she says.
“Where did they take you?”
“We went to my apartment to get my stuff.”
“And then what happened?
“The car wouldn’t start so I got a cab.”
“To the nursing home?”
“Yeah, where’s my suitcase and boxes?”
“Your suitcase is right here. We don’t have any boxes.”
She looks around in a panic.
“I brought them with me.”
“Well, they are either there or they’re in the cab of your friends’ car or at your place. Tell me a little more about what you did at your place.”
“What I did?”
“Yeah, like heroin.”
“I did not.”
“Gena, come one, you can tell me.”
She starts to deny it again, but then she breaks into a smile as she shrugs. “Hey, they offered,” she says, “Who am I to say no?”
“And do you know where the paperwork is?”
“I had it with me. Where are my boxes?”
I tell the story at the hospital. Discharged from the cardiac unit. Shows up at the nursing home five hours later by cab. No papers. Hypoglycemic and with heroin on board. The triage nurse just shakes her head and tells me, “Put her in the hall outside 21.”
Tuesday, December 04, 2007
The Motions
I haven’t been writing much lately. I’ve been working a lot, doing lots of calls, but nothing I haven’t done before. I’ve been trying to follow my renewed anti-whine, anti-complaint, try to be an easy going nice guy policy. I’ve had a fair amount of success. It is much less tiring going with the flow than constantly complaining. Want to go to the farthest hospital? Fine. Don’t want to give me your social security number, no problem. Complaining about being cold even though you are already bundled up, here’s another blanket. Not comfortable, let me get you more comfortable? You want me to do transfers all day while you send basics on codes? Fine, as long as my pay check is good at the bank. You want me to go on a priority for a psych because we have a long response because we were three towns away when you gave us the call, fine, I’m just not turning my lights on. Sorry about that one. You called an ambulance for a runny nose, okay, what hospital do you want to go to?
I come to work on time, I check my gear, and I do my job. ABCs, head to toe, vitals, IV, 02, monitor. Write up my report. Sign here. Good luck. Hope you are feeling better. You are very welcome. It’s not bad work.
Baby Medic has a new post. Sailing Rough Waters After six months of being a medic, he is starting to get in a routine and is worried because he is no longer on edge about each call, he is losing his edge. By no longer looking for zebras in the low priority routine call, he is worried he might miss something important. I enjoy reading his posts because it reminds me of my own past and often causes me to question my present.
The ebbs and flows of a medic’s excitement toward the job always fascinate me. What causes burnout? What motivates excitement? I often feel that lately I have just been going through the motions. But I really think now that there is nothing wrong with that. When I started it was very important that I get everything right – that I not miss anything. And while I still don’t want to miss anything and kick myself when I do, I am less concerned about getting the diagnosis right. It is less important that I know exactly what is going on, than that I treat the patient appropriately or appropriately don’t treat. I know now that in many cases it is mostly beyond us to know what is wrong. That’s what they do at the hospital. They have lab tests, X-rays, MRIs and a host of other technological tests and medical experts that help them pinpoint what is really going on. And even then, they might not be able to figure it out. This is particularly true with many of the patients I have who are old and sick. An EMT asked me what I thought was wrong with one elderly patient, and my answer was just that, “She’s old and sick.” I find no shame in telling the nurse, “I don’t know what’s going on. It might be CHF, it might be COPD. It could be pneumonia or a combination of the 3.” Better that than to insist it is CHF and give them lasix and have it turn out to be pneumonia. Do no harm.
I heard a funny joke recently: An internist, a surgeon and an ED doctor are out duck hunting. Five birds fly by. The internist raises his rifle, follows the flock, but doesn’t shoot. Why didn’t he pull the trigger? He is asked. “I’m not certain if any of them were ducks,” he responds. “I need to do more tests.” Then another flock flies past. The surgeon raises his rifle and takes one shot, knocking a single bird from the sky. “How do you know that was duck? The internist asks. “Never question me,” the surgeon says. “It was a duck.” Then another flock flies past. The ED doctor raises a shot gun and shoots from the hip. All five birds drop from the sky. The internist and surgeon look at the ED doctor and say, “What are you doing?” “I don’t know about all of them,” the ED doctor says, “But one of them was definitely a duck.”
The idea being that in emergency medicine you sometimes have to fire everything you have to get the job done, to kill the duck.
That may be true when the patient is circling the drain, but for most of our patients as paramedics, it is not important that we cure them, that we kill the duck.
I view my calls now in different categories. There are calls where I have to do something (meaning provide a treatment) and calls where I don’t. There are obviously some calls where you need to act aggressively to save the patient’s life, when you have to kill the duck. You have to not only think critically, you have to be fast and successful in your skills. These include cardiogenic shock, acute respiratory failure, any unstable airway call, and sudden anaphylaxis. Then there are the routine critical calls – asystolic cardiac arrest, ST elevation MI with stable or stroke with patent airway and stable vitals -- where you need to know what you are doing, but you are basically following an established algorithm.
In the non-critical category, there are as well those you treat to stabilize (hypoglycemia, asthma, etc) and those you merely assess and transport (weakness, for example). And there are those you merely provide comfort (morphine for the woman with the broken hip, Zofran for the man with nausea/vomiting).
I think as important a skill for a paramedic as figuring out what is going on with a patient is the ability to see that the patient gets the proper attention at the hospital. This is probably only true for large hospitals, but a paramedic can make a huge difference in whether or not that patient with the hidden MI masking as weakness gets put in a medical alert room or a hallway, that a trauma patient without a mark on him (but a lacerated liver)gets the full work up in the trauma room or again the hallway. It is more important for a medic to be able to say “I don’t know what is going on with this patient, but they need to be seen right away,” than to be able to definitively say what the diagnosis is.
Going through the motions as a medic is okay -- as long as going through the motions means doing your assessments, taking your histories, doing your routine ALS. You do that; your patient will be in good hands.
I come to work on time, I check my gear, and I do my job. ABCs, head to toe, vitals, IV, 02, monitor. Write up my report. Sign here. Good luck. Hope you are feeling better. You are very welcome. It’s not bad work.
Baby Medic has a new post. Sailing Rough Waters After six months of being a medic, he is starting to get in a routine and is worried because he is no longer on edge about each call, he is losing his edge. By no longer looking for zebras in the low priority routine call, he is worried he might miss something important. I enjoy reading his posts because it reminds me of my own past and often causes me to question my present.
The ebbs and flows of a medic’s excitement toward the job always fascinate me. What causes burnout? What motivates excitement? I often feel that lately I have just been going through the motions. But I really think now that there is nothing wrong with that. When I started it was very important that I get everything right – that I not miss anything. And while I still don’t want to miss anything and kick myself when I do, I am less concerned about getting the diagnosis right. It is less important that I know exactly what is going on, than that I treat the patient appropriately or appropriately don’t treat. I know now that in many cases it is mostly beyond us to know what is wrong. That’s what they do at the hospital. They have lab tests, X-rays, MRIs and a host of other technological tests and medical experts that help them pinpoint what is really going on. And even then, they might not be able to figure it out. This is particularly true with many of the patients I have who are old and sick. An EMT asked me what I thought was wrong with one elderly patient, and my answer was just that, “She’s old and sick.” I find no shame in telling the nurse, “I don’t know what’s going on. It might be CHF, it might be COPD. It could be pneumonia or a combination of the 3.” Better that than to insist it is CHF and give them lasix and have it turn out to be pneumonia. Do no harm.
I heard a funny joke recently: An internist, a surgeon and an ED doctor are out duck hunting. Five birds fly by. The internist raises his rifle, follows the flock, but doesn’t shoot. Why didn’t he pull the trigger? He is asked. “I’m not certain if any of them were ducks,” he responds. “I need to do more tests.” Then another flock flies past. The surgeon raises his rifle and takes one shot, knocking a single bird from the sky. “How do you know that was duck? The internist asks. “Never question me,” the surgeon says. “It was a duck.” Then another flock flies past. The ED doctor raises a shot gun and shoots from the hip. All five birds drop from the sky. The internist and surgeon look at the ED doctor and say, “What are you doing?” “I don’t know about all of them,” the ED doctor says, “But one of them was definitely a duck.”
The idea being that in emergency medicine you sometimes have to fire everything you have to get the job done, to kill the duck.
That may be true when the patient is circling the drain, but for most of our patients as paramedics, it is not important that we cure them, that we kill the duck.
I view my calls now in different categories. There are calls where I have to do something (meaning provide a treatment) and calls where I don’t. There are obviously some calls where you need to act aggressively to save the patient’s life, when you have to kill the duck. You have to not only think critically, you have to be fast and successful in your skills. These include cardiogenic shock, acute respiratory failure, any unstable airway call, and sudden anaphylaxis. Then there are the routine critical calls – asystolic cardiac arrest, ST elevation MI with stable or stroke with patent airway and stable vitals -- where you need to know what you are doing, but you are basically following an established algorithm.
In the non-critical category, there are as well those you treat to stabilize (hypoglycemia, asthma, etc) and those you merely assess and transport (weakness, for example). And there are those you merely provide comfort (morphine for the woman with the broken hip, Zofran for the man with nausea/vomiting).
I think as important a skill for a paramedic as figuring out what is going on with a patient is the ability to see that the patient gets the proper attention at the hospital. This is probably only true for large hospitals, but a paramedic can make a huge difference in whether or not that patient with the hidden MI masking as weakness gets put in a medical alert room or a hallway, that a trauma patient without a mark on him (but a lacerated liver)gets the full work up in the trauma room or again the hallway. It is more important for a medic to be able to say “I don’t know what is going on with this patient, but they need to be seen right away,” than to be able to definitively say what the diagnosis is.
Going through the motions as a medic is okay -- as long as going through the motions means doing your assessments, taking your histories, doing your routine ALS. You do that; your patient will be in good hands.
Monday, November 26, 2007
Four Electrodes
At night I empty my pockets on the dresser. Once a week I clean the dresser top off. Crumpled gloves. ECG strips. Narcotics slips. Med lists scribbled on a notepad. An empty drug or saline vial. Four ECG electrodes stuck together.
The call is for the man who can't be woken up, cold to the touch.
He's on the living room floor, lying on his left side, his head resting on his hand in a sort of horizontal Rodin "The Thinker" statue pose, his head being supported by an invisible pillow, his neck rigored. It turns out he was found on the couch, and then was put down on the floor.
The officer tells me no one had seen him since last night when he had complained of chest pains. He was just visiting the house. Actually the truth was his wife had just booted him out of his.
While my partner gets the patient's name and date of birth from the officer, I lay the monitor by the dead man's side and unwind the leads. I open up a fresh pack of electrodes and attach them to the leads. I put one on each exposed ankle, one on each wrist. I turn on the machine and stare at three long flat lines. I print out a six second strip. Then on another piece of paper, I write my name, license number and date of birth, along with the time of presumption. The officer will need the information for his report. I shut the monitor off, and then carefully peel the electrodes off. First the right ankle, and then the left. I attach each electrode to the next so at the end I have four electrodes stuck together. I put them in my pocket, and then I roll up the lead wires and put them back in the monitor pouch. On my way out the door, I hand the officer the piece of paper with the presumption information.
The electrodes stay in my pocket all day until I discover them at night when I empty my pockets. A couple days later, I clean the dresser top off and the electrodes go out in the trash.
The call is for the man who can't be woken up, cold to the touch.
He's on the living room floor, lying on his left side, his head resting on his hand in a sort of horizontal Rodin "The Thinker" statue pose, his head being supported by an invisible pillow, his neck rigored. It turns out he was found on the couch, and then was put down on the floor.
The officer tells me no one had seen him since last night when he had complained of chest pains. He was just visiting the house. Actually the truth was his wife had just booted him out of his.
While my partner gets the patient's name and date of birth from the officer, I lay the monitor by the dead man's side and unwind the leads. I open up a fresh pack of electrodes and attach them to the leads. I put one on each exposed ankle, one on each wrist. I turn on the machine and stare at three long flat lines. I print out a six second strip. Then on another piece of paper, I write my name, license number and date of birth, along with the time of presumption. The officer will need the information for his report. I shut the monitor off, and then carefully peel the electrodes off. First the right ankle, and then the left. I attach each electrode to the next so at the end I have four electrodes stuck together. I put them in my pocket, and then I roll up the lead wires and put them back in the monitor pouch. On my way out the door, I hand the officer the piece of paper with the presumption information.
The electrodes stay in my pocket all day until I discover them at night when I empty my pockets. A couple days later, I clean the dresser top off and the electrodes go out in the trash.
Monday, November 12, 2007
Searching for Serenity
I seek a state of grace. I want to do every call the way it should be done. I’m not talking about the medical aspect, although I try to do everything right. It is in my case or maybe in anyone’s case, not possible. I do the best I can. What I am talking about it the attitude aspect. I want to have the right attitude – toward the patients, toward the job, toward the work, toward the profession.
I think sometimes to do that I need to retire from the discussion – from the talk about the patients, the talk about other medics and EMTs, other ambulance companies, hospitals, nursing homes. Did you hear? These jokers…Can you believe? And they call themselves. This f-ing guy? Blah, blah, blah…
I have always admired the older quiet medics, who come to work, do their job, sit quietly while they write their reports, never engage in the chit chat of the moment, just go back out and do the job, provide good care, are nice to everyone, and then go home.
EMS, by a strange set of events happened to become my profession, my work, and a large focus of my life. I like that when the day is over, my work is largely over. I don’t have reports due or projects. But I am on committees, I do write about it, and for better or worse, it is a big part of who I am (And I work so many hours). I get caught up in it and everything it sometimes entails.
I get fired up too easily when I think about all the things that aren’t perfect about EMS or the people in it. I’m not even going to list one for fear of raising my blood pressure or going down a path I don’t want to. And while I admire people who tackle problems and fix them, who want to be a part of the solution, sometimes I just want to cleanse myself of all of it. I don’t want to judge, I don’t want to have a bad opinion. I just want to go through my day quietly, trying to be a good man by my own standards, and not judging anyone or saying a word, until I can achieve that state.
Now I’m not going to stop going to meetings or unfortunately, gossiping in the EMS room or at crew change or even writing in this blog. It is just a small wish that I could just be good at all the small things. Maybe what I do need is a vow of silence for awhile. A vow that I will not speak ill of anyone or anything just to hear the sound of my own voice. I want serenity.
***
I had a stressful day on Saturday, including two “medical alerts” – an unresponsive with a difficult carry down and a bad COPDer from a nursing home -- and then a cardiac arrest at the end of the shift. The cardiac arrest was also at a nursing home. It came in as an unconscious. On the way we were updated that universal precautions were in effect for the patient. A nurse’s aide, fully gowned, met us in the hallway and started putting gowns and face masks on us. I asked why? What was the condition? but all she would say was the nurse would tell us. So she put long yellow gowns on us, and face masks and still wouldn’t even tell me what the patient condition was. Then she pointed to the room and we walked in, and wouldn’t you know, they were doing CPR on a naked man laying on the floor with a full colostomy bag that looked like it was about to burst. Three minutes we had been standing in the hall, getting the gowns on and trying to get a story. I guess they had gowned us because he had respiratory MRSA. It was my partner’s first code. We got the patient from asystole into a PEA and had to transport, but they called him dead at the hospital. All told, counting scene and transport, we did CPR for 45 minutes to no avail. When we arrived at the hospital, my partner didn’t know how to turn the siren off, plus the parking lot was filled up, so we were parked on an angle with the siren going full tilt, until I could finally get her to hit the right switch. We jumped out still wearing our yellow gowns and masks and the initial people who had come over to help suddenly disappeared. Once we got inside, the hospital sort of chuckled at our torn infection suits. Some places take respiratory MRSA more serious than others. If everyone else is wearing a gown, and they are dressing me in one, I let them put it on me. If they didn’t have gowns, I probably wouldn’t have thought to put on one. Can’t hurt, I guess. Particularly if I am the one who has to intubate.
It took a long time to cleanup and restock. I punched out late, drove home, slept for a few hours, and then got up at five and headed back to work.
It was a much better day. After checking my gear, I got to sleep for a couple hours, and then did a couple routine calls. I had a hearty lunch – thick clam chowder with fresh nine grain bread -- watched some football, and then decided since it was such a nice day, I would ride my bike around the industrial circle for awhile. I just got the bike back from the shop the day before and hadn’t ridden for a week. For the last year I have been doing my triathlon training and really enjoy the solitude of biking. I put my radio in my pocket and just pedal around the .7 mile loop. Being a Sunday I can do a figure 8 and go down another road and around the town garage since there is no traffic there on Sunday. It makes a more pleasant mile long course. I had just done four easy miles and was thinking, this is great – what a day, what a life – I feel great -- today I am going to go for a record. I’m going to do 16 miles, when the tone went off.
I recognized the address. Georgia again. Our most frequent flyer and subject of my last post.
We drove to her apartment complex non-priority. The complaint – same as always – pain. Now as I wrote in my previous post, I was feeling a little guilty that I had not picked up on her fractured shoulder head that last time, so despite the fact that I could still be riding my bike through the leaves on this maybe last pleasant Sunday of autumn, I resolved that I would be nice to her – extra nice.
How are you Georgia? I asked as I went into her apartment. How’s the shoulder?
It hurt that’s why I called.
How come your arm isn’t in a sling?
I got tired of wearing it. Get my cane and my coat.
Did the hospital give you pain medicine?
Yes, but my arthritis patch is done and I don’t have any refills, so they are going to have to give me a new patch.
Back to Hospital A?
No, I ain’t going there. Take me to Hospital B.
But Hospital A is the hospital we always take you too – they are the ones who have been treating you?
I don’t like the way they treat me. Take me to Hospital B.
Reminding myself that I am going to try to be nice to everyone regardless, I don’t argue, even though my girlfriend is working at Hospital A, which is also the closest hospital. Hospital B is on the far side of the other town.
Whatever you want, Georgia, I say.
I help her onto the stretcher and fluff her pillow and am pleasant to her all the way in.
At the hospital, they put her in the hallway. I wish her well.
When we get back to the base, I slide my radio into my pocket, get back on my bike and ride my slow loop, feeling the breeze in my face, the clear air in my lungs, taking in all the color -- the red, yellow and orange -- before the sun sets behind the trees.
I think sometimes to do that I need to retire from the discussion – from the talk about the patients, the talk about other medics and EMTs, other ambulance companies, hospitals, nursing homes. Did you hear? These jokers…Can you believe? And they call themselves. This f-ing guy? Blah, blah, blah…
I have always admired the older quiet medics, who come to work, do their job, sit quietly while they write their reports, never engage in the chit chat of the moment, just go back out and do the job, provide good care, are nice to everyone, and then go home.
EMS, by a strange set of events happened to become my profession, my work, and a large focus of my life. I like that when the day is over, my work is largely over. I don’t have reports due or projects. But I am on committees, I do write about it, and for better or worse, it is a big part of who I am (And I work so many hours). I get caught up in it and everything it sometimes entails.
I get fired up too easily when I think about all the things that aren’t perfect about EMS or the people in it. I’m not even going to list one for fear of raising my blood pressure or going down a path I don’t want to. And while I admire people who tackle problems and fix them, who want to be a part of the solution, sometimes I just want to cleanse myself of all of it. I don’t want to judge, I don’t want to have a bad opinion. I just want to go through my day quietly, trying to be a good man by my own standards, and not judging anyone or saying a word, until I can achieve that state.
Now I’m not going to stop going to meetings or unfortunately, gossiping in the EMS room or at crew change or even writing in this blog. It is just a small wish that I could just be good at all the small things. Maybe what I do need is a vow of silence for awhile. A vow that I will not speak ill of anyone or anything just to hear the sound of my own voice. I want serenity.
***
I had a stressful day on Saturday, including two “medical alerts” – an unresponsive with a difficult carry down and a bad COPDer from a nursing home -- and then a cardiac arrest at the end of the shift. The cardiac arrest was also at a nursing home. It came in as an unconscious. On the way we were updated that universal precautions were in effect for the patient. A nurse’s aide, fully gowned, met us in the hallway and started putting gowns and face masks on us. I asked why? What was the condition? but all she would say was the nurse would tell us. So she put long yellow gowns on us, and face masks and still wouldn’t even tell me what the patient condition was. Then she pointed to the room and we walked in, and wouldn’t you know, they were doing CPR on a naked man laying on the floor with a full colostomy bag that looked like it was about to burst. Three minutes we had been standing in the hall, getting the gowns on and trying to get a story. I guess they had gowned us because he had respiratory MRSA. It was my partner’s first code. We got the patient from asystole into a PEA and had to transport, but they called him dead at the hospital. All told, counting scene and transport, we did CPR for 45 minutes to no avail. When we arrived at the hospital, my partner didn’t know how to turn the siren off, plus the parking lot was filled up, so we were parked on an angle with the siren going full tilt, until I could finally get her to hit the right switch. We jumped out still wearing our yellow gowns and masks and the initial people who had come over to help suddenly disappeared. Once we got inside, the hospital sort of chuckled at our torn infection suits. Some places take respiratory MRSA more serious than others. If everyone else is wearing a gown, and they are dressing me in one, I let them put it on me. If they didn’t have gowns, I probably wouldn’t have thought to put on one. Can’t hurt, I guess. Particularly if I am the one who has to intubate.
It took a long time to cleanup and restock. I punched out late, drove home, slept for a few hours, and then got up at five and headed back to work.
It was a much better day. After checking my gear, I got to sleep for a couple hours, and then did a couple routine calls. I had a hearty lunch – thick clam chowder with fresh nine grain bread -- watched some football, and then decided since it was such a nice day, I would ride my bike around the industrial circle for awhile. I just got the bike back from the shop the day before and hadn’t ridden for a week. For the last year I have been doing my triathlon training and really enjoy the solitude of biking. I put my radio in my pocket and just pedal around the .7 mile loop. Being a Sunday I can do a figure 8 and go down another road and around the town garage since there is no traffic there on Sunday. It makes a more pleasant mile long course. I had just done four easy miles and was thinking, this is great – what a day, what a life – I feel great -- today I am going to go for a record. I’m going to do 16 miles, when the tone went off.
I recognized the address. Georgia again. Our most frequent flyer and subject of my last post.
We drove to her apartment complex non-priority. The complaint – same as always – pain. Now as I wrote in my previous post, I was feeling a little guilty that I had not picked up on her fractured shoulder head that last time, so despite the fact that I could still be riding my bike through the leaves on this maybe last pleasant Sunday of autumn, I resolved that I would be nice to her – extra nice.
How are you Georgia? I asked as I went into her apartment. How’s the shoulder?
It hurt that’s why I called.
How come your arm isn’t in a sling?
I got tired of wearing it. Get my cane and my coat.
Did the hospital give you pain medicine?
Yes, but my arthritis patch is done and I don’t have any refills, so they are going to have to give me a new patch.
Back to Hospital A?
No, I ain’t going there. Take me to Hospital B.
But Hospital A is the hospital we always take you too – they are the ones who have been treating you?
I don’t like the way they treat me. Take me to Hospital B.
Reminding myself that I am going to try to be nice to everyone regardless, I don’t argue, even though my girlfriend is working at Hospital A, which is also the closest hospital. Hospital B is on the far side of the other town.
Whatever you want, Georgia, I say.
I help her onto the stretcher and fluff her pillow and am pleasant to her all the way in.
At the hospital, they put her in the hallway. I wish her well.
When we get back to the base, I slide my radio into my pocket, get back on my bike and ride my slow loop, feeling the breeze in my face, the clear air in my lungs, taking in all the color -- the red, yellow and orange -- before the sun sets behind the trees.
Tuesday, November 06, 2007
Georgia
Georgia Johnson has been our most frequent flyer for the last year. Georgia calls five or six times a month with a complaint of being tired and hurting all over. She never calls her doctor, just 911. She is a big woman who walks with a cane and lives in elderly housing. The entrance to apartment is such that we can never fit the stretcher in, but she always says she can walk out, so we set the stretcher up right outside the door and help her walk out. She has gout and arthritis and is on several pain killers, including a fentnyl patch. Her pain has been bad enough that I have given her morphine before on a couple occasions – maybe twice out of thirty or more transports -- but lately I do little more than take her vitals, and pop her on the heart monitor quick because she always mentions chest pain in her litany of places that hurt before she ends up qualifying it as “My body hurts all over.”
I took her in on Friday, and the triage nurse had us lower our stretcher and move her over to a wheelchair, and then wheel her out to the waiting room. I took her in again on Sunday. She seemed in a good amount of pain, more than usual. Her right shoulder hurt and her right wrist, and her chest, and her back, and her legs, and “my body hurts all over.” As I said, she was grimacing more than usual, and when I asked her the pain scale, she said, “It hurts real bad.” She had a couple tears in her eyes as she spoke, which was not unusual. I asked her what they had done for her at the hospital on Friday and she said, “Nothing. They didn’t tell me anything, just gave me more pills that don’t work.”
I was going to give her some morphine, but when I put the tourniquet around her arm to start the IV, she told me to only put the IV in her hand. She had a nice vein in her AC, but the hand veins were just little spidery things. “I’d rather put it up here,” I said, pointing to the big vein.
“No, that’ll hurt too much. Why don’t you just wait till we get to the hospital?”
“Okay, fine,” I said, thinking you’re the one in pain, not me. Your problem, not mine. I offered to help. You just suck it up. I’m tired of picking you up anyway.
The triage nurse had us put her in a bed. The nurse for the room looked at her and said, “What is she doing back here? She’s here all the time. She needs to be a social service case.”
“I know,” I said sympathizing. “She’s our most frequent flyer.”
Yesterday, while bringing another patient in, I saw Georgia sitting in a wheelchair in the hallway of the overcrowded ED. After I’d moved my patient into his room, I went back and talked to her.
“How are you doing, Georgia?”
“Okay, I guess.”
“Are you still here from yesterday or did they bring you in again today?”
“From yesterday still,” she said.
I noticed then her arm was in a sling. “What’s up with your arm?”
“I got a fractured shoulder,” she said.
“When did that happen? Did you fall?”
“I don’t know. They took an X-ray and said my shoulder broke and then give me some more pills.”
Fractured shoulder. No wonder she was in more pain than normal. I just assumed…
I took her in on Friday, and the triage nurse had us lower our stretcher and move her over to a wheelchair, and then wheel her out to the waiting room. I took her in again on Sunday. She seemed in a good amount of pain, more than usual. Her right shoulder hurt and her right wrist, and her chest, and her back, and her legs, and “my body hurts all over.” As I said, she was grimacing more than usual, and when I asked her the pain scale, she said, “It hurts real bad.” She had a couple tears in her eyes as she spoke, which was not unusual. I asked her what they had done for her at the hospital on Friday and she said, “Nothing. They didn’t tell me anything, just gave me more pills that don’t work.”
I was going to give her some morphine, but when I put the tourniquet around her arm to start the IV, she told me to only put the IV in her hand. She had a nice vein in her AC, but the hand veins were just little spidery things. “I’d rather put it up here,” I said, pointing to the big vein.
“No, that’ll hurt too much. Why don’t you just wait till we get to the hospital?”
“Okay, fine,” I said, thinking you’re the one in pain, not me. Your problem, not mine. I offered to help. You just suck it up. I’m tired of picking you up anyway.
The triage nurse had us put her in a bed. The nurse for the room looked at her and said, “What is she doing back here? She’s here all the time. She needs to be a social service case.”
“I know,” I said sympathizing. “She’s our most frequent flyer.”
Yesterday, while bringing another patient in, I saw Georgia sitting in a wheelchair in the hallway of the overcrowded ED. After I’d moved my patient into his room, I went back and talked to her.
“How are you doing, Georgia?”
“Okay, I guess.”
“Are you still here from yesterday or did they bring you in again today?”
“From yesterday still,” she said.
I noticed then her arm was in a sling. “What’s up with your arm?”
“I got a fractured shoulder,” she said.
“When did that happen? Did you fall?”
“I don’t know. They took an X-ray and said my shoulder broke and then give me some more pills.”
Fractured shoulder. No wonder she was in more pain than normal. I just assumed…
Saturday, November 03, 2007
Rant and Rude Business
I have been thinking about all this rant business, and promised some thoughts on it. I was on the phone the other day trying to get an issue resolved with a telephone person and I was frustrated and trying to get her to understand my dilemma and how it wasn't my problem, but their problem. I raised my voice a couple times. She remained unfailingly polite, even though she probably wanted to hang up on me or tell me to stop yelling. Maybe she is just used to people yelling at her in her job or maybe if she was rude back to me, she would be fired because after all it is a taped line. You know the "someone may be listening in" message you always get.
I have also over the years been to doctors' offices and dentists' offices and always found the people polite and friendly, even if they looked like they were having a bad day. I was a customer and they tried to always at least smile, even if they were making me wait or screwing up my bill. No doubt if they had been rude to me, I would have gone looking for another doctor.
Which brings us to EMS and I will include the ED in this. I have never seen more rude behaviour toward patients or people anywhere. Sure most of the time most of us are polite, but a lot of the time, some of us at least can be real jerks to patients and other people like nursing home staff. Don't you dare vomit in my truck. Your legs aren't hurt, you can walk. You're just going to have to wait, there are sicker people than you. A nonreabreather at 2 liters, what you trying to do, suffacate them? Etc.
Giving someone a good telling off seems to be an admirable thing in EMS.
So why are we rude and why do we rant about the people- the patients -- who are such a bother to us?
A part of it, I think is a sense of moral superiority. We are doing this job for crappy pay because we supposedly love it and we are lifesavers, so don't waste our time if your life doesn't need saving.
Another part is we at the caregiver level in emergency medicine aren't paid based on customer satisfaction level at least in the immediate sense. If we saw more pay at the end of the day based on customer surveys, you can bet we would be nicer.
Another part is we have a monopoly. The patient can't chose who responds. They are stuck with us. Company A is rude to them, the next time they call 911, they can't ask for company B. They get company A. EDs at least -- they can go across town and they often do, where unfortunately they get the same the hell with you treatment because there are more sick people than hospitals can handle so they don't have to worry about offending people. Business is too good.
The final part is we very rarely get fired for being rude. You have to be pretty out of control to lose your job in EMS for being rude. You make a racial or religious slur, you will be fired. Aside from that, the only people I have ever heard of being fired for being rude to patients are ones who ended up physically assaulting the patient -- punching them or trying to smother them with a pillow.
So what of all this rant and rude business -- I tend to rant more than I am rude, but I find neither attractive. I will try not to do it if I can help it. I am in this work of my own choosing, so there must be enough rewards in it. Most days there are.
***
I was just talking about this issue with an EMT friend and he said something really funny. In our ambulances we have black boxes that beep when we drive too fast, take a corner too hard, backup without a spotter or don't wear a seat belt, all the while recording the violation to computer for review and score at the end of the month. He said he was waiting for the day they put black boxes on us. They would beep whenever you swore or raised your voice or were rude.
I have also over the years been to doctors' offices and dentists' offices and always found the people polite and friendly, even if they looked like they were having a bad day. I was a customer and they tried to always at least smile, even if they were making me wait or screwing up my bill. No doubt if they had been rude to me, I would have gone looking for another doctor.
Which brings us to EMS and I will include the ED in this. I have never seen more rude behaviour toward patients or people anywhere. Sure most of the time most of us are polite, but a lot of the time, some of us at least can be real jerks to patients and other people like nursing home staff. Don't you dare vomit in my truck. Your legs aren't hurt, you can walk. You're just going to have to wait, there are sicker people than you. A nonreabreather at 2 liters, what you trying to do, suffacate them? Etc.
Giving someone a good telling off seems to be an admirable thing in EMS.
So why are we rude and why do we rant about the people- the patients -- who are such a bother to us?
A part of it, I think is a sense of moral superiority. We are doing this job for crappy pay because we supposedly love it and we are lifesavers, so don't waste our time if your life doesn't need saving.
Another part is we at the caregiver level in emergency medicine aren't paid based on customer satisfaction level at least in the immediate sense. If we saw more pay at the end of the day based on customer surveys, you can bet we would be nicer.
Another part is we have a monopoly. The patient can't chose who responds. They are stuck with us. Company A is rude to them, the next time they call 911, they can't ask for company B. They get company A. EDs at least -- they can go across town and they often do, where unfortunately they get the same the hell with you treatment because there are more sick people than hospitals can handle so they don't have to worry about offending people. Business is too good.
The final part is we very rarely get fired for being rude. You have to be pretty out of control to lose your job in EMS for being rude. You make a racial or religious slur, you will be fired. Aside from that, the only people I have ever heard of being fired for being rude to patients are ones who ended up physically assaulting the patient -- punching them or trying to smother them with a pillow.
So what of all this rant and rude business -- I tend to rant more than I am rude, but I find neither attractive. I will try not to do it if I can help it. I am in this work of my own choosing, so there must be enough rewards in it. Most days there are.
***
I was just talking about this issue with an EMT friend and he said something really funny. In our ambulances we have black boxes that beep when we drive too fast, take a corner too hard, backup without a spotter or don't wear a seat belt, all the while recording the violation to computer for review and score at the end of the month. He said he was waiting for the day they put black boxes on us. They would beep whenever you swore or raised your voice or were rude.
Saturday, October 27, 2007
Coming Soon
Why do we rant in EMS? That's what I want to write about. I want to write about it in a way that is not a rant, and I want to write about it in a way that will help to stop me from ranting because I don't think it is a particularly attractive quality.
Yesterday after I wrote my ranting anti-rant which on reading seems still like a ranting rant, I had quite a day to rant about, which I will try to avoid ranting about here. I did spend much time thinking about why we rant, and may have some answers but will need more time to write it up because I don't want it to be a rant.
I will mention one call where I had a chance to atone for my ranting, but I did not.
The short of it was a patient who slipped getting out of bed, hurt all over, and was ordered out to be evaluated. He had a constant history of pneumonia, and recently had MRSA, but evidently didn't have it any more according to the nurse. He coughed all the way to the hospital -- coughed up thick mucus -- enough to fill a bowl of oatmeal. His eyes watered as he coughed and you could see how fatigued he was. His nasal cannula had dried secretions all over it. He was also covered is what I initially thought was shit because he said he was covered with shit, but then qualified it as the chocolate milk shake he was holding when he fell out of bed, probably from coughing so hard. I didn't even want to touch him he was so nasty. Now, I'm not admiting I just copied his vitals off the nursing home W-10, but I did the bare minimum on the call. On the way in, he asks me "Do you think they'll brush my teeth there?" He asked it almost like a little boy, who is hopeful, yet used to disappointment.
"They don't brush your teeth at the nursing home?" I asked.
He shook his head and said "No, they never do."
"They probably will if you ask them," I said. "They have toothbrushes in all the rooms, the disposable kinds."
He nodded, but I saw nothing but fatality in his eyes. "I just want to die," he said.
In the hospital room, I found one of the toothbrushes and said to him, "Here's the toothbrush. I'm going to leave it here so you can remember to ask the nurse when she comes in."
He muttered thanks.
It wasn't until I was back out at the ambulance that it occurred to me I had had a chance for a gesture of kindness, a chance to break through and in the smallest of ways make the world a better place. "I should have brushed his teeth," I said aloud -- not to anyone because I was out there by myself. I just said it to the stretcher, to the ambulance, to the graying sky.
Yesterday after I wrote my ranting anti-rant which on reading seems still like a ranting rant, I had quite a day to rant about, which I will try to avoid ranting about here. I did spend much time thinking about why we rant, and may have some answers but will need more time to write it up because I don't want it to be a rant.
I will mention one call where I had a chance to atone for my ranting, but I did not.
The short of it was a patient who slipped getting out of bed, hurt all over, and was ordered out to be evaluated. He had a constant history of pneumonia, and recently had MRSA, but evidently didn't have it any more according to the nurse. He coughed all the way to the hospital -- coughed up thick mucus -- enough to fill a bowl of oatmeal. His eyes watered as he coughed and you could see how fatigued he was. His nasal cannula had dried secretions all over it. He was also covered is what I initially thought was shit because he said he was covered with shit, but then qualified it as the chocolate milk shake he was holding when he fell out of bed, probably from coughing so hard. I didn't even want to touch him he was so nasty. Now, I'm not admiting I just copied his vitals off the nursing home W-10, but I did the bare minimum on the call. On the way in, he asks me "Do you think they'll brush my teeth there?" He asked it almost like a little boy, who is hopeful, yet used to disappointment.
"They don't brush your teeth at the nursing home?" I asked.
He shook his head and said "No, they never do."
"They probably will if you ask them," I said. "They have toothbrushes in all the rooms, the disposable kinds."
He nodded, but I saw nothing but fatality in his eyes. "I just want to die," he said.
In the hospital room, I found one of the toothbrushes and said to him, "Here's the toothbrush. I'm going to leave it here so you can remember to ask the nurse when she comes in."
He muttered thanks.
It wasn't until I was back out at the ambulance that it occurred to me I had had a chance for a gesture of kindness, a chance to break through and in the smallest of ways make the world a better place. "I should have brushed his teeth," I said aloud -- not to anyone because I was out there by myself. I just said it to the stretcher, to the ambulance, to the graying sky.
Friday, October 26, 2007
Weak
My plan today was to write a response to Baby Medic’s rant Bad Day -- a rant I have had myself on too many a day, week, month and year -- but in order to write what I really feel -- about the privilege of this job despite all the bullshit -- I need not to be having a bad day myself.
The small stuff is getting to me.
I hate coming to work and finding half used drug vials in the med kit. It says right on the side of the vial “Discard any used portion.” Multidose doesn’t mean multi-patient. How would you like to get 1.2 mg of narcan injected into you from the same vial that maybe an AIDS infected heroin addict received two injections from? Maybe another medic drew up 1.2 mg and gave an IM injection to the addict, and when that didn’t work, drew up another .8 from the same vial with the same syringe, and now you are lying unresponsive – maybe from a head injury -- and your medic draws up the narcan from the same vial that either he or his EMT partner put back in the med kit because they either didn’t know you were supposed to dump the vial or they were too lazy to restock.
And I should talk about leaving the ambulance a mess because while I do my best, I am not a rubber gloves up to the elbows, bleach and toothbrush in hand scrub everything till it isn’t there anymore kind of guy, but what happened to the hospital gowns I stock and how about a blanket? I have to climb my tired ass out of the ambulance, back to the laundry rack, grab a couple gowns and a thick blanket and instead of climbing back in to the ambulance, I just open the back door and toss the blanket and one gown on the stretcher and toss the other gown on the bench. I can put it on the shelf later.
And who designed the houses in this town? Every one I have been to today is a split level. You have to walk up stairs to get in the house where you come in on a landing where you either have to go up more stairs or down stairs to get to your patient. And if they are in the back bedroom, you can’t get the stretcher in because the hallway is too narrow, and there is no turning radius. Let’s not even get into the size of the patients and their lifelong diet and eating habits. Or bathing habits for that matter.
The Red Sox won a great game last night and now lead the World Series 2-0, yet I am angry that the game started so late and lasted so long that I got to bed way past my bed time and so I am tired and irritable this morning, instead of being grateful.
And hey old Parkinson’s guy feeling a little weak with your companion a little too demented to give me any kind of rational history, why did you spend the night on the floor? And your batty doesn’t know she has Alzheimer’s yet companion didn’t call us to help you until this morning? And damn, even though you are not hurt, I can’t rightly leave you here and go back to my disturbed nap, my cheek pressed to the pillow, the blanket tucked up to my neck, me all curled up like a middle-aged baby. So I guess we have to take you in. If my partner can only get the stretcher in here.
I am sorry I am apparently too tired and tangled with my own gripes to take in the awfulness of where life leaves once fierce vibrant people.
Let's get you up. Here's my hand.
The small stuff is getting to me.
I hate coming to work and finding half used drug vials in the med kit. It says right on the side of the vial “Discard any used portion.” Multidose doesn’t mean multi-patient. How would you like to get 1.2 mg of narcan injected into you from the same vial that maybe an AIDS infected heroin addict received two injections from? Maybe another medic drew up 1.2 mg and gave an IM injection to the addict, and when that didn’t work, drew up another .8 from the same vial with the same syringe, and now you are lying unresponsive – maybe from a head injury -- and your medic draws up the narcan from the same vial that either he or his EMT partner put back in the med kit because they either didn’t know you were supposed to dump the vial or they were too lazy to restock.
And I should talk about leaving the ambulance a mess because while I do my best, I am not a rubber gloves up to the elbows, bleach and toothbrush in hand scrub everything till it isn’t there anymore kind of guy, but what happened to the hospital gowns I stock and how about a blanket? I have to climb my tired ass out of the ambulance, back to the laundry rack, grab a couple gowns and a thick blanket and instead of climbing back in to the ambulance, I just open the back door and toss the blanket and one gown on the stretcher and toss the other gown on the bench. I can put it on the shelf later.
And who designed the houses in this town? Every one I have been to today is a split level. You have to walk up stairs to get in the house where you come in on a landing where you either have to go up more stairs or down stairs to get to your patient. And if they are in the back bedroom, you can’t get the stretcher in because the hallway is too narrow, and there is no turning radius. Let’s not even get into the size of the patients and their lifelong diet and eating habits. Or bathing habits for that matter.
The Red Sox won a great game last night and now lead the World Series 2-0, yet I am angry that the game started so late and lasted so long that I got to bed way past my bed time and so I am tired and irritable this morning, instead of being grateful.
And hey old Parkinson’s guy feeling a little weak with your companion a little too demented to give me any kind of rational history, why did you spend the night on the floor? And your batty doesn’t know she has Alzheimer’s yet companion didn’t call us to help you until this morning? And damn, even though you are not hurt, I can’t rightly leave you here and go back to my disturbed nap, my cheek pressed to the pillow, the blanket tucked up to my neck, me all curled up like a middle-aged baby. So I guess we have to take you in. If my partner can only get the stretcher in here.
I am sorry I am apparently too tired and tangled with my own gripes to take in the awfulness of where life leaves once fierce vibrant people.
Let's get you up. Here's my hand.
Tuesday, October 16, 2007
Room
I’ve been doing a serious garage and house cleaning. I do it a couple times a year. I always manage to throw a good bit out, but never quite get control. I’m no pack rat. Paramedics won’t find my rigored body underneath a collapsed stack of yellowed newspapers, but I have stuff.
A month ago I cut my book collection in half – loaded up about fifty boxes and took them to the library. I still have way more books than I could ever read again. I have my best books on the bookshelf in the living room -- Moby Dick, The Great Gatsby, The Catcher in the Rye, Don Quioxte, On the Road, and others. The rest are piled high in plastic bins in the garage.
I have other bins too, but instead of books inside the bins are jumbled messes of old letters from past girlfriends, photos, concert tickets, records, magazines, momentos, souvenirs, old baseball gloves, sports equipment and trophies, and journals and papers and stories I wrote in grade school and high school and college, and then articles and speeches and more stories I wrote as an adult. They probably aren’t all worth saving. But I feel if I throw them out, I am throwing out a part of myself.
I go into the houses and apartments of old people – some piled high with junk and barely navigatable, others barren – not much more than a couch, a TV on a stand, a bed, a table with two chairs, -- and I wonder what my home or apartment will look like when EMS comes for me on that hopefully far off day.
Sometimes I think I’d like to weed my stuff down to only what I could fit on a dresser in a one room elderly apartment. What would I bring? A sperm whale tooth I got as a child, a baseball card of my first hero Red Sox Tony Conigliaro, a cloth bookmark a girl sewed for me with the stitched words “Wise Madness is Better than Foolish Sanity,” two small Indian stone carvings one of a buffalo, the other a wolf, a few photos of close family and friends. What more do I really need?
Years ago, a friend of mine said I would one day end up like the old man in the Robert Frost poem, An Old Man’s Winter Night.
All out of doors looked darkly in at him
Through the thin frost, almost in separate stars,
That gathers on the pane in empty rooms.
What kept his eyes from giving back the gaze
Was the lamp tilted near them in his hand.
What kept him from remembering what it was
That brought him to that creaking room was age.
He stood with barrels round him -- at a loss.
And having scared the cellar under him
In clomping there, he scared it once again
In clomping off; -- and scared the outer night,
Which has its sounds, familiar, like the roar
Of trees and crack of branches, common things,
But nothing so like beating on a box.
A light he was to no one but himself
Where now he sat, concerned with he knew what,
A quiet light, and then not even that.
He consigned to the moon, such as she was,
So late-arising, to the broken moon
As better than the sun in any case
For such a charge, his snow upon the roof,
His icicles along the wall to keep;
And slept. The log that shifted with a jolt
Once in the stove, disturbed him and he shifted,
And eased his heavy breathing, but still slept.
One aged man -- one man -- can't keep a house,
A farm, a countryside, or if he can,
It's thus he does it of a winter night.
-Robert Frost
"A light he was to no one but himself."
But I am not alone now. I share my house with a woman and two children, and another one on the way. I need to make room.
A month ago I cut my book collection in half – loaded up about fifty boxes and took them to the library. I still have way more books than I could ever read again. I have my best books on the bookshelf in the living room -- Moby Dick, The Great Gatsby, The Catcher in the Rye, Don Quioxte, On the Road, and others. The rest are piled high in plastic bins in the garage.
I have other bins too, but instead of books inside the bins are jumbled messes of old letters from past girlfriends, photos, concert tickets, records, magazines, momentos, souvenirs, old baseball gloves, sports equipment and trophies, and journals and papers and stories I wrote in grade school and high school and college, and then articles and speeches and more stories I wrote as an adult. They probably aren’t all worth saving. But I feel if I throw them out, I am throwing out a part of myself.
I go into the houses and apartments of old people – some piled high with junk and barely navigatable, others barren – not much more than a couch, a TV on a stand, a bed, a table with two chairs, -- and I wonder what my home or apartment will look like when EMS comes for me on that hopefully far off day.
Sometimes I think I’d like to weed my stuff down to only what I could fit on a dresser in a one room elderly apartment. What would I bring? A sperm whale tooth I got as a child, a baseball card of my first hero Red Sox Tony Conigliaro, a cloth bookmark a girl sewed for me with the stitched words “Wise Madness is Better than Foolish Sanity,” two small Indian stone carvings one of a buffalo, the other a wolf, a few photos of close family and friends. What more do I really need?
Years ago, a friend of mine said I would one day end up like the old man in the Robert Frost poem, An Old Man’s Winter Night.
All out of doors looked darkly in at him
Through the thin frost, almost in separate stars,
That gathers on the pane in empty rooms.
What kept his eyes from giving back the gaze
Was the lamp tilted near them in his hand.
What kept him from remembering what it was
That brought him to that creaking room was age.
He stood with barrels round him -- at a loss.
And having scared the cellar under him
In clomping there, he scared it once again
In clomping off; -- and scared the outer night,
Which has its sounds, familiar, like the roar
Of trees and crack of branches, common things,
But nothing so like beating on a box.
A light he was to no one but himself
Where now he sat, concerned with he knew what,
A quiet light, and then not even that.
He consigned to the moon, such as she was,
So late-arising, to the broken moon
As better than the sun in any case
For such a charge, his snow upon the roof,
His icicles along the wall to keep;
And slept. The log that shifted with a jolt
Once in the stove, disturbed him and he shifted,
And eased his heavy breathing, but still slept.
One aged man -- one man -- can't keep a house,
A farm, a countryside, or if he can,
It's thus he does it of a winter night.
-Robert Frost
"A light he was to no one but himself."
But I am not alone now. I share my house with a woman and two children, and another one on the way. I need to make room.
Sunday, October 14, 2007
The Gear
I've pretty much been a stickler over the years about carrying gear. You get a call -- whether its chest pain, a fever, or a fall -- you bring all your gear in. Monitor, house bag, 02. You never know.
Many years ago, I was working with a partner named Steve. Good partner. We had lots of fun together. We get called to an assault in the north end. This is a pretty common call. Someone gets punched in the face or scratched -- the cops call us, we go. The patient is giving a statement. We either get a refusal or we walk the patient to the ambulance. No problem. Most of the time they are sitting on the front stoop. Anyway, we get called, and the cop coming out of the apartment building says nonchalantly, "he's up on the 2nd floor." We walk up there nonchalantly. See a cop writing up a report. He nods down by his feet where a man in laying prone with a pool of blood around his head. "He got the shit kicked out of him," the cop says -- "steel toed boots." "Uh-o," Steve says to me. "Go get the gear," I say to Steve.
We work together the next week. No "uh-o" moments we both agree. We'll bring the gear in on every call. First call of the night is for a "woman drunk wants to go to rehab." This is a call we do all the time too. We walk in, meet the patient, who says, "I want to go to rehab." And we take them to the rehab place. Piece of cake. But this time, a man meets us at the door -- also up on the second floor. "My daughter is an alcoholic," he says. "She needs to get cleaned up. I don't think she's breathing." Uh-o. Go get the gear.
My partners hate it because I insist we carry all the gear in and out of every call. What bothers them is insist on bringing the gear even though I am generally a work-them-in-the-ambulance-not-on-the-scene-medic -- unless they really need to be worked on scene. Why do I carry everything in since I never use it? they ask. You always have to be prepared, I say. I make all my preceptees do the same thing. Same deal. Carry everything.
But I am slacking off a little of late. For the late year I have been training for triathlons -- swim, bike, run -- I am in excellent cardio shape -- good for going up stairs -- but my upper body has suffered a little bit for the all the aerobics activity at the expense of weight-lifting. I've lost some muscle. The gear is getting a little heavy. Plus we have medical dispatch in one of the towns I work in so I get a fairly detailed report on what I can expect to find. I confess to sometimes leaving my gear in the ambulance. Not on every call, but a little more than I used to.
Sixty-year old lady with abd pain. Alert, etc. Sounds like a put-them-on-the-stretcher-take-them-to-the-hospital call. Let's just bring the stretcher in, I say. We'll leave it outside and then go in and see what's up.
We find her sitting on the toilet. She says she feels a little nauseous and dizzy. Just get the stair chair, I tell my partner. She has a pulse. Skin is a little clammy. She's talking to me. We get her on the stair chair, strap her in, tell her not to reach out. Just as we are going through the front door, she starts waving her arms. "Stop! Stop!" she says, and then her head drops onto her chest and she speaks not another word in this lifetime.
The other day we got called for an overdose. There are a couple cop cars there. A few family members standing around outside. No one looks too distressed. The address is deep at one end of a town and we had to cross two towns to get there. Not once were we updated or asked for our ETA. I expect to find the person sitting at the kitchen table, telling officers she took more pills than she should have. One cop comes out of the house, and smiles at us as we step out of the ambulance. We apologize for the late response. He says, "No problem. She's inside." Another cop meets us at the door as we enter. "What's up?" I ask. "Overdose," he says. "Some Tylenol and benadryl." "Where is she?"I ask. "Over there," he says.
I walk past him and look to where he pointed. She's on the floor. She looks like she's dead. There is some chest movement, but her GCS is 3. No response at all. Vomit all over her face and hair. "Get the gear," I tell my partner.
Many years ago, I was working with a partner named Steve. Good partner. We had lots of fun together. We get called to an assault in the north end. This is a pretty common call. Someone gets punched in the face or scratched -- the cops call us, we go. The patient is giving a statement. We either get a refusal or we walk the patient to the ambulance. No problem. Most of the time they are sitting on the front stoop. Anyway, we get called, and the cop coming out of the apartment building says nonchalantly, "he's up on the 2nd floor." We walk up there nonchalantly. See a cop writing up a report. He nods down by his feet where a man in laying prone with a pool of blood around his head. "He got the shit kicked out of him," the cop says -- "steel toed boots." "Uh-o," Steve says to me. "Go get the gear," I say to Steve.
We work together the next week. No "uh-o" moments we both agree. We'll bring the gear in on every call. First call of the night is for a "woman drunk wants to go to rehab." This is a call we do all the time too. We walk in, meet the patient, who says, "I want to go to rehab." And we take them to the rehab place. Piece of cake. But this time, a man meets us at the door -- also up on the second floor. "My daughter is an alcoholic," he says. "She needs to get cleaned up. I don't think she's breathing." Uh-o. Go get the gear.
My partners hate it because I insist we carry all the gear in and out of every call. What bothers them is insist on bringing the gear even though I am generally a work-them-in-the-ambulance-not-on-the-scene-medic -- unless they really need to be worked on scene. Why do I carry everything in since I never use it? they ask. You always have to be prepared, I say. I make all my preceptees do the same thing. Same deal. Carry everything.
But I am slacking off a little of late. For the late year I have been training for triathlons -- swim, bike, run -- I am in excellent cardio shape -- good for going up stairs -- but my upper body has suffered a little bit for the all the aerobics activity at the expense of weight-lifting. I've lost some muscle. The gear is getting a little heavy. Plus we have medical dispatch in one of the towns I work in so I get a fairly detailed report on what I can expect to find. I confess to sometimes leaving my gear in the ambulance. Not on every call, but a little more than I used to.
Sixty-year old lady with abd pain. Alert, etc. Sounds like a put-them-on-the-stretcher-take-them-to-the-hospital call. Let's just bring the stretcher in, I say. We'll leave it outside and then go in and see what's up.
We find her sitting on the toilet. She says she feels a little nauseous and dizzy. Just get the stair chair, I tell my partner. She has a pulse. Skin is a little clammy. She's talking to me. We get her on the stair chair, strap her in, tell her not to reach out. Just as we are going through the front door, she starts waving her arms. "Stop! Stop!" she says, and then her head drops onto her chest and she speaks not another word in this lifetime.
The other day we got called for an overdose. There are a couple cop cars there. A few family members standing around outside. No one looks too distressed. The address is deep at one end of a town and we had to cross two towns to get there. Not once were we updated or asked for our ETA. I expect to find the person sitting at the kitchen table, telling officers she took more pills than she should have. One cop comes out of the house, and smiles at us as we step out of the ambulance. We apologize for the late response. He says, "No problem. She's inside." Another cop meets us at the door as we enter. "What's up?" I ask. "Overdose," he says. "Some Tylenol and benadryl." "Where is she?"I ask. "Over there," he says.
I walk past him and look to where he pointed. She's on the floor. She looks like she's dead. There is some chest movement, but her GCS is 3. No response at all. Vomit all over her face and hair. "Get the gear," I tell my partner.
Saturday, October 06, 2007
D'oh
I consider myself on the cutting edge of pain management. I have worked within the state and region to increase the amount of morphine paramedics can give patients on standing order and I am very aggressive with my use of morphine. You have pain, I want to take it away. Instead of screaming with pain, I want you singing "The Farmer in the Dell." Recently, I helped our region get Toradol so we have an alternative pain med for patients allergic to Morphine, in addition to being able to give toradol to patients with kidney stones for which it is particularly good for pain relief.
So it is with some embarrassment that I make the following confession.
But first a bit of blame.
Many years ago another paramedic told me if a patient is allergic to sulfa, you can't give them Morphine. Why? Because Morphine is in fact Morphine Sulfate.
Okay, makes sense.
So for all those patients, I said, sorry I can't give you any morphine because you are allergic to sulfa, I am profoundly sorry.
I had a patient with a hip fracture the other day who was allergic to sulfa and to NSAIDS. I told her I couldn't give her any pain meds unless I talked to the doctor first. We put her rather painfully onto the scoop stretcher and got her out to the ambulance, where pained by her distress, I decided to call medical control and ask if it was okay if I gave her some morphine. She was unable to tell me what happened when she took sulfa drugs, so if she had a reaction, well, I do carry the full complement of anti-allergic reaction drugs -- epi, benadryl, solumedrol, albuterol, 02, fluid.
After describing her injury, pain 10 of 10, vitals, and history, I said, "I'm calling because the patient is allergic to sulfa, but she can't tell me what happens when she takes sulfa. She is in a terrible amount of pain. 10 of 10 and I was calling to consult whether or not giving her morphine is appropriate."
Give her the morphine was the answer.
Later I talked briefly to the doc, and told her I had been told long ago, you couldn't give morphine to a patient with sulfa allergies. She smiled and said, "You can," and then went back to her charts.
Further research and questions confirmed this. The sulfa in a sulfa allergy is different from the sulfate in Morphine Sulfate.
D'oh.
***
This all brings up the issue of how we learn in EMS. We are taught certain things in class, but much of what we learn comes from the street, from calls, from conversations. Much of the information we learn is good, some of it is conflicted, and some of it is plain wrong. And some stuff changes.
When I started as a medic before every shift I used to grab a handful of ammonia inhalants. We get called for a drunk or an overdose, an ammonia inhalant goes under the nose and the patient is roused. One day -- quite a number of years ago -- our clinical coordinator was reviewing the run form of one of my preceptees and discovered a passage in the narrative about rousing the patient with an ammonia inhalant. He wanted to know what was going on. I explained. The guy was drunk. We couldn't rouse him. We stuck an ammonia inhalant under his nose. He woke up. Do it all the time. Been doing it for years. Then the coordinator said, "That isn't done anymore." He explained that it is, in fact, a dangerous practice (see links below).
I have long stopped using ammonia inhalants, but I still occasionally see them show up in the supply room or hear of someone telling about using them. Once even at the hospital, an older nurse woke up my unresponsive patient with one(just like I used to), and said, "he's just a drunk."
"You're not supposed to use those anymore," I said.
"You're a funny man," she said.
***
One common practice that is apparently passed from EMS person to EMS person is the use of the blue duct tape strap that comes with the popular "head-beds." People attach one end of the blue tape to the board by the patient's head at ear/forehead level, then loop the tape down under the patient's chin, and then crank it back to the board by the other side of the head, often hyperextending the patient's neck. When a partner of mine does it, I undo it, and if necessary resecure it straight across the head over the soft white strap. Sometimes I will get out the instructions and show it to my partner and explain how it hyperextends the neck when done improperly. The instructions allow for the tape to go either straight across the head or straight across the neck (c-collar). When I started as an EMT in the late 1980's, I would have been crucified by our then medical director for putting any thick tape across the neck, so to this day I don't tape the neck.
The use of the tape across the neck then back up to the head is so prevalent, I have almost given up trying to correct people. Another medic who shares my views on the device said he was in the ER the other day and a new EMT looked at his c-spined patient (he had placed the tape over the white strap across the head), and the EMT made a remark about how some idiot had taped the head instead of hooking it down under the chin.
Stuff just gets passed on.
Anyway, a second apology to all those sulfa allergy patients with broken bones who had to suffer through my ignorance. And another apology out there to patients past and future who may be the victims of any other misinformed information I have but am as yet unaware of.
***
Ammonia Inhalants:
Not to be taken lightly
This Procedure Stinks
Head-Bed Video
So it is with some embarrassment that I make the following confession.
But first a bit of blame.
Many years ago another paramedic told me if a patient is allergic to sulfa, you can't give them Morphine. Why? Because Morphine is in fact Morphine Sulfate.
Okay, makes sense.
So for all those patients, I said, sorry I can't give you any morphine because you are allergic to sulfa, I am profoundly sorry.
I had a patient with a hip fracture the other day who was allergic to sulfa and to NSAIDS. I told her I couldn't give her any pain meds unless I talked to the doctor first. We put her rather painfully onto the scoop stretcher and got her out to the ambulance, where pained by her distress, I decided to call medical control and ask if it was okay if I gave her some morphine. She was unable to tell me what happened when she took sulfa drugs, so if she had a reaction, well, I do carry the full complement of anti-allergic reaction drugs -- epi, benadryl, solumedrol, albuterol, 02, fluid.
After describing her injury, pain 10 of 10, vitals, and history, I said, "I'm calling because the patient is allergic to sulfa, but she can't tell me what happens when she takes sulfa. She is in a terrible amount of pain. 10 of 10 and I was calling to consult whether or not giving her morphine is appropriate."
Give her the morphine was the answer.
Later I talked briefly to the doc, and told her I had been told long ago, you couldn't give morphine to a patient with sulfa allergies. She smiled and said, "You can," and then went back to her charts.
Further research and questions confirmed this. The sulfa in a sulfa allergy is different from the sulfate in Morphine Sulfate.
D'oh.
***
This all brings up the issue of how we learn in EMS. We are taught certain things in class, but much of what we learn comes from the street, from calls, from conversations. Much of the information we learn is good, some of it is conflicted, and some of it is plain wrong. And some stuff changes.
When I started as a medic before every shift I used to grab a handful of ammonia inhalants. We get called for a drunk or an overdose, an ammonia inhalant goes under the nose and the patient is roused. One day -- quite a number of years ago -- our clinical coordinator was reviewing the run form of one of my preceptees and discovered a passage in the narrative about rousing the patient with an ammonia inhalant. He wanted to know what was going on. I explained. The guy was drunk. We couldn't rouse him. We stuck an ammonia inhalant under his nose. He woke up. Do it all the time. Been doing it for years. Then the coordinator said, "That isn't done anymore." He explained that it is, in fact, a dangerous practice (see links below).
I have long stopped using ammonia inhalants, but I still occasionally see them show up in the supply room or hear of someone telling about using them. Once even at the hospital, an older nurse woke up my unresponsive patient with one(just like I used to), and said, "he's just a drunk."
"You're not supposed to use those anymore," I said.
"You're a funny man," she said.
***
One common practice that is apparently passed from EMS person to EMS person is the use of the blue duct tape strap that comes with the popular "head-beds." People attach one end of the blue tape to the board by the patient's head at ear/forehead level, then loop the tape down under the patient's chin, and then crank it back to the board by the other side of the head, often hyperextending the patient's neck. When a partner of mine does it, I undo it, and if necessary resecure it straight across the head over the soft white strap. Sometimes I will get out the instructions and show it to my partner and explain how it hyperextends the neck when done improperly. The instructions allow for the tape to go either straight across the head or straight across the neck (c-collar). When I started as an EMT in the late 1980's, I would have been crucified by our then medical director for putting any thick tape across the neck, so to this day I don't tape the neck.
The use of the tape across the neck then back up to the head is so prevalent, I have almost given up trying to correct people. Another medic who shares my views on the device said he was in the ER the other day and a new EMT looked at his c-spined patient (he had placed the tape over the white strap across the head), and the EMT made a remark about how some idiot had taped the head instead of hooking it down under the chin.
Stuff just gets passed on.
Anyway, a second apology to all those sulfa allergy patients with broken bones who had to suffer through my ignorance. And another apology out there to patients past and future who may be the victims of any other misinformed information I have but am as yet unaware of.
***
Ammonia Inhalants:
Not to be taken lightly
This Procedure Stinks
Head-Bed Video
Friday, September 28, 2007
Hey, Look at This
The call is for a possible stroke -- a fifty-year old cancer patient can't move her right side.
I'm thinking it's not a stroke. Maybe weakness, maybe a tumor. But it could be a stroke. We'll see when we get there.
The woman is lying in bed. Her eyes look up at me as I come through the doorway. She is alert, her skin is warm and dry. She looks scared.
She was fine a half hour ago, she says when she took a nap. She woke up and now can't move her right arm or right leg.
Her right arm lies lifeless at her side. She can't squeeze my hand. I lift the arm up and it falls back to the bed. She can't lift her right leg, but when I have her try to push against my hand, I feel some force against it, like the strength is coming from her hip. Odd.
Her speech is clear. No facial droop. Never had anything like this happen before.
Her only history is breast cancer that was cured, and then a year ago, cervical cancer. She's undergoing chemo. And now she can't move her right side. Fifty years old
We lift her up onto our stretcher. She can't weigh more than a hundred pounds.
Out in the ambulance, I check her out. Her heart rate is in the 130's. Her BP is 110/70. Lungs are clear.
No headache. Pupils are equal and reactive. Her right arm is still flaccid. Odd.
I check her other arm for a vein and don't see much. She tells me she has a port.
Okay, I say. I'll let them use that at the hospital. Spare you a needle.
Thanks. I've had my share of needles lately.
I do have to check your sugar, I say. It's just protocol. You ever had any sugar problems? Diabetes?
No.
It's a little prick in the finger. We have to do one on all possible stroke patients. I don't do it, they'll ask what your sugar is, and I'll say, I don't know, but your not diabetic, but they'll still need to do it anyway. Its best to just do it.
Okay.
I prick her finger and squeeze out a little drop of blood. I press the glucometer strip against it, and watch as the blood is sucked into the strip, and the machine starts its countdown.
5, 4, 3, 2, 1. Reading -- 66.
Okay, that's interesting. Your sugar is a little low. Not greatly so -- the normal range is 70-110 -- but a little low. Have you been eating?
Not much. I haven't had an appetite.
Well, protocol again. I really should put in an IV and give you a little sugar water. Just to cover all the bases. So we can rule out your sugar being the cause, which I doubt it is. I've had patients I thought were having massive strokes only to find their sugar down in the 20's, but 66 isn't very low.
If you have to, she says.
All I can find is a thin vein in her hand, which I thread a 24 into.
I squirt out half an amp of D50 into the sharps box, and then stick the needle into a 250 bag of saline and draw out 25 cc. I shake the new mix of 12.5 grams of D25 up and then push it through the saline lock. It flows easily. When I am done, I toss the bristojet into the sharps box, and pick up my clipboard to notate it.
As I am writing, I feel a tap on my leg.
I look over at the patient.
"Hey, look at this," she says. She kicks her right leg up and down and waves her right arm, squeezing her hand in and out, in time like a vaudeville performer.
She has a smile on her face like a little girl at a magic show.
I'm thinking it's not a stroke. Maybe weakness, maybe a tumor. But it could be a stroke. We'll see when we get there.
The woman is lying in bed. Her eyes look up at me as I come through the doorway. She is alert, her skin is warm and dry. She looks scared.
She was fine a half hour ago, she says when she took a nap. She woke up and now can't move her right arm or right leg.
Her right arm lies lifeless at her side. She can't squeeze my hand. I lift the arm up and it falls back to the bed. She can't lift her right leg, but when I have her try to push against my hand, I feel some force against it, like the strength is coming from her hip. Odd.
Her speech is clear. No facial droop. Never had anything like this happen before.
Her only history is breast cancer that was cured, and then a year ago, cervical cancer. She's undergoing chemo. And now she can't move her right side. Fifty years old
We lift her up onto our stretcher. She can't weigh more than a hundred pounds.
Out in the ambulance, I check her out. Her heart rate is in the 130's. Her BP is 110/70. Lungs are clear.
No headache. Pupils are equal and reactive. Her right arm is still flaccid. Odd.
I check her other arm for a vein and don't see much. She tells me she has a port.
Okay, I say. I'll let them use that at the hospital. Spare you a needle.
Thanks. I've had my share of needles lately.
I do have to check your sugar, I say. It's just protocol. You ever had any sugar problems? Diabetes?
No.
It's a little prick in the finger. We have to do one on all possible stroke patients. I don't do it, they'll ask what your sugar is, and I'll say, I don't know, but your not diabetic, but they'll still need to do it anyway. Its best to just do it.
Okay.
I prick her finger and squeeze out a little drop of blood. I press the glucometer strip against it, and watch as the blood is sucked into the strip, and the machine starts its countdown.
5, 4, 3, 2, 1. Reading -- 66.
Okay, that's interesting. Your sugar is a little low. Not greatly so -- the normal range is 70-110 -- but a little low. Have you been eating?
Not much. I haven't had an appetite.
Well, protocol again. I really should put in an IV and give you a little sugar water. Just to cover all the bases. So we can rule out your sugar being the cause, which I doubt it is. I've had patients I thought were having massive strokes only to find their sugar down in the 20's, but 66 isn't very low.
If you have to, she says.
All I can find is a thin vein in her hand, which I thread a 24 into.
I squirt out half an amp of D50 into the sharps box, and then stick the needle into a 250 bag of saline and draw out 25 cc. I shake the new mix of 12.5 grams of D25 up and then push it through the saline lock. It flows easily. When I am done, I toss the bristojet into the sharps box, and pick up my clipboard to notate it.
As I am writing, I feel a tap on my leg.
I look over at the patient.
"Hey, look at this," she says. She kicks her right leg up and down and waves her right arm, squeezing her hand in and out, in time like a vaudeville performer.
She has a smile on her face like a little girl at a magic show.
Tuesday, September 25, 2007
Nephews
For years I have been on the regional medical advisory council. One of our responsibilities is to come out with the regional paramedic guidelines. It is always very exciting for me to get to use a new guideline for the first time. I think we worked on this for so long, went though many drafts and discussions and now here I am actually putting our work into play.
I remember the thrills of giving ativan on standing orders for a seizure for the first time, utilizing the spinal immobilization guidelines where I no longer had to put a collar around their neck and strap to a board every patient from a fall or MVA, and ceasing a futile resuscitation after 20 minutes of ACLS. Recently I gave Zofran for nausea for the first time and was able to give up to 15 mg of Morphine for pain on standing order.
I think wow all that effort around the meeting table actually made a difference here on the street.
***
Last week we got called to a person collapsed with no pulse. Okay, I told myself, I'm going to get a tube. I haven't had one for a while. This will be my first tube under our new regional intubation guidelines. After much discussion our committee decided to limit the number of intubation attempts to 2. An attempt is defined as putting the blade in the patient's mouth. You do it twice and don't get the tube, you use a rescue airway or allow a second medic one attempt. (There is an exception clause, which permits another attempt, but requires significant justification). I usually always get the tube on the 1st or 2nd attempt, but still there have been a couple times I have had to go in again. I ask myself, what will I do if I don't get the tube on the first two attempts. Will I go to the LMA or will I try again. I didn't particularly agree with the committee's decision on this one but I did agree with their point about if you are going to intubate, give yourself your best chance to get the tube -- set up right, get the head in proper position, have suction available, have the bougie out if needed. Don't just go in blindly.(I guess the literature shows the more intubation attempts the worse outcomes and greater the trauma to the patient.)
As we approach, we get updated. CPR in progress. Oh, yeah, and by the way, the patient weighs 500 pounds.
When we pull into the driveway I see a woman rolling on the ground screaming. A man approaches us, waving to us to hurry. He is in tears.
I get out of the passenger side, open up the side door and jump in the back. I detach the portable suction and grab a bougie, which lays on the counter and put them both on the stretcher where I already have my monitor, 02 and house bag secured. I jump back out, go around to the back and help my partner pull out the stretcher. The man tells us the patient -- his aunt dropped in the garage when a car backfired as it was pulling out. As we wheel around the corner we survey the scene -- a huge woman lies on her back. One police officer is doing CPR -- standing up straddling the patient, while another works the ambu-bag. Around them are several young men, who we learn are nephews, all anxiously asking how is she doing? How is she doing?
I apply the monitor -- asystole. The officers says they got in one shock, but the last check showed no shock advised.
I go to the airway now. The patient's head is purple and as large as I have ever seen a head. I learn she is only 40, but has a significant heart history. I strap the tube holder around her neck in preparation, then larengyscope in hand, a number 8 tube laid on a wrapped to the side, I try to open her mouth. She has protruding teeth and her jaw is heavy. I can barely open the mouth, and slide the blade in. Thankfully, there is no vomitus. I lift up and gaze in at the now lit airway. I can't see anything. I move the blade to the left and lift higher, moving the tongue out of the way. Again, I am in luck it is not the biggest tongue. At least there is room to pass a tube -- only there is no view of the chords. I can just make out the epiglottis. But time is running out and there goes my first attempt.
It's back to the ambu-bag.
"How's she doing? Is she breathing?"
I ask for a pillow to put under her head. I attach the capnography filter to the end of the ET tube and reach for the boogie. Here goes. I go in again. Again all I see is the epiglottis. I pass the bougie running it along the epiglottis till the tip disappears from view and then I feel the bumps of the tracheal rings. I realize only now that I have forgotten to place the tube over the bougie. No matter. I place it over the bougie and thread it down until it stops. I crank it to the right with a twist and have my partner pull the bougie which is now sticking out of the top out. I look at the monitor and am thrilled with what I see.
insert strip
The tiny oscillations of CPR. I'm in. I attach the ambu back. Good wave form. Check lung sounds. Equal.
I struggle to attach the tube holder, but it won't fit around her head. My partner hands me some tape and I finally get it secured.
"How come your not going to the hospital? How's she doing? Sir, can you tell us?"
What follows is chaos.
The crowd of nephews more seeming to arrive with each minute presses in on us. I send my partner for the board, and while on one hand I want the officers to hold the crowd back, on the other we are going to need them to help lift the patient. I also need to get an IV, but she has no neck and in the dimness of the garage I can't see any veins. I'm thinking let's get her in the ambulance and then maybe I can get something.
We still don't have the EZ-IO yet, so my only choice is down the tube with epi, which I do. Still asystole.
We need to tie straps to straps to get them to fit around the patient. I am still amazed that the officers switching on and off CPR are able to do CPR on their feet. The woman's sternum must be two and a half feet off the ground.
We finally get her rolled onto the board and strapped. The board starts to break apart as we lift, my partner and I, the two officers and at least five crying nephews, but we manage to get it on the stretcher and then with the same muscle power get the stretcher up. I am holding the tube. My eyes on the monitor.
insert strip.
Still good wave form. Thank god for capnography.
In the ambulance, one officer does CPR, while my partner bags and I look for an IV. The other officer sits in the driver's seat, ready for the word to go. I tell the other officer I'll cut him loose as soon as I get an IV and get some drugs in. The back door opens and a nephew jumps in. How's she doing? You need to get out. Why aren't you going to the hospital? The other officer says we better get moving, they are going nuts out there. I get the flash and start slamming in epi and atropine. I take over CPR while the officer gets out. We're on our way.
I look out the back window and see the other officer following us in his cruiser and behind him a caravan of speeding nephews.
The capnography is up to 70. I see an organized rhythm.
insert strip
But I can't feel a pulse -- there is no place to even attempt. No neck. I would have to cut her pants to get to a femoral if I could even find that, plus it is hard enough just keeping her on the stretcher with her belly shifting its center of gravity with each turn. The officer is doing a great job of driving slow. I look out the side window and see one of the nephews has overtaken the police officer behind us and is driving parallel to the ambulance, trying to see what is going on. I feel like I am in a movie chase scene -- a wagon train being overtaken by Indians or an undercover hero being chased by foreign agents.
The capnography drops down to 18, and now there is no question but to do CPR again. More epi and atropine. I try to patch to the hospital, and as I give the report, we go around a corner and the patient shifts on the stretcher and my legs are pinned between the body and the bench seat. I'll tell you the rest at the hospital, I say. Is the patient intubated? they ask. Yes! I throw the radio down. And with great effort manage to center the woman back on the board.
At the hospital the back door opens and the nephews pile in. How's she doing? Easy, I say.
Again, we need them to help ease the patient out of the back. I have to shout at them to pull out slowly. The capnography wave form is still looking good. I know the tube is still solid.
Into the ER we go, nephews and all. They have us go to one room, but it is too small, so we parade back through the ER to another room, we finally slide the patient onto their bed, and the nephews are lead from the room by the officers and security.
The patient is asystole. The total down time is deduced at almost forty minutes now. The physicians argue about whether to declare the patient dead, which they do.
A tech comes up to me and says he gives me credit for bringing the patient in and not calling her at the scene.
I don't even bother to explain.
Sorry, nephews, your aunts dead. We're not going to the hospital. Ashes to ashes. We're out of here.
I don't think so.
Later one of the nephews tearfully thanks me for our efforts. Another walks by seething and says nothing.
***
I am glad for many things. For getting the tube. For bougies and wave form capnography. Ten years ago, I wouldn't have gotten the tube and that would have made the situation that much more stressful.
I'm grateful that we will be getting the EZ-IO on our trucks, although I wish it was now and not "soon." Maybe if I could have gotten earlier IV assess the drugs might have brought her back and not just produced a temporary rhythm and possible marginal cardiac output.
I'm glad no one was hurt on the call.
I'm glad I'm not 500 pounds.
I'm glad that she was as loved as she was.
I remember the thrills of giving ativan on standing orders for a seizure for the first time, utilizing the spinal immobilization guidelines where I no longer had to put a collar around their neck and strap to a board every patient from a fall or MVA, and ceasing a futile resuscitation after 20 minutes of ACLS. Recently I gave Zofran for nausea for the first time and was able to give up to 15 mg of Morphine for pain on standing order.
I think wow all that effort around the meeting table actually made a difference here on the street.
***
Last week we got called to a person collapsed with no pulse. Okay, I told myself, I'm going to get a tube. I haven't had one for a while. This will be my first tube under our new regional intubation guidelines. After much discussion our committee decided to limit the number of intubation attempts to 2. An attempt is defined as putting the blade in the patient's mouth. You do it twice and don't get the tube, you use a rescue airway or allow a second medic one attempt. (There is an exception clause, which permits another attempt, but requires significant justification). I usually always get the tube on the 1st or 2nd attempt, but still there have been a couple times I have had to go in again. I ask myself, what will I do if I don't get the tube on the first two attempts. Will I go to the LMA or will I try again. I didn't particularly agree with the committee's decision on this one but I did agree with their point about if you are going to intubate, give yourself your best chance to get the tube -- set up right, get the head in proper position, have suction available, have the bougie out if needed. Don't just go in blindly.(I guess the literature shows the more intubation attempts the worse outcomes and greater the trauma to the patient.)
As we approach, we get updated. CPR in progress. Oh, yeah, and by the way, the patient weighs 500 pounds.
When we pull into the driveway I see a woman rolling on the ground screaming. A man approaches us, waving to us to hurry. He is in tears.
I get out of the passenger side, open up the side door and jump in the back. I detach the portable suction and grab a bougie, which lays on the counter and put them both on the stretcher where I already have my monitor, 02 and house bag secured. I jump back out, go around to the back and help my partner pull out the stretcher. The man tells us the patient -- his aunt dropped in the garage when a car backfired as it was pulling out. As we wheel around the corner we survey the scene -- a huge woman lies on her back. One police officer is doing CPR -- standing up straddling the patient, while another works the ambu-bag. Around them are several young men, who we learn are nephews, all anxiously asking how is she doing? How is she doing?
I apply the monitor -- asystole. The officers says they got in one shock, but the last check showed no shock advised.
I go to the airway now. The patient's head is purple and as large as I have ever seen a head. I learn she is only 40, but has a significant heart history. I strap the tube holder around her neck in preparation, then larengyscope in hand, a number 8 tube laid on a wrapped to the side, I try to open her mouth. She has protruding teeth and her jaw is heavy. I can barely open the mouth, and slide the blade in. Thankfully, there is no vomitus. I lift up and gaze in at the now lit airway. I can't see anything. I move the blade to the left and lift higher, moving the tongue out of the way. Again, I am in luck it is not the biggest tongue. At least there is room to pass a tube -- only there is no view of the chords. I can just make out the epiglottis. But time is running out and there goes my first attempt.
It's back to the ambu-bag.
"How's she doing? Is she breathing?"
I ask for a pillow to put under her head. I attach the capnography filter to the end of the ET tube and reach for the boogie. Here goes. I go in again. Again all I see is the epiglottis. I pass the bougie running it along the epiglottis till the tip disappears from view and then I feel the bumps of the tracheal rings. I realize only now that I have forgotten to place the tube over the bougie. No matter. I place it over the bougie and thread it down until it stops. I crank it to the right with a twist and have my partner pull the bougie which is now sticking out of the top out. I look at the monitor and am thrilled with what I see.
insert strip
The tiny oscillations of CPR. I'm in. I attach the ambu back. Good wave form. Check lung sounds. Equal.
I struggle to attach the tube holder, but it won't fit around her head. My partner hands me some tape and I finally get it secured.
"How come your not going to the hospital? How's she doing? Sir, can you tell us?"
What follows is chaos.
The crowd of nephews more seeming to arrive with each minute presses in on us. I send my partner for the board, and while on one hand I want the officers to hold the crowd back, on the other we are going to need them to help lift the patient. I also need to get an IV, but she has no neck and in the dimness of the garage I can't see any veins. I'm thinking let's get her in the ambulance and then maybe I can get something.
We still don't have the EZ-IO yet, so my only choice is down the tube with epi, which I do. Still asystole.
We need to tie straps to straps to get them to fit around the patient. I am still amazed that the officers switching on and off CPR are able to do CPR on their feet. The woman's sternum must be two and a half feet off the ground.
We finally get her rolled onto the board and strapped. The board starts to break apart as we lift, my partner and I, the two officers and at least five crying nephews, but we manage to get it on the stretcher and then with the same muscle power get the stretcher up. I am holding the tube. My eyes on the monitor.
insert strip.
Still good wave form. Thank god for capnography.
In the ambulance, one officer does CPR, while my partner bags and I look for an IV. The other officer sits in the driver's seat, ready for the word to go. I tell the other officer I'll cut him loose as soon as I get an IV and get some drugs in. The back door opens and a nephew jumps in. How's she doing? You need to get out. Why aren't you going to the hospital? The other officer says we better get moving, they are going nuts out there. I get the flash and start slamming in epi and atropine. I take over CPR while the officer gets out. We're on our way.
I look out the back window and see the other officer following us in his cruiser and behind him a caravan of speeding nephews.
The capnography is up to 70. I see an organized rhythm.
insert strip
But I can't feel a pulse -- there is no place to even attempt. No neck. I would have to cut her pants to get to a femoral if I could even find that, plus it is hard enough just keeping her on the stretcher with her belly shifting its center of gravity with each turn. The officer is doing a great job of driving slow. I look out the side window and see one of the nephews has overtaken the police officer behind us and is driving parallel to the ambulance, trying to see what is going on. I feel like I am in a movie chase scene -- a wagon train being overtaken by Indians or an undercover hero being chased by foreign agents.
The capnography drops down to 18, and now there is no question but to do CPR again. More epi and atropine. I try to patch to the hospital, and as I give the report, we go around a corner and the patient shifts on the stretcher and my legs are pinned between the body and the bench seat. I'll tell you the rest at the hospital, I say. Is the patient intubated? they ask. Yes! I throw the radio down. And with great effort manage to center the woman back on the board.
At the hospital the back door opens and the nephews pile in. How's she doing? Easy, I say.
Again, we need them to help ease the patient out of the back. I have to shout at them to pull out slowly. The capnography wave form is still looking good. I know the tube is still solid.
Into the ER we go, nephews and all. They have us go to one room, but it is too small, so we parade back through the ER to another room, we finally slide the patient onto their bed, and the nephews are lead from the room by the officers and security.
The patient is asystole. The total down time is deduced at almost forty minutes now. The physicians argue about whether to declare the patient dead, which they do.
A tech comes up to me and says he gives me credit for bringing the patient in and not calling her at the scene.
I don't even bother to explain.
Sorry, nephews, your aunts dead. We're not going to the hospital. Ashes to ashes. We're out of here.
I don't think so.
Later one of the nephews tearfully thanks me for our efforts. Another walks by seething and says nothing.
***
I am glad for many things. For getting the tube. For bougies and wave form capnography. Ten years ago, I wouldn't have gotten the tube and that would have made the situation that much more stressful.
I'm grateful that we will be getting the EZ-IO on our trucks, although I wish it was now and not "soon." Maybe if I could have gotten earlier IV assess the drugs might have brought her back and not just produced a temporary rhythm and possible marginal cardiac output.
I'm glad no one was hurt on the call.
I'm glad I'm not 500 pounds.
I'm glad that she was as loved as she was.
Sunday, September 16, 2007
Hyperexcitability and Abnormal Movements
The 84 year old woman, who lives at home, says she is light-headed, feels shaky and is seeing white spots, but she really doesn’t want to go to the hospital.
“Well, if you are light-headed, feeling shaky and seeing white spots, you need to go to the hospital,” I say.
“Okay,” she says.
That was easy.
We get her in a Johnny top and on the stretcher. Out in the ambulance, I do a 12 lead and a full assessment. She has a sinus rhythm with occasional PACs and a right bundle branch block. No ST elevations. Her lungs are slightly decreased, but it could just be that my hearing is slightly decreased. Her skin is warm now, although she says she felt sweaty earlier. Her abdomen is soft, her grip strengths are equal.
Her blood pressure is 180/100. Her heart rate is in the 90’s. She is Satting at 95% so I put her on a cannula at 2 lpm.
I try to get a history, but she is 84, partially deaf and a poor historian.
On the way to the hospital, I notice that she seems uncomfortable.
I ask her is she is in pain and she says her back hurts. Is this new pain or old pain?
I have arthritis, she says.
So you have had this pain before?
What?
The pain.
She is holding her belly and looks like she is trying to sit up more, so I undo the belt and slide her up, but it doesn’t seem to help. She seems very anxious.
I am starting to get concerned, but no matter what I ask, I can’t get a good answer.
I’m going to throw up, she says.
I quickly grab an emesis basin, and while she belches, I take out the med kit and pull out an ampule of Phenergan. I draw up 12.5 mg and dilute it in 10 cc of NS. I tell her I am giving her something for her nausea as I push it slowly through the saline lock I put in her arm.
We are just a few minutes from the hospital now so I tell her I am going to call the hospital and tell them we are coming.
My patch starts out routine. “I’m four minutes out with an 84 year old female complaining of light-headedness, shakiness and seeing white spots...” But as I am talking she is changing in front of my eyes. She gets a crazy unfocused look. She seems like she is trying to come off the stretcher, but doesn’t seem to have control of her left side. She arches her back and is grasping at her chest with her right arm.
I don’t remember what I say on the rest of the patch, something about the patient is going nuts and I’m not certain what is going on.
When we get to triage the patient cannot follow commands, her left side is weak, she is moving strangely, almost spastically, and she is still nauseous. If I ask her a question, I get a nonsensical answer. She is completely altered. Her skin is also diaphoretic and she looks quite pale.
We get her into a room and the nurse gets a doctor and as I relate the history, he assesses her. He runs through the same diagnostic possibilities I had thought of – everything from throwing a clot to MI to AAA.
I did give her some Phenergan – 12.5 for her nausea, I say.
Phenergan? He says.
Yeah. Phenergan 12.5
Was she like this before you gave her the Phenergan?
No, she was a little crazy, something was going on, but she wasn't like this. She could talk to me at least.
It could be the Phenergan, he says – it’ll make them do this.
Really? I've seen it makes them very lethargic, and I know it can produce a produce a dystonic reaction, but nothing like this.
***
I see the nurse the next day. I ask her about the patient. The CAT scan was clean. As soon as the Phenergan wore off, she was alert and oriented with equal neuros. Still, they admitted her for observation. She did after all have that problem about being light-headed, feeling shaky and seeing white spots.
***
I check the drug appendix for Phenergan at the back of my protocol book.
Under side effects, it says: “May impair mental and physical ability.”
Under contraindications, it reads “Hx of prior idiosyncratic/hypersensitivity reactions to Phenergan.”
I hope they tell her to remind any future paramedics who offer her Phenergan that she now apparently is one of those people who have had an idiosyncratic/hypersensitivity reaction to Phenergan.
I talk to some other medical people who have witnessed the same phenomenon in patients, particularly elderly. Phenergan can make them go crazy, they say.
The link below on Phenergan side effects mentions "Hyperexcitability and abnormal movements."
***
Next time, I give Zofran.
(Or if I am out of Zofran, for the elderly at least start with 6.25 mg of Phenergan instead of the full 12.5 mg.)
“Well, if you are light-headed, feeling shaky and seeing white spots, you need to go to the hospital,” I say.
“Okay,” she says.
That was easy.
We get her in a Johnny top and on the stretcher. Out in the ambulance, I do a 12 lead and a full assessment. She has a sinus rhythm with occasional PACs and a right bundle branch block. No ST elevations. Her lungs are slightly decreased, but it could just be that my hearing is slightly decreased. Her skin is warm now, although she says she felt sweaty earlier. Her abdomen is soft, her grip strengths are equal.
Her blood pressure is 180/100. Her heart rate is in the 90’s. She is Satting at 95% so I put her on a cannula at 2 lpm.
I try to get a history, but she is 84, partially deaf and a poor historian.
On the way to the hospital, I notice that she seems uncomfortable.
I ask her is she is in pain and she says her back hurts. Is this new pain or old pain?
I have arthritis, she says.
So you have had this pain before?
What?
The pain.
She is holding her belly and looks like she is trying to sit up more, so I undo the belt and slide her up, but it doesn’t seem to help. She seems very anxious.
I am starting to get concerned, but no matter what I ask, I can’t get a good answer.
I’m going to throw up, she says.
I quickly grab an emesis basin, and while she belches, I take out the med kit and pull out an ampule of Phenergan. I draw up 12.5 mg and dilute it in 10 cc of NS. I tell her I am giving her something for her nausea as I push it slowly through the saline lock I put in her arm.
We are just a few minutes from the hospital now so I tell her I am going to call the hospital and tell them we are coming.
My patch starts out routine. “I’m four minutes out with an 84 year old female complaining of light-headedness, shakiness and seeing white spots...” But as I am talking she is changing in front of my eyes. She gets a crazy unfocused look. She seems like she is trying to come off the stretcher, but doesn’t seem to have control of her left side. She arches her back and is grasping at her chest with her right arm.
I don’t remember what I say on the rest of the patch, something about the patient is going nuts and I’m not certain what is going on.
When we get to triage the patient cannot follow commands, her left side is weak, she is moving strangely, almost spastically, and she is still nauseous. If I ask her a question, I get a nonsensical answer. She is completely altered. Her skin is also diaphoretic and she looks quite pale.
We get her into a room and the nurse gets a doctor and as I relate the history, he assesses her. He runs through the same diagnostic possibilities I had thought of – everything from throwing a clot to MI to AAA.
I did give her some Phenergan – 12.5 for her nausea, I say.
Phenergan? He says.
Yeah. Phenergan 12.5
Was she like this before you gave her the Phenergan?
No, she was a little crazy, something was going on, but she wasn't like this. She could talk to me at least.
It could be the Phenergan, he says – it’ll make them do this.
Really? I've seen it makes them very lethargic, and I know it can produce a produce a dystonic reaction, but nothing like this.
***
I see the nurse the next day. I ask her about the patient. The CAT scan was clean. As soon as the Phenergan wore off, she was alert and oriented with equal neuros. Still, they admitted her for observation. She did after all have that problem about being light-headed, feeling shaky and seeing white spots.
***
I check the drug appendix for Phenergan at the back of my protocol book.
Under side effects, it says: “May impair mental and physical ability.”
Under contraindications, it reads “Hx of prior idiosyncratic/hypersensitivity reactions to Phenergan.”
I hope they tell her to remind any future paramedics who offer her Phenergan that she now apparently is one of those people who have had an idiosyncratic/hypersensitivity reaction to Phenergan.
I talk to some other medical people who have witnessed the same phenomenon in patients, particularly elderly. Phenergan can make them go crazy, they say.
The link below on Phenergan side effects mentions "Hyperexcitability and abnormal movements."
***
Next time, I give Zofran.
(Or if I am out of Zofran, for the elderly at least start with 6.25 mg of Phenergan instead of the full 12.5 mg.)
Monday, September 10, 2007
Evaluations
Some towns' police departments call us to check out prisoners' medical complaints, typically those suffering from jailitis. The cops get annoyed when we bring the stretcher in. He's not going to the hospital, we just want you to check him out, they say.
If you want to make the cops happy, you finesse a refusal out of the prisoner. You say: "You look okay, sign here."
But that is sort of against official EMS policy. In this state, we are required to offer treatment and transport three times before getting a refusal.
The issue of evaluations is murky. We cannot tell anyone they can't go to the hospital if they think they are sick. You have a complaint, we transport. That's the nature of the job. That's how the system is set up.
So I ask the prisoner if he wants us to take him to the hospital and he says yes. When I tell this to the sergeant, he says, "Bull-!" He isn't going to the hospital!"
I want to say, "Then why did you call us?"
It seems they want us to evaluate the prisoners so they can write in their report the patient was medically cleared, but we can't clear people. It's not in our scope of practice.
This has now been communicated again to the towns and for a little while now, we have stopped getting prisoner evaluation calls. But we do get other requests for evaluations.
We get called to evaluate the 2 year old who was locked in the car for ten minutes. We get called to evaluate the man punched in the nose. We get called to look at the scratches a woman got on her arm during a fight with another woman.
Your kid looks fine.
You got punched in the nose.
Yes, you have scratches on your arm.
The refusal form says "I am refusing treatment and/or transport against the recommendation of..."
But the thing of it is as a man of I hope some common sense I really don't want to recommend to someone that they sit in a waiting room for five hours only to be told:
"Your kid looks fine -- I mean he was only in the car for ten minutes."
"Yes, you got punched in the nose. Medical science hasn't yet figured out how to unpunch someone. Suck it up."
"Yeah, those are scratches. Don't lick them."
Legally we have to recommend treatment and transport to everyone.
"While it appears you are fine and not hurt, legally I must recommend treatment and transport to you. It's just something I have to do. It is standard policy."
The other day we get called for a fall at a business. We find two women sitting on couches in the lobby. One tripped on the escalator, the other says she hurt her knee helping the other up. Two patients, one ambulance. I'm wondering if I need another ambulance. My first question is "What hospital do you want to go to?"
"I don't want to go to the hospital," says one.
"Me, neither," says the other.
Okay...
"I just want to be evaluated," says the one.
"Me too. I just want an evaluation," says the other.
What do I say:
1. "I have nothing available today, but I can try to fit you in at 10:30 tomorrow."
2. "I can take you to the hospital and they can evaluate you there. In fact, I recommend (times 3) that you be treated and/or transported. If you refuse my recommendation (times 3), sign right here at the 'X' times one."
3. "Evaluation! Get out of here! Just go on! Get! What are you doing? Calling an ambulance for an evaluation? Go on! Git!"
What did I do? I told them I could take them to the hospital where a doctor could evaluate them or they could go see their own doctor. They shrugged and got up and walked back to their offices.
Later the first responder told me the women had been joking while waiting for us (He had slowed us down to a non-priority response.) "Good thing we're not bleeding to death."
***
I guess I have no real problem with someone wanting to know my opinion. My problem is that I am not supposed to tell them what I really think. Or can I? I don't think you need to go to the hospital, but you might want to go see a doctor or someone with more specialized training. I'm just a paramedic, and while I think I am good at my job, legally I can't give you the medical opinion you seek. If you don't want to go to the hospital with us, we just ask that you call us if you change your mind or your condition changes.
That's what I say and it usually does the job.
I don't know why I get so worked up about it.
Nature of the business, I guess.
As far as the cops go, if they don't want the patient to go, I say, well, he may not be hurt or sick, and I'm not convinced he is, but if he wants to go and you don't want him to, then I'm going to need you to sign my run form, clearing me from liability.
If you want to make the cops happy, you finesse a refusal out of the prisoner. You say: "You look okay, sign here."
But that is sort of against official EMS policy. In this state, we are required to offer treatment and transport three times before getting a refusal.
The issue of evaluations is murky. We cannot tell anyone they can't go to the hospital if they think they are sick. You have a complaint, we transport. That's the nature of the job. That's how the system is set up.
So I ask the prisoner if he wants us to take him to the hospital and he says yes. When I tell this to the sergeant, he says, "Bull-!" He isn't going to the hospital!"
I want to say, "Then why did you call us?"
It seems they want us to evaluate the prisoners so they can write in their report the patient was medically cleared, but we can't clear people. It's not in our scope of practice.
This has now been communicated again to the towns and for a little while now, we have stopped getting prisoner evaluation calls. But we do get other requests for evaluations.
We get called to evaluate the 2 year old who was locked in the car for ten minutes. We get called to evaluate the man punched in the nose. We get called to look at the scratches a woman got on her arm during a fight with another woman.
Your kid looks fine.
You got punched in the nose.
Yes, you have scratches on your arm.
The refusal form says "I am refusing treatment and/or transport against the recommendation of..."
But the thing of it is as a man of I hope some common sense I really don't want to recommend to someone that they sit in a waiting room for five hours only to be told:
"Your kid looks fine -- I mean he was only in the car for ten minutes."
"Yes, you got punched in the nose. Medical science hasn't yet figured out how to unpunch someone. Suck it up."
"Yeah, those are scratches. Don't lick them."
Legally we have to recommend treatment and transport to everyone.
"While it appears you are fine and not hurt, legally I must recommend treatment and transport to you. It's just something I have to do. It is standard policy."
The other day we get called for a fall at a business. We find two women sitting on couches in the lobby. One tripped on the escalator, the other says she hurt her knee helping the other up. Two patients, one ambulance. I'm wondering if I need another ambulance. My first question is "What hospital do you want to go to?"
"I don't want to go to the hospital," says one.
"Me, neither," says the other.
Okay...
"I just want to be evaluated," says the one.
"Me too. I just want an evaluation," says the other.
What do I say:
1. "I have nothing available today, but I can try to fit you in at 10:30 tomorrow."
2. "I can take you to the hospital and they can evaluate you there. In fact, I recommend (times 3) that you be treated and/or transported. If you refuse my recommendation (times 3), sign right here at the 'X' times one."
3. "Evaluation! Get out of here! Just go on! Get! What are you doing? Calling an ambulance for an evaluation? Go on! Git!"
What did I do? I told them I could take them to the hospital where a doctor could evaluate them or they could go see their own doctor. They shrugged and got up and walked back to their offices.
Later the first responder told me the women had been joking while waiting for us (He had slowed us down to a non-priority response.) "Good thing we're not bleeding to death."
***
I guess I have no real problem with someone wanting to know my opinion. My problem is that I am not supposed to tell them what I really think. Or can I? I don't think you need to go to the hospital, but you might want to go see a doctor or someone with more specialized training. I'm just a paramedic, and while I think I am good at my job, legally I can't give you the medical opinion you seek. If you don't want to go to the hospital with us, we just ask that you call us if you change your mind or your condition changes.
That's what I say and it usually does the job.
I don't know why I get so worked up about it.
Nature of the business, I guess.
As far as the cops go, if they don't want the patient to go, I say, well, he may not be hurt or sick, and I'm not convinced he is, but if he wants to go and you don't want him to, then I'm going to need you to sign my run form, clearing me from liability.
Monday, September 03, 2007
Better Safe than Sorry
It was twenty minutes before my crew change when the tones went off. A fall at a local restaurant. I shook my head. I had dinner out plans for the evening that were going to get shot to hell now.
Outside the restaurant we found a polite well dressed man in his sixties sitting on a bench. He was alert, but his brow was slightly clammy. His wife said as they were leaving, he told her he suddenly felt weak, and then his eyes rolled back and he keeled over. Fortunately she was able to ease him down. He was unconcious for maybe thirty seconds, but he was looking much better now, she said.
I asked a few questions. He told me he had no chest pain, no trouble breathing. He said he felt fine and apologized for troubling us. He'd been overworked lately, and probably not eating or drinking enough.
His vitals sitting were normal. We had him stand and I did orthostatics. His heart rate went up ten beats, but his blood pressure stayed the same. He asked what I thought.
It might be nothing, I said. You could go home and take it easy and make certain you get plenty of fluids (And I could make it to Outback in time for a grilled sirlon and a cold Foster's before they close for the night), and then follow up with your doctor in the morning, but then I added, that's no guarantee that it won't happen again. As much of an inconvenience as it might be for you (And no steak for me), my recommendation is that we take you down to the ED. You always have to take it seriously when someone passes out. It might be nothing, but it could be something serious. Best to get it checked out now. You know, better safe than sorry.
Okay, whatever you think is best, he said. I'm agreeable.
We chatted on the way to the hospital. I explained his 12 lead ECG looked normal, his lungs were clear, his blood sugar and vital signs were good. I talked about what he could expect at the hospital -- blood tests, another ECG. He asked a few questions, occasionally using a medical term like syncope.
You obviously have some type of medical background, I said.
No, I'm in law, he said, I've just picked it up over the years.
He was a nice man, and I had an odd feeling that I knew him from somewhere, but couldn't place him.
At the hospital, he thanked me for our care and shook my hand.
Later that night sitting in front of the TV finally having my dinner (a sandwich and a can of beer) I did a double take. There on the 35" TV screen was my patient.
"Been a victim of medical malpractice?" he snarled. "Missed work or suffering needless pain? I'm attorney XXX. I'll fight for YOUR rights!"
Better Safe than Eating Out.
Outside the restaurant we found a polite well dressed man in his sixties sitting on a bench. He was alert, but his brow was slightly clammy. His wife said as they were leaving, he told her he suddenly felt weak, and then his eyes rolled back and he keeled over. Fortunately she was able to ease him down. He was unconcious for maybe thirty seconds, but he was looking much better now, she said.
I asked a few questions. He told me he had no chest pain, no trouble breathing. He said he felt fine and apologized for troubling us. He'd been overworked lately, and probably not eating or drinking enough.
His vitals sitting were normal. We had him stand and I did orthostatics. His heart rate went up ten beats, but his blood pressure stayed the same. He asked what I thought.
It might be nothing, I said. You could go home and take it easy and make certain you get plenty of fluids (And I could make it to Outback in time for a grilled sirlon and a cold Foster's before they close for the night), and then follow up with your doctor in the morning, but then I added, that's no guarantee that it won't happen again. As much of an inconvenience as it might be for you (And no steak for me), my recommendation is that we take you down to the ED. You always have to take it seriously when someone passes out. It might be nothing, but it could be something serious. Best to get it checked out now. You know, better safe than sorry.
Okay, whatever you think is best, he said. I'm agreeable.
We chatted on the way to the hospital. I explained his 12 lead ECG looked normal, his lungs were clear, his blood sugar and vital signs were good. I talked about what he could expect at the hospital -- blood tests, another ECG. He asked a few questions, occasionally using a medical term like syncope.
You obviously have some type of medical background, I said.
No, I'm in law, he said, I've just picked it up over the years.
He was a nice man, and I had an odd feeling that I knew him from somewhere, but couldn't place him.
At the hospital, he thanked me for our care and shook my hand.
Later that night sitting in front of the TV finally having my dinner (a sandwich and a can of beer) I did a double take. There on the 35" TV screen was my patient.
"Been a victim of medical malpractice?" he snarled. "Missed work or suffering needless pain? I'm attorney XXX. I'll fight for YOUR rights!"
Better Safe than Eating Out.
Friday, August 24, 2007
Tuesday, August 21, 2007
Reversals
The call is at a nursing home for groin pain. We find a seventy year old man holding his groin and writhing on the bed. He has dementia so it is hard to have any kind of conversation. The daughter looks familiar and she says I brought her father in to the hospital last week. I ask what for. She says for low blood pressure. It doesn’t ring a bell. “I do so many calls,” I say, “but you look familiar.”
The daughter says she thinks her father has a fever. His forehead feels warm and dry, but his core is definitely hot. The daughter says they took a catheter out a couple days ago. I ask what was the outcome of his hospital stay and she says they couldn’t figure it out – they think it may have been related to his constipation – straining to go to the bathroom had made him hypotensive.
We load him on the stretcher and I tell my partner – a new EMT -- to head for the hospital on a non-priority. On the way I have a hard time getting a blood pressure because the patient keeps tightening his arm. I finally hear it at about 70. I put him on the monitor. The rhythm catches my attention:
F-Me I think. He's in V-Tack.
Here I am bumping down the highway. I have a writhing feverish patient, no IV, haven’t done a 12 lead and he is in what looks like V-Tach. What an idiot I am going to look like at the hospital. But how can he be in VT?
The only thing going for me is that he doesn’t look like he is about to die. I did not expect to see a rhythm like this. I look at it closer. Odd looking. It looks on first impression like VT, but now that my heart has stilled, I look at it more critically, and I also quickly apply the 12-lead and hope that it will analyze on the move. It surprisingly does.
Suspect Arm reversal the ECG reads:
Opps.
I have the left and the right arms mixed up. That'll do it.
I switch the arm leads and it looks a little different. Much better.
I read his W10. He has a history of afib and hypotension. I remember him now. I got a manual blood pressure last week of 90/50, but when the hospital put him on their machine at triage it came out 60/40 and he was sent to a medical alert room, where I suddenly found myself having to give a report to a room full of doctors and nurses. "I got 90, your machine got 60. I did a manual…”
“Do a manual,” the doctor said to a nurse.
When I came back with the completed paperwork there was only a nurse in the room – all the doctors were back at their stations. People in afib shouldn’t have their BPs taken with automatic cuffs because missed beats will cause the pressure to read lower. Even when you take it manually, you have to lower the pressure very slowly.
I pop in an IV as we pull into the ER – not much a 22 in the hand, but it is all I can access because of his thrashing. I pretty much think I have it figured out now. He has a fever and an infection possibly from the catheter he had in, and that’s what’s causing the groin pain, with the fever also causing the rigors.
At the hospital, their machine shows a pressure of 110/62. In a reversal from last week, he goes to a regular room this time – even though I admit the only pressure I could hear was 70 -- not that it was right. The hospital machine is like an all-knowing Aztec god. We bow before it – always right, always accurate, always saving providers from having to get off their butts and take a manual pressure.
Turns out he has a fever of 103.5. That'll do it.
The daughter says she thinks her father has a fever. His forehead feels warm and dry, but his core is definitely hot. The daughter says they took a catheter out a couple days ago. I ask what was the outcome of his hospital stay and she says they couldn’t figure it out – they think it may have been related to his constipation – straining to go to the bathroom had made him hypotensive.
We load him on the stretcher and I tell my partner – a new EMT -- to head for the hospital on a non-priority. On the way I have a hard time getting a blood pressure because the patient keeps tightening his arm. I finally hear it at about 70. I put him on the monitor. The rhythm catches my attention:
F-Me I think. He's in V-Tack.
Here I am bumping down the highway. I have a writhing feverish patient, no IV, haven’t done a 12 lead and he is in what looks like V-Tach. What an idiot I am going to look like at the hospital. But how can he be in VT?
The only thing going for me is that he doesn’t look like he is about to die. I did not expect to see a rhythm like this. I look at it closer. Odd looking. It looks on first impression like VT, but now that my heart has stilled, I look at it more critically, and I also quickly apply the 12-lead and hope that it will analyze on the move. It surprisingly does.
Suspect Arm reversal the ECG reads:
Opps.
I have the left and the right arms mixed up. That'll do it.
I switch the arm leads and it looks a little different. Much better.
I read his W10. He has a history of afib and hypotension. I remember him now. I got a manual blood pressure last week of 90/50, but when the hospital put him on their machine at triage it came out 60/40 and he was sent to a medical alert room, where I suddenly found myself having to give a report to a room full of doctors and nurses. "I got 90, your machine got 60. I did a manual…”
“Do a manual,” the doctor said to a nurse.
When I came back with the completed paperwork there was only a nurse in the room – all the doctors were back at their stations. People in afib shouldn’t have their BPs taken with automatic cuffs because missed beats will cause the pressure to read lower. Even when you take it manually, you have to lower the pressure very slowly.
I pop in an IV as we pull into the ER – not much a 22 in the hand, but it is all I can access because of his thrashing. I pretty much think I have it figured out now. He has a fever and an infection possibly from the catheter he had in, and that’s what’s causing the groin pain, with the fever also causing the rigors.
At the hospital, their machine shows a pressure of 110/62. In a reversal from last week, he goes to a regular room this time – even though I admit the only pressure I could hear was 70 -- not that it was right. The hospital machine is like an all-knowing Aztec god. We bow before it – always right, always accurate, always saving providers from having to get off their butts and take a manual pressure.
Turns out he has a fever of 103.5. That'll do it.
Thursday, August 09, 2007
Home
We were there last night. The call came in five minutes before my crew change. Husband said wife was too weak to get up and he was too weak to pick her up. Sounded like a lift assist. Pick her up, put her in bed, get a signed refusal. I could still get home at a decent time, I thought. I could have some cold chicken and beer and sit on my old, but comfortable couch, put my feet up and get in a little of the Red Sox game before getting to bed before another day of work.
The address was up in the hills on the west side of town. As we drove up the long winding driveway, I recognized that we had been there before. The husband has cancer and is usually the weak one, the wife is feisty and devoted to him. But now it was the woman who was sick. I was used to seeing her all neatly made up and every hair in place, but she was sprawled half-naked on the bed, her grey hair long and tangled, her skin hot and bloated. A portable toilet sat just a few feet away from the bed.
"I can't get her up," the husband said. He wore a snow hat on his chemo bald head, and looked like he has lost considerable weight. "I'm too weak."
She'd been weak for several days, her husband told us, and had fallen twice. She winced when I touched her wrist, which was swollen and looked broken. I asked what hospital she wanted to go to.
"I don't want to go to the hospital. We've had such bad experiences there -- they make you wait all night."
"Seven hours we waited the last time," the husband said.
"I'm not going to lie to you, that's how it is," I said, "But her wrist looks broken and she has a fever."
"Can you just get me on the toilet and then I'll see how I feel in the morning? I'd really rather just be home."
"You're burning up. You need to go to the hospital."
"Just help me up. I'll see how I feel in the morning."
"We don't know what's causing your fever."
"But they are so horrible there...."
It took a half an hour to get her to agree to go and she would only go because we had the husband worried now about her fever. "But dear, you have a fever. I've never demanded anything of you before, but please for me, you must go, I'll be with you the whole time."
She finally relented.
I wrapped up her wrist, and asked her about her pain. It was an 8 on the 0-10 scale. I gave her some morphine and she was much less uncomfortable.
We brought her into the hospital on the monitor with an IV hanging, and she got assigned a room, where a nurse came down right away. I told the nurse she needed to keep an eye on the husband too, as he was very weak and prone to shortness of breath.
The couple thanked us, and they seemed happy that she was being cared for right away, even if that care was just the nurse saying hello and taking her vital signs.
***
The next morning, the first call was to the same address for a lift assist. We shook our heads, but at least we'd get to hear how they'd made out at the hospital. We arrived to find wife on the floor in the foyer between the garage and kitchen, the husband sitting on the steps, still wearing his snow cap, holding his side.
"What a shape we're in," she said. "I was too weak to make it up the stairs."
"I tried to catch her, but I was too weak and we both went over."
She said she wasn't hurt, but had no strength to get up. Her right arm was in a cast -- her wrist had been broken.
"They think she might have a little pneumonia," the husband said. "They wanted her to stay a few days, but she wanted to get home so they discharged her."
"I just wanted to make it home so I could rest," she said.
We got her in a stair chair and carried her the rest of the way into the house, and down to the bedroom, where we got her situated. We got some chucks out of the ambulance and laid them on the bed to keep the sheets from being soiled in the event of an accident. We checked out the man's back, but he said he was okay. They thanked us and we told them to call if they needed us again.
***
Now it's evening and we're headed back to the same address for the fall.
The address was up in the hills on the west side of town. As we drove up the long winding driveway, I recognized that we had been there before. The husband has cancer and is usually the weak one, the wife is feisty and devoted to him. But now it was the woman who was sick. I was used to seeing her all neatly made up and every hair in place, but she was sprawled half-naked on the bed, her grey hair long and tangled, her skin hot and bloated. A portable toilet sat just a few feet away from the bed.
"I can't get her up," the husband said. He wore a snow hat on his chemo bald head, and looked like he has lost considerable weight. "I'm too weak."
She'd been weak for several days, her husband told us, and had fallen twice. She winced when I touched her wrist, which was swollen and looked broken. I asked what hospital she wanted to go to.
"I don't want to go to the hospital. We've had such bad experiences there -- they make you wait all night."
"Seven hours we waited the last time," the husband said.
"I'm not going to lie to you, that's how it is," I said, "But her wrist looks broken and she has a fever."
"Can you just get me on the toilet and then I'll see how I feel in the morning? I'd really rather just be home."
"You're burning up. You need to go to the hospital."
"Just help me up. I'll see how I feel in the morning."
"We don't know what's causing your fever."
"But they are so horrible there...."
It took a half an hour to get her to agree to go and she would only go because we had the husband worried now about her fever. "But dear, you have a fever. I've never demanded anything of you before, but please for me, you must go, I'll be with you the whole time."
She finally relented.
I wrapped up her wrist, and asked her about her pain. It was an 8 on the 0-10 scale. I gave her some morphine and she was much less uncomfortable.
We brought her into the hospital on the monitor with an IV hanging, and she got assigned a room, where a nurse came down right away. I told the nurse she needed to keep an eye on the husband too, as he was very weak and prone to shortness of breath.
The couple thanked us, and they seemed happy that she was being cared for right away, even if that care was just the nurse saying hello and taking her vital signs.
***
The next morning, the first call was to the same address for a lift assist. We shook our heads, but at least we'd get to hear how they'd made out at the hospital. We arrived to find wife on the floor in the foyer between the garage and kitchen, the husband sitting on the steps, still wearing his snow cap, holding his side.
"What a shape we're in," she said. "I was too weak to make it up the stairs."
"I tried to catch her, but I was too weak and we both went over."
She said she wasn't hurt, but had no strength to get up. Her right arm was in a cast -- her wrist had been broken.
"They think she might have a little pneumonia," the husband said. "They wanted her to stay a few days, but she wanted to get home so they discharged her."
"I just wanted to make it home so I could rest," she said.
We got her in a stair chair and carried her the rest of the way into the house, and down to the bedroom, where we got her situated. We got some chucks out of the ambulance and laid them on the bed to keep the sheets from being soiled in the event of an accident. We checked out the man's back, but he said he was okay. They thanked us and we told them to call if they needed us again.
***
Now it's evening and we're headed back to the same address for the fall.
Tuesday, July 31, 2007
Shock
The call is for difficulty breathing at a nursing home. A nurse meets us at the curb – a bad sign. “You have to get him out of here quick!” she says. “We can’t get his SATs above 60.”
Another nurse meets us at the door. “This way,” she says and starts walking speedily ahead of us.
In the room three other nurses are gathered around the bed and a crash cart. “We have him on a non-rebreather at 15 lpm,” the nurse administrator tells me, as another nurse says, “I can’t get a blood pressure.”
The ashen eighty-year old man’s eyes are open, but he doesn’t seem to be seeing. He is breathing, but it is borderline agonal. His arms are cold.
“What’s his code status?” I ask.
“Full,” the nurse says.
“Let’s just get him on the stretcher,” I say to my partner. “And out of here.” If he is going to code, I want him on my stretcher and in the ambulance.
He is light and we lift him easily on the sheets. It is then I notice an orange DNR bracelet on his right wrist. I look for the nurses, but they have all fled the room. We wheel the patient out into the hall, and down toward the nurse’s station where the nurses are now busily trying to get the paperwork ready. A nurse approaches us and says, “He was a DNR, but the family is changing its mind.”
There are two women standing in the hallway and ask if they are family. They identify themselves as daughter and granddaughter.
“Do you want us to resuscitate him if he stops breathing?” I ask.
“No, we want him to go to the hospital and for them to do everything they can, but don’t make him suffer.”
“No tubes down the throat to help him breathe?”
“No, just make him comfortable. Save his life if you can.”
“Do you want us to do chest compressions?”
“No.”
At the desk a large beefy woman, who I learn is another granddaughter, is talking with a nurse who has an advanced directives sheet on the countertop and going over it line by line. “Do you want hydration?” the nurse asks.
“Yeah, hydration, that would all right,” the woman says.
“How about artificial nutrition?”
“Now, what would that be?”
“It’s like minerals and nutrients.”
“Yeah, okay, anything to make him healthy.”
“I’m going to need the W-10,” I say to the nurse.
“We’ll bring it out to you. I’m sorry, we’re just finishing the paperwork,” another nurse says.
“We’ll be out in the ambulance,” I say.
In the back of the ambulance, I switch the O2 to the main. I glance at the monitor. Not looking good. A widening bradycardia. I can’t get a manual pressure, the machine pressure reads 84/60 – higher than I would have thought. I put on an ETCO2 cannula and it reads 8. The apnea alarm goes off and I try to reposition the cannula, but get no improvement. The patient is still breathing, but I don’t know if there is much gas exchange air coming out. The bradycardia continues to slow and widen.
The nurse comes out with the paperwork. She opens the side door and hands it to me. I ask her to wait while I quickly look through it, reconfirming that the patient is a do not intubate, do not resuscitate.
The man’s daughter is sitting in front. I tell my partner to drive, but no lights and sirens.
The daughter looks toward the back and says, “How he’s doing?”
The apnea alarm goes off again and the bradycardia is down to 30. I am trying to get a line, but the patient’s arm is bloodless.
“He’s passing right now,” I say. “If you want to come back for a moment and say goodbye. Now’s the time.”
“He’s dying? He’s dying! Stop! Stop the ambulance and let me out!” she screams. “I can’t handle this! Let me out of here!” We have barely stopped rolling when she jumps from the front seat and I see her running across the nursing home grass, screaming, “Granpa dead! Granpa dead!”
I look out the back window and see other family members, and they all seem to be suddenly screaming or crying in contagion. The large granddaughter approaches and knocks hard on the back door, which I open for her.
The lines on the monitor are beginning to roll.
“He’s passing now, if you want to say goodbye,” I say. “Now’s the time. Maybe he can hear you on his way out. You can tell him you love him and wish him well.” I always like to give family members a chance to say goodbye, for them to believe their last words are heard, which maybe they are.
She muscles past me and grabs the old man by the neck and starts shaking him. “You promised! Don’t you die! Don’t you die on me! You promised.”
The man’s head flops back and forth.
“Easy, say goodbye, it’s his time. Tell him you love him,” I say.
“No it isn’t! You ain’t dying! You promised. Don’t you die and leave us! That ain’t fair! That ain’t right. You ain’t a quitter, don’t quit now!”
I battle against her girth to get her to ease her grip. “Easy, easy,” I say, struggling to get position on her, and get the man's head back down on the pillow.
“It’s his wishes,” I say.
“I love you, Granpa,” she says. “Don’t you die on me. Don’t you die!”
“Granpa dead! Granpa dead!” I hear from outside. The daughter is still running around on the grass.
“Just get him to the hospital, get him to the hospital now!” the granddaughter says.
“Okay, we’ll see you there,” I say, helping ease her away and out the back door.
“Don’t you quit!” she calls in as she steps out.
I close the back door.
The monitor shows three straight lines.
We’re driving out of the nursing home parking lot now.
The family is scattered on the lawn and sidewalk, still seeming in a state of shock.
The old man’s mouth and eyes are open. His pupils are already fixed and dilated. I place a finger tip on each eye lid and close them.
Another nurse meets us at the door. “This way,” she says and starts walking speedily ahead of us.
In the room three other nurses are gathered around the bed and a crash cart. “We have him on a non-rebreather at 15 lpm,” the nurse administrator tells me, as another nurse says, “I can’t get a blood pressure.”
The ashen eighty-year old man’s eyes are open, but he doesn’t seem to be seeing. He is breathing, but it is borderline agonal. His arms are cold.
“What’s his code status?” I ask.
“Full,” the nurse says.
“Let’s just get him on the stretcher,” I say to my partner. “And out of here.” If he is going to code, I want him on my stretcher and in the ambulance.
He is light and we lift him easily on the sheets. It is then I notice an orange DNR bracelet on his right wrist. I look for the nurses, but they have all fled the room. We wheel the patient out into the hall, and down toward the nurse’s station where the nurses are now busily trying to get the paperwork ready. A nurse approaches us and says, “He was a DNR, but the family is changing its mind.”
There are two women standing in the hallway and ask if they are family. They identify themselves as daughter and granddaughter.
“Do you want us to resuscitate him if he stops breathing?” I ask.
“No, we want him to go to the hospital and for them to do everything they can, but don’t make him suffer.”
“No tubes down the throat to help him breathe?”
“No, just make him comfortable. Save his life if you can.”
“Do you want us to do chest compressions?”
“No.”
At the desk a large beefy woman, who I learn is another granddaughter, is talking with a nurse who has an advanced directives sheet on the countertop and going over it line by line. “Do you want hydration?” the nurse asks.
“Yeah, hydration, that would all right,” the woman says.
“How about artificial nutrition?”
“Now, what would that be?”
“It’s like minerals and nutrients.”
“Yeah, okay, anything to make him healthy.”
“I’m going to need the W-10,” I say to the nurse.
“We’ll bring it out to you. I’m sorry, we’re just finishing the paperwork,” another nurse says.
“We’ll be out in the ambulance,” I say.
In the back of the ambulance, I switch the O2 to the main. I glance at the monitor. Not looking good. A widening bradycardia. I can’t get a manual pressure, the machine pressure reads 84/60 – higher than I would have thought. I put on an ETCO2 cannula and it reads 8. The apnea alarm goes off and I try to reposition the cannula, but get no improvement. The patient is still breathing, but I don’t know if there is much gas exchange air coming out. The bradycardia continues to slow and widen.
The nurse comes out with the paperwork. She opens the side door and hands it to me. I ask her to wait while I quickly look through it, reconfirming that the patient is a do not intubate, do not resuscitate.
The man’s daughter is sitting in front. I tell my partner to drive, but no lights and sirens.
The daughter looks toward the back and says, “How he’s doing?”
The apnea alarm goes off again and the bradycardia is down to 30. I am trying to get a line, but the patient’s arm is bloodless.
“He’s passing right now,” I say. “If you want to come back for a moment and say goodbye. Now’s the time.”
“He’s dying? He’s dying! Stop! Stop the ambulance and let me out!” she screams. “I can’t handle this! Let me out of here!” We have barely stopped rolling when she jumps from the front seat and I see her running across the nursing home grass, screaming, “Granpa dead! Granpa dead!”
I look out the back window and see other family members, and they all seem to be suddenly screaming or crying in contagion. The large granddaughter approaches and knocks hard on the back door, which I open for her.
The lines on the monitor are beginning to roll.
“He’s passing now, if you want to say goodbye,” I say. “Now’s the time. Maybe he can hear you on his way out. You can tell him you love him and wish him well.” I always like to give family members a chance to say goodbye, for them to believe their last words are heard, which maybe they are.
She muscles past me and grabs the old man by the neck and starts shaking him. “You promised! Don’t you die! Don’t you die on me! You promised.”
The man’s head flops back and forth.
“Easy, say goodbye, it’s his time. Tell him you love him,” I say.
“No it isn’t! You ain’t dying! You promised. Don’t you die and leave us! That ain’t fair! That ain’t right. You ain’t a quitter, don’t quit now!”
I battle against her girth to get her to ease her grip. “Easy, easy,” I say, struggling to get position on her, and get the man's head back down on the pillow.
“It’s his wishes,” I say.
“I love you, Granpa,” she says. “Don’t you die on me. Don’t you die!”
“Granpa dead! Granpa dead!” I hear from outside. The daughter is still running around on the grass.
“Just get him to the hospital, get him to the hospital now!” the granddaughter says.
“Okay, we’ll see you there,” I say, helping ease her away and out the back door.
“Don’t you quit!” she calls in as she steps out.
I close the back door.
The monitor shows three straight lines.
We’re driving out of the nursing home parking lot now.
The family is scattered on the lawn and sidewalk, still seeming in a state of shock.
The old man’s mouth and eyes are open. His pupils are already fixed and dilated. I place a finger tip on each eye lid and close them.
Sunday, July 29, 2007
A Day in the City
I took a city shift yesterday. I try to work at least two city shifts a week, but the last couple weeks I’ve been busy with my triathlon training, plus it’s been harder to pick up overtime shifts lately. I get my 40 hours in the suburbs, but city overtime time is scarce. It’s a cyclical thing. They hire new classes, college students are home trying to make some money, the schedule fills up. But then people don’t work out or they leave and the schedule has openings again.
Even being away just a couple weeks seems like a long time. There are many new faces and sometimes old ones – we have a new supervisor who used to work for us years ago, left to work for other companies and has returned, which is good because he’s a good guy.
We chat a little, getting caught up while I sit down and look through the schedule book for open shifts for the next two weeks, but there are no openings. I pick up my paycheck and find I am short 16 hours. I must have missed a punch out on my long day. I make a note to call payroll on Monday.
I check out my gear and then the ambulance which is one of the new ones. Over the years it seems the ambulances are getting smaller and smaller in the front and I have to sit with knees bend and angled against the dash. In the back the narc lock box is in a cabinet above the monitor shelf by the side door. It requires two odd shaped keys to open, and is impossible to open from standing outside the open side doors. I have to stand up in the back of the ambulance and fiddle in poor light with the keys to get it to open. Now I always open it at the beginning of the shift, take out one set of narcs – a sealed kit containing two 10 mg syringes of morphine, two 5 mg vials of Versed and two 2 mg of Ativan – a put the kit in my left side pants pocket – I wear those pants that have the big pockets sewn on the side of the legs. This way I don’t have to bother with the lock if I need them.
My partner and I start out for a post in the city, but we haven’t gone two miles before the windshield wipers stop working and the dashboard starts shaking with a loud humming sound. We return to base and the supervisor puts us in another ambulance. I replace the narcs from the one ambulance and then get a set out from the next one. Like the other ambulance, it is new one, so no relief for my knees. At least I am able to use the same medic gear so I don’t have to check out a new pack and monitor.
Our first call is a priority one to a suburban town to stage for a domestic disturbance. I question the dispatcher whether we heard priority one right. He acknowledges, saying the town wants us on a one. Unless they know something they are not telling us sending us on a one really torques me. It is pouring rain now and "the town" wants us lights and sirens and they aren’t even ready for us to take care of anyone. Maybe they heard shots fired or know someone is badly hurt, but if that is the case, they ought to relay that.
I have just put a new battery into my pager so now I am hearing this aggravating high pitched beep, coming out of my pocket, as the call page finally comes over. I fumble for the pager, and then try to remember how to set the silent vibrate alarm on the pager. I keep hitting the wrong buttons and it is getting very frustrating as it beeps again. I finally fix it, and as I start to look up, I feel a sudden sway and slip in the ambulance, hear my partner cuss, and see an oncoming car veer out of our traffic lane, cutting back around a car pulled to the side of the road. It is over before I can even appreciate the danger we have just survived. My partner is trembling.
“He almost hit us. Did you see that?”
“Good job,” I say, meaning it. “I’m glad I was looking down when he made his move. I didn't need to see that.”
I have a feeling then that I have had a few times before in my life. Boy, am I glad she swerved and we didn’t hydroplane and that I am not in a smashed rolled over ambulance with both my patellas and femor fractured against the dash, and my head brain-injured. I must immediately start loving life more and not complaining about the small stuff. I am alive! ALIVE!
Just then I feel my pager vibrate and I look down to read the messaged. “**elled by police.”
“I think we just got cancelled,” I say. “It’s garbled, but I think it means we're cancelled.”
We call dispatch and they confirm. “919, you’re cancelled by PD.”
“I guess there wasn’t anything to the call.”
“And we were just talking about how we shouldn’t be going on a priority to a standby.”
We turn around and head back to the city. A moment later we are sent for an unresponsive child, but are soon cancelled as another car says they are closer. Two other cars are sent to a cardiac arrest. The arrest turns out to be a presumption and the unresponsive child is a refusal.
We post in our location when another car clears and asks for a different post than the one they are given, so the dispatcher moves them to our area and we are sent where they didn’t want to go. I’m tired of driving and wish just to be stopped so I can open the door and stick my legs out and read my magazine. The other car (Ha!) gets sent to a wreck on the highway, and once we get to the area we are posted to, we finally get to stop and I get to stretch and read my magazine and all is good.
While we are sitting there a car pulls up and a man gets out and walks over to me. He is a Hispanic man in his middle twenties. He shows me his arm and points to the bicep. “Is this infected? It’s a bite – a human bite.” Sure enough there is nice round set of upper and lower teeth marks deep in the arm. No feeble bite. The skin is bruised and red and yellow.
“Have you had a tetanus shot?” I ask.
“No.”
“You need to go to the hospital or a walk-in clinic and get a tetanus shot and probably antibiotics. Human bites are worse than dog bites. That one is infected.”
He nods grimly and gets back in his car and drives off.
My partner tells me I should have charged him.
I shrug.
We get sent for an assault, which is nothing more than a police officer who wants us to clean up the face of a man who was punched in the face and is now in custody along with his assailant. He wasn’t knocked out, has no neck or back pain, just a mashed bloody nose. I ask him if he wants to go to the hospital. He says no and then spits on the pavement. I offer him transport X 3 as if required and he says he doesn’t want to go. I wipe the blood off his nose and then ask the cop to sign as a witness to the refusal. The request seems to make him uncomfortable. Instead he offers to uncuff the man so the man can sign, which he does. I then ask the cop to sign as witness to the prisoner’s refusal. He looks at me like I have just faked him out in some way, but signs anyway, and asks “Is this a new policy or something?”
I shake my head. “It’s how we’re supposed to do it.”
The next call is for a fractured foot. It is in an expensive high-rise near one of the hospitals. We find an elderly couple. The man with a cast on his foot and wearing a plush bathrobe is walking rather freely about with his walker. His wife is fretting with her pocketbook. Niether seem to be in any hurry to tell us why we are there. The man wants to put his hearing aids in first. It takes a long to time to sort everything out. The man it seems broke his foot six weeks ago and has been slow to heal and has had several different casts on. He was in pain earlier, but he took one of his pills and feels better now. But is worried about when the pill stops working. The wife shows us some other pills he was given on another occasion for stomach pain. She says she gave him one yesterday when his first pill wore off and the stomach pain pill made him feel better. The pill for his foot is Vicodin. The stomach pain med is darvocet. I ask if they have talked to their doctor for his advice, but they say it is the weekend and his office is closed. I look at the meds and read the label. It says he can take one Vicodin four times a day as needed. Really, I can take more than one a day? he says, I didn’t know that. But it makes him constipated, the wife say. Yes, yes, I get quite constipated, he says.
It’s your choice. Constipation or pain?
We are there a long time. We are told to transport anyone who wants to go to the hospital, and we make clear that we are more than willing to take him, but…
He already knows his foot is broken, he is under a doctor’s care, he is not in pain right now, and he has more pain medicine that he can take if the pain comes back. There are four pills left in the bottle.
I explain that they should perhaps call his doctor’s office and that the answering service will put the on-call doctor in touch with them and they can discuss it with him. He may want him to go to the hospital. He may just tell him to take his medicine as prescribed and then go see his regular doctor on Monday at his office. This all takes a very long time to explain. He gets constipated sometimes, the wife says when I am done explaining the options.
I end up end up calling his doctor’s office for them – the answering service says the on-call doctor will call back within fifteen minutes. I look at the old couple and after all the time it took us to get the story out of them, I think I should probably stay and wait to explain it to the doctor. So we wait. He calls back and I explain the situation. He agrees that an ER trip is not necessary and promises to call in another pain script to the pharmacy so the man will have enough to make it until Monday. He says he should take only the Vicodin and not any of the Darvocet.
Everyone seems happy with the solution, and we get a signed refusal and a promise to call us if the pain comes back and the medicine doesn’t help.
We are there almost an hour.
We then go from their beautiful apartment to a dirty apartment in a beaten down building where we find a middle-aged man with swollen legs sitting in his own shit on a bare mattress. His cousin tells us he’s been like this for two weeks. I ask him what kind of medical history he has, but I just get a shrug. I ask the patient and he doesn’t answer. The only meds I can find are lasix and spiraldactone.
We clean him up and get him in a wheel chair we find in the living room and wheel him out to the hall and into the tiny elevator and then down to the first floor where we get him on our stretcher. His vitals and room air SAT are good, but he has severe ascites, says he hurts all over, and just looks sick. His arms are tattooed and lined with track marks. I am lucky to get a 20 into his wrist. His sugar is good. I try to get some demographics from him, but his answers are nonsensical. I have this happen periodically. You get a patient, they tell you their name, they answer your basic questions and you think well, they can give me all their demographics in the ambulance and then when you have them out there, you realize they are not right in their mind. I can’t even get his date of birth or social out of him. He is just babbling a seemingly random number. He denies taking any drugs, not that I find his answer reliable. We go to the hospital in nonemergency mode. En route he begins to complain of severe pain, but first it is in his legs, then his side, then he says, in his butt. While he remains alert with warm, dry skin, I am finding it very difficult to have any kind of conversation with him. At the hospital, I tell the nurse, I have no idea what is up with the guy.
Just as I am finishing my paperwork, we get called out to intercept with a basic crew on a diabetic. Man from a nursing home found unresponsive with a sugar of 40, got some glucagon from the home and is now responsive, but groggy. I check his sugar – its 200. The man can answer my questions, but he is still clammy, and his lungs are very rhocorous. The W10 says he has had pneumonia and just finished a course of Zithromax. His vitals are stable and with 02 by canuala, his Sat is 96. He has Alzheimers, a CHF history in addition to the pneumonia and is an insulin-dependent diabetic. I don’t do much more than put in an IV and pop him on the monitor. While his lungs are nasty sounding, he seems to be breathing okay, even laying supine. I’m pretty certain it is pneumonia. Being sick and not eating probably knocked his sugar down.
At the hospital, we put the patient in the room next to our last patient. I ask the nurse if they have figured out what is wrong with him yet and she says he has septic emboli throughout his body. Septic emboli is a term I haven't heard before. Septic emboli are emboli made up of pus and bacteria that travel through the bloodstream from one site in the body to others, spreading the infection, often ending up lodged in the lungs, heart and brain, which explains his mental status. It turns out he also has an extensive history of the usual chronic diseases that plague IV drug abusers. He may not be dying right now, but he is a very sick man in the latter stages of his diseases.
After we clear the hospital, we are posted on another corner when a pretty young woman – maybe 18 -- comes up to my side window and shows me her hand and points to a vein, which is bruised and reddened. “I just shot up and it really hurts,” she says. “Is there anything I can do for it?”
“You’re damaging the tissue,” I said. “Ice will make it feel better, but you are definitely going to have to stop using that vein. It’s only going to get worse. Go see a doctor.”
She nods and thanks me without much enthusiasm, and then walks back across the street and stands next to a man drinking a liter bottle of orange soda. Together they watch traffic.
“Does this happen to you all the time?” my partner asks. “You should open a clinic.”
“I tell them to go to the hospital," I say.
They send us in on the early side, and after gassing, washing and resupplying the rig, and finishing up our paperwork, I punch out for the night.
Even being away just a couple weeks seems like a long time. There are many new faces and sometimes old ones – we have a new supervisor who used to work for us years ago, left to work for other companies and has returned, which is good because he’s a good guy.
We chat a little, getting caught up while I sit down and look through the schedule book for open shifts for the next two weeks, but there are no openings. I pick up my paycheck and find I am short 16 hours. I must have missed a punch out on my long day. I make a note to call payroll on Monday.
I check out my gear and then the ambulance which is one of the new ones. Over the years it seems the ambulances are getting smaller and smaller in the front and I have to sit with knees bend and angled against the dash. In the back the narc lock box is in a cabinet above the monitor shelf by the side door. It requires two odd shaped keys to open, and is impossible to open from standing outside the open side doors. I have to stand up in the back of the ambulance and fiddle in poor light with the keys to get it to open. Now I always open it at the beginning of the shift, take out one set of narcs – a sealed kit containing two 10 mg syringes of morphine, two 5 mg vials of Versed and two 2 mg of Ativan – a put the kit in my left side pants pocket – I wear those pants that have the big pockets sewn on the side of the legs. This way I don’t have to bother with the lock if I need them.
My partner and I start out for a post in the city, but we haven’t gone two miles before the windshield wipers stop working and the dashboard starts shaking with a loud humming sound. We return to base and the supervisor puts us in another ambulance. I replace the narcs from the one ambulance and then get a set out from the next one. Like the other ambulance, it is new one, so no relief for my knees. At least I am able to use the same medic gear so I don’t have to check out a new pack and monitor.
Our first call is a priority one to a suburban town to stage for a domestic disturbance. I question the dispatcher whether we heard priority one right. He acknowledges, saying the town wants us on a one. Unless they know something they are not telling us sending us on a one really torques me. It is pouring rain now and "the town" wants us lights and sirens and they aren’t even ready for us to take care of anyone. Maybe they heard shots fired or know someone is badly hurt, but if that is the case, they ought to relay that.
I have just put a new battery into my pager so now I am hearing this aggravating high pitched beep, coming out of my pocket, as the call page finally comes over. I fumble for the pager, and then try to remember how to set the silent vibrate alarm on the pager. I keep hitting the wrong buttons and it is getting very frustrating as it beeps again. I finally fix it, and as I start to look up, I feel a sudden sway and slip in the ambulance, hear my partner cuss, and see an oncoming car veer out of our traffic lane, cutting back around a car pulled to the side of the road. It is over before I can even appreciate the danger we have just survived. My partner is trembling.
“He almost hit us. Did you see that?”
“Good job,” I say, meaning it. “I’m glad I was looking down when he made his move. I didn't need to see that.”
I have a feeling then that I have had a few times before in my life. Boy, am I glad she swerved and we didn’t hydroplane and that I am not in a smashed rolled over ambulance with both my patellas and femor fractured against the dash, and my head brain-injured. I must immediately start loving life more and not complaining about the small stuff. I am alive! ALIVE!
Just then I feel my pager vibrate and I look down to read the messaged. “**elled by police.”
“I think we just got cancelled,” I say. “It’s garbled, but I think it means we're cancelled.”
We call dispatch and they confirm. “919, you’re cancelled by PD.”
“I guess there wasn’t anything to the call.”
“And we were just talking about how we shouldn’t be going on a priority to a standby.”
We turn around and head back to the city. A moment later we are sent for an unresponsive child, but are soon cancelled as another car says they are closer. Two other cars are sent to a cardiac arrest. The arrest turns out to be a presumption and the unresponsive child is a refusal.
We post in our location when another car clears and asks for a different post than the one they are given, so the dispatcher moves them to our area and we are sent where they didn’t want to go. I’m tired of driving and wish just to be stopped so I can open the door and stick my legs out and read my magazine. The other car (Ha!) gets sent to a wreck on the highway, and once we get to the area we are posted to, we finally get to stop and I get to stretch and read my magazine and all is good.
While we are sitting there a car pulls up and a man gets out and walks over to me. He is a Hispanic man in his middle twenties. He shows me his arm and points to the bicep. “Is this infected? It’s a bite – a human bite.” Sure enough there is nice round set of upper and lower teeth marks deep in the arm. No feeble bite. The skin is bruised and red and yellow.
“Have you had a tetanus shot?” I ask.
“No.”
“You need to go to the hospital or a walk-in clinic and get a tetanus shot and probably antibiotics. Human bites are worse than dog bites. That one is infected.”
He nods grimly and gets back in his car and drives off.
My partner tells me I should have charged him.
I shrug.
We get sent for an assault, which is nothing more than a police officer who wants us to clean up the face of a man who was punched in the face and is now in custody along with his assailant. He wasn’t knocked out, has no neck or back pain, just a mashed bloody nose. I ask him if he wants to go to the hospital. He says no and then spits on the pavement. I offer him transport X 3 as if required and he says he doesn’t want to go. I wipe the blood off his nose and then ask the cop to sign as a witness to the refusal. The request seems to make him uncomfortable. Instead he offers to uncuff the man so the man can sign, which he does. I then ask the cop to sign as witness to the prisoner’s refusal. He looks at me like I have just faked him out in some way, but signs anyway, and asks “Is this a new policy or something?”
I shake my head. “It’s how we’re supposed to do it.”
The next call is for a fractured foot. It is in an expensive high-rise near one of the hospitals. We find an elderly couple. The man with a cast on his foot and wearing a plush bathrobe is walking rather freely about with his walker. His wife is fretting with her pocketbook. Niether seem to be in any hurry to tell us why we are there. The man wants to put his hearing aids in first. It takes a long to time to sort everything out. The man it seems broke his foot six weeks ago and has been slow to heal and has had several different casts on. He was in pain earlier, but he took one of his pills and feels better now. But is worried about when the pill stops working. The wife shows us some other pills he was given on another occasion for stomach pain. She says she gave him one yesterday when his first pill wore off and the stomach pain pill made him feel better. The pill for his foot is Vicodin. The stomach pain med is darvocet. I ask if they have talked to their doctor for his advice, but they say it is the weekend and his office is closed. I look at the meds and read the label. It says he can take one Vicodin four times a day as needed. Really, I can take more than one a day? he says, I didn’t know that. But it makes him constipated, the wife say. Yes, yes, I get quite constipated, he says.
It’s your choice. Constipation or pain?
We are there a long time. We are told to transport anyone who wants to go to the hospital, and we make clear that we are more than willing to take him, but…
He already knows his foot is broken, he is under a doctor’s care, he is not in pain right now, and he has more pain medicine that he can take if the pain comes back. There are four pills left in the bottle.
I explain that they should perhaps call his doctor’s office and that the answering service will put the on-call doctor in touch with them and they can discuss it with him. He may want him to go to the hospital. He may just tell him to take his medicine as prescribed and then go see his regular doctor on Monday at his office. This all takes a very long time to explain. He gets constipated sometimes, the wife says when I am done explaining the options.
I end up end up calling his doctor’s office for them – the answering service says the on-call doctor will call back within fifteen minutes. I look at the old couple and after all the time it took us to get the story out of them, I think I should probably stay and wait to explain it to the doctor. So we wait. He calls back and I explain the situation. He agrees that an ER trip is not necessary and promises to call in another pain script to the pharmacy so the man will have enough to make it until Monday. He says he should take only the Vicodin and not any of the Darvocet.
Everyone seems happy with the solution, and we get a signed refusal and a promise to call us if the pain comes back and the medicine doesn’t help.
We are there almost an hour.
We then go from their beautiful apartment to a dirty apartment in a beaten down building where we find a middle-aged man with swollen legs sitting in his own shit on a bare mattress. His cousin tells us he’s been like this for two weeks. I ask him what kind of medical history he has, but I just get a shrug. I ask the patient and he doesn’t answer. The only meds I can find are lasix and spiraldactone.
We clean him up and get him in a wheel chair we find in the living room and wheel him out to the hall and into the tiny elevator and then down to the first floor where we get him on our stretcher. His vitals and room air SAT are good, but he has severe ascites, says he hurts all over, and just looks sick. His arms are tattooed and lined with track marks. I am lucky to get a 20 into his wrist. His sugar is good. I try to get some demographics from him, but his answers are nonsensical. I have this happen periodically. You get a patient, they tell you their name, they answer your basic questions and you think well, they can give me all their demographics in the ambulance and then when you have them out there, you realize they are not right in their mind. I can’t even get his date of birth or social out of him. He is just babbling a seemingly random number. He denies taking any drugs, not that I find his answer reliable. We go to the hospital in nonemergency mode. En route he begins to complain of severe pain, but first it is in his legs, then his side, then he says, in his butt. While he remains alert with warm, dry skin, I am finding it very difficult to have any kind of conversation with him. At the hospital, I tell the nurse, I have no idea what is up with the guy.
Just as I am finishing my paperwork, we get called out to intercept with a basic crew on a diabetic. Man from a nursing home found unresponsive with a sugar of 40, got some glucagon from the home and is now responsive, but groggy. I check his sugar – its 200. The man can answer my questions, but he is still clammy, and his lungs are very rhocorous. The W10 says he has had pneumonia and just finished a course of Zithromax. His vitals are stable and with 02 by canuala, his Sat is 96. He has Alzheimers, a CHF history in addition to the pneumonia and is an insulin-dependent diabetic. I don’t do much more than put in an IV and pop him on the monitor. While his lungs are nasty sounding, he seems to be breathing okay, even laying supine. I’m pretty certain it is pneumonia. Being sick and not eating probably knocked his sugar down.
At the hospital, we put the patient in the room next to our last patient. I ask the nurse if they have figured out what is wrong with him yet and she says he has septic emboli throughout his body. Septic emboli is a term I haven't heard before. Septic emboli are emboli made up of pus and bacteria that travel through the bloodstream from one site in the body to others, spreading the infection, often ending up lodged in the lungs, heart and brain, which explains his mental status. It turns out he also has an extensive history of the usual chronic diseases that plague IV drug abusers. He may not be dying right now, but he is a very sick man in the latter stages of his diseases.
After we clear the hospital, we are posted on another corner when a pretty young woman – maybe 18 -- comes up to my side window and shows me her hand and points to a vein, which is bruised and reddened. “I just shot up and it really hurts,” she says. “Is there anything I can do for it?”
“You’re damaging the tissue,” I said. “Ice will make it feel better, but you are definitely going to have to stop using that vein. It’s only going to get worse. Go see a doctor.”
She nods and thanks me without much enthusiasm, and then walks back across the street and stands next to a man drinking a liter bottle of orange soda. Together they watch traffic.
“Does this happen to you all the time?” my partner asks. “You should open a clinic.”
“I tell them to go to the hospital," I say.
They send us in on the early side, and after gassing, washing and resupplying the rig, and finishing up our paperwork, I punch out for the night.
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