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.
Tuesday, July 31, 2007
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.
Thursday, July 19, 2007
Pain
We're on our way back from the hospital when we get sent non-priority to a motor vehicle accident for shoulder pain. The accident happened awhile ago, but one of the patients has decided they want to go to the hospital now so we are being sent.
The police direct us to our patient -- a man in his early sixties who is taking a small briefcase out of the back seat of his SUV. He is well-dressed in casual clothes, his thinning hair neatly combed. "Yes, my shoulder feels a bit stiff," he says when I ask him what is wrong. "I banged it against the door. I'd like to get it X-rayed as quickly as possible, so I'd like to go down to the emergency room, if I could." I glance at his car. The front wheel is pushed in so it is undriveable. There isn't much other damage.
"Can you do this?" I ask. I raise my arm above my head.
He raises his arm above his shoulder without problem. I press again his shoulder, but don't elicit much of a response. He denies any neck or back pain. I follow the selective immobilization protocol. "I'm fine," he says. "Its just my shoulder is a little stiff. Better to get it checked out now, then wait."
"All right," I say. "What hospital do you want to go to?"
"Who'll ever see me quickest."
I name the closest hospital, and he agrees.
"This way," I say and we walk back to our ambulance. I open the side door and he climbs in carrying his briefcase.
I'm supposed to put him on the stretcher, but instead, I sit him in the captain's chair and get him buckled in. I don't really view him as a patient; its more like he is just a passenger. I try not to show irritation with him. I take his vitals and as we start to the hospital, he asks if it is okay if he uses his cell phone. He explains he delivers meals for meal-on-wheels and with his car out of commission, they will need to find someone to cover his route tomorrow. After he is done with his call, out of curiousity I ask him about his route. He delivers meals to the elderly housing apartments where we so often respond. We probably share many of the same clientel. He delivers one hot and one cold meal. He volunteers one day a week and has for several years now. Its the least he can do to help, he says. The deliveries are made five days a week and on holidays. The people pay five dollars a day for the meals. The meals are cooked in the cafeteria of a large local business.
He asks me about my job. I say I've been busy lately -- lots of calls, almost non-stop -- the hospitals are crowded too. Too many sick people, not enough resources.
"I hope I won't have to wait to long," he says. "An x-ray shouldn't take too long?"
I don't say anything.
We get to the hospital, we put him in a wheel chair and take him out to the waiting room triage. The room is overflowing. Two security guards wrestle with a ten year old boy who is screaming. No one seems to be paying them any mind. I hand the secrtetary my patient's information (name, social, date of birth) so she can log him into the computer, and then I wait with him until the nurse can take my report. Just ahead of us the nurse is talking to a woman in a wheelchair who already wears a hospital gown and is recieving IV fluid.
"I'm sorry," the nurse says. "There are seven people ahead of you for beds. It's going to be awhile longer."
"So, you telling me, I can't get a bed," the woman says. "You telling me my baby dead then.
"No, it's just that we don't have a bed."
"I'm sitting here in blood and you telling me my baby dead."
"No, we don't know that. You're only ten weeks along. It may be nothing. Whatever is happening is a natural process that we really can't control. You're vitals are good. You're stable. We just don't have a room yet."
"I'm sitting in blood and you're telling me my baby dead. I can't believe you don't have a bed for me and my baby. My dead baby. I'm sitting in blood. And you can't find me a bed."
My patient, watches this scene silently. For the first time I can see pain in his eyes.
The police direct us to our patient -- a man in his early sixties who is taking a small briefcase out of the back seat of his SUV. He is well-dressed in casual clothes, his thinning hair neatly combed. "Yes, my shoulder feels a bit stiff," he says when I ask him what is wrong. "I banged it against the door. I'd like to get it X-rayed as quickly as possible, so I'd like to go down to the emergency room, if I could." I glance at his car. The front wheel is pushed in so it is undriveable. There isn't much other damage.
"Can you do this?" I ask. I raise my arm above my head.
He raises his arm above his shoulder without problem. I press again his shoulder, but don't elicit much of a response. He denies any neck or back pain. I follow the selective immobilization protocol. "I'm fine," he says. "Its just my shoulder is a little stiff. Better to get it checked out now, then wait."
"All right," I say. "What hospital do you want to go to?"
"Who'll ever see me quickest."
I name the closest hospital, and he agrees.
"This way," I say and we walk back to our ambulance. I open the side door and he climbs in carrying his briefcase.
I'm supposed to put him on the stretcher, but instead, I sit him in the captain's chair and get him buckled in. I don't really view him as a patient; its more like he is just a passenger. I try not to show irritation with him. I take his vitals and as we start to the hospital, he asks if it is okay if he uses his cell phone. He explains he delivers meals for meal-on-wheels and with his car out of commission, they will need to find someone to cover his route tomorrow. After he is done with his call, out of curiousity I ask him about his route. He delivers meals to the elderly housing apartments where we so often respond. We probably share many of the same clientel. He delivers one hot and one cold meal. He volunteers one day a week and has for several years now. Its the least he can do to help, he says. The deliveries are made five days a week and on holidays. The people pay five dollars a day for the meals. The meals are cooked in the cafeteria of a large local business.
He asks me about my job. I say I've been busy lately -- lots of calls, almost non-stop -- the hospitals are crowded too. Too many sick people, not enough resources.
"I hope I won't have to wait to long," he says. "An x-ray shouldn't take too long?"
I don't say anything.
We get to the hospital, we put him in a wheel chair and take him out to the waiting room triage. The room is overflowing. Two security guards wrestle with a ten year old boy who is screaming. No one seems to be paying them any mind. I hand the secrtetary my patient's information (name, social, date of birth) so she can log him into the computer, and then I wait with him until the nurse can take my report. Just ahead of us the nurse is talking to a woman in a wheelchair who already wears a hospital gown and is recieving IV fluid.
"I'm sorry," the nurse says. "There are seven people ahead of you for beds. It's going to be awhile longer."
"So, you telling me, I can't get a bed," the woman says. "You telling me my baby dead then.
"No, it's just that we don't have a bed."
"I'm sitting here in blood and you telling me my baby dead."
"No, we don't know that. You're only ten weeks along. It may be nothing. Whatever is happening is a natural process that we really can't control. You're vitals are good. You're stable. We just don't have a room yet."
"I'm sitting in blood and you're telling me my baby dead. I can't believe you don't have a bed for me and my baby. My dead baby. I'm sitting in blood. And you can't find me a bed."
My patient, watches this scene silently. For the first time I can see pain in his eyes.
Thursday, July 12, 2007
Blue Sky
A long procession of cars, many with their windows whitewashed "RIP Hector" line both sides of the narrow road deep in the cemetery.
I kneel on the lush grass. Family and friends dressed in black suits and dresses press against me as I try to calm the young woman who thrashes about and cries out "Hector! Hector Te Amo!"
We are on the precipice of the grave. I look down not a foot behind me and see the white casket resting deep in the earth, red roses draped upon it. (It looks a lot further down than six feet).
Mourners fan the woman and bend over her touching her arms and face. Dangling from their necks are the same photo (encased in plastic) -- a smiling young man with a backwards baseball cap, loose baggy pants, posed flashing hand signs, looking like he owns the day. "Calma te, Calma te," they say to her.
I have been told she had a seizure or fit and fell forward striking her head hard on one of the steel bars (they form a rectangle around the grave) that lowered the casket. Thankfully, they grabbed her before she could fall in. They said she was initially unconscious. Now she won't be still. "Mami! Mami!" she cries. "Mi Hector!"
"No se mueve," I whisper to her to little effect, as I try to hold her head still, while waiting for my partner to retrieve the c-spine equipment. "No se mueve."
I look back down at the casket, and then up the wall of the brown earth, the living grass line, the dancing photos of Hector, and up to the circle of light blue above the leaning heads. What a beautiful clear day. The sky seems to rise forever.
I kneel on the lush grass. Family and friends dressed in black suits and dresses press against me as I try to calm the young woman who thrashes about and cries out "Hector! Hector Te Amo!"
We are on the precipice of the grave. I look down not a foot behind me and see the white casket resting deep in the earth, red roses draped upon it. (It looks a lot further down than six feet).
Mourners fan the woman and bend over her touching her arms and face. Dangling from their necks are the same photo (encased in plastic) -- a smiling young man with a backwards baseball cap, loose baggy pants, posed flashing hand signs, looking like he owns the day. "Calma te, Calma te," they say to her.
I have been told she had a seizure or fit and fell forward striking her head hard on one of the steel bars (they form a rectangle around the grave) that lowered the casket. Thankfully, they grabbed her before she could fall in. They said she was initially unconscious. Now she won't be still. "Mami! Mami!" she cries. "Mi Hector!"
"No se mueve," I whisper to her to little effect, as I try to hold her head still, while waiting for my partner to retrieve the c-spine equipment. "No se mueve."
I look back down at the casket, and then up the wall of the brown earth, the living grass line, the dancing photos of Hector, and up to the circle of light blue above the leaning heads. What a beautiful clear day. The sky seems to rise forever.
Saturday, July 07, 2007
MedicCast - Running Cardiac Arrests
Tuesday night (Tuesday, July 10, 2007) at 10:00 P.M. EST Jamie Davis will be hosting MedicCast Live an internet call-in show "Running the Code: CPR oversight and team leadership" discussing managing cardiac arrests and other difficult calls.
MedicCast
MedicCast Live
Visit Talkshoe.com to register for free and get a pin number to login.
Talkshoe.com
The show runs for an hour.
If you miss it, you can download the show later.
***
Jamie asked me for my thoughts on the topic, so here they are:
One of the most satisfying aspects of the paramedic job is directing a code when you do it well. A well-run cardiac arrest is like a finely choreographed ballet. And then there are the codes from hell, which we will save for another day.
When I first started as a medic I had a tendency to focus right in on my skills -- getting the tube, in particular, while losing sight of the big picture -- directing CPR (When I said stop CPR, I didn't mean stop it forever), getting the history (Oh, the patient's a DNR. Sorry), mapping out an extrication route(What do you mean, you can't move the refrigerator) among the many tasks needed.
I have always worked in a single medic system where you have to not only direct, but also perform all the skills. It took me quite awhile to feel fairly competent running a code. In the early years we rarely even had first responders.
I used to feel worthless in the first minutes of a code (after the initial placing on the monitor) because while everyone else was working on the patient, I would be getting out my airway kit, unzipping it, taking out the scope and blade, an ET tube, a stylet, a 10 cc syringe, unzipping another compartment to take out an ET holder, opening up the tube holder, placing it around the patient's neck, putting the stylet in the ET tube, attaching the syringe, snapping the blade onto the scope, and then finally after what seemed an inordinate amount of time, announcing I was ready to tube. Then if I got the tube, I'd have to get out my IV kit and do the whole set up again, and climb over to the arm and put in an IV, and then climb back to where my med bag was, all the while glancing at the monitor and then having to reach over people to hit the shock button if necessary.
Now, if first responders are already on scene, I observe their CPR and ventilating while I attach my monitor and listen to the history. If I am first on scene, I attach the monitor and then get out the ambu bag and see how well the patient ventilates with just the bag mask. I'll pass off the CPR and bagging to others, but only after making certain it is being done well.
One of the key things I have learned over the years is to position the monitor so it is close to me -- not just within reach, but close enough I can see the difference between asystole and fine v-fib (years ago I could see this distinction across the room, now I need it closer). That can be difficult from across the patient. One medic I know taught me years ago to go for an EJ first. That way you can sit at the patient's head and control of the airway, have the monitor sitting to one side in easy reach and have IV access right in front of you so you can run your meds.
Capnography has made codes much easier to run. You have ready verification of your tube, you can assess the quality of CPR, and you can spot return of spontaneous circulation or loss of it.
Capnography for Paramedics
Changing protocols have also made it easier with the cessation of resuscitation becoming more common so we often don't have to worry about the extrication part unless we revive the patient.
***
Try to check out the show. It should be an interesting listen as well as a chance to participate.
MedicCast Live
MedicCast
MedicCast Live
Visit Talkshoe.com to register for free and get a pin number to login.
Talkshoe.com
The show runs for an hour.
If you miss it, you can download the show later.
***
Jamie asked me for my thoughts on the topic, so here they are:
One of the most satisfying aspects of the paramedic job is directing a code when you do it well. A well-run cardiac arrest is like a finely choreographed ballet. And then there are the codes from hell, which we will save for another day.
When I first started as a medic I had a tendency to focus right in on my skills -- getting the tube, in particular, while losing sight of the big picture -- directing CPR (When I said stop CPR, I didn't mean stop it forever), getting the history (Oh, the patient's a DNR. Sorry), mapping out an extrication route(What do you mean, you can't move the refrigerator) among the many tasks needed.
I have always worked in a single medic system where you have to not only direct, but also perform all the skills. It took me quite awhile to feel fairly competent running a code. In the early years we rarely even had first responders.
I used to feel worthless in the first minutes of a code (after the initial placing on the monitor) because while everyone else was working on the patient, I would be getting out my airway kit, unzipping it, taking out the scope and blade, an ET tube, a stylet, a 10 cc syringe, unzipping another compartment to take out an ET holder, opening up the tube holder, placing it around the patient's neck, putting the stylet in the ET tube, attaching the syringe, snapping the blade onto the scope, and then finally after what seemed an inordinate amount of time, announcing I was ready to tube. Then if I got the tube, I'd have to get out my IV kit and do the whole set up again, and climb over to the arm and put in an IV, and then climb back to where my med bag was, all the while glancing at the monitor and then having to reach over people to hit the shock button if necessary.
Now, if first responders are already on scene, I observe their CPR and ventilating while I attach my monitor and listen to the history. If I am first on scene, I attach the monitor and then get out the ambu bag and see how well the patient ventilates with just the bag mask. I'll pass off the CPR and bagging to others, but only after making certain it is being done well.
One of the key things I have learned over the years is to position the monitor so it is close to me -- not just within reach, but close enough I can see the difference between asystole and fine v-fib (years ago I could see this distinction across the room, now I need it closer). That can be difficult from across the patient. One medic I know taught me years ago to go for an EJ first. That way you can sit at the patient's head and control of the airway, have the monitor sitting to one side in easy reach and have IV access right in front of you so you can run your meds.
Capnography has made codes much easier to run. You have ready verification of your tube, you can assess the quality of CPR, and you can spot return of spontaneous circulation or loss of it.
Capnography for Paramedics
Changing protocols have also made it easier with the cessation of resuscitation becoming more common so we often don't have to worry about the extrication part unless we revive the patient.
***
Try to check out the show. It should be an interesting listen as well as a chance to participate.
MedicCast Live
Friday, July 06, 2007
New Medic
Congratulations to Baby Medic on completing his precepting. He is out there now on his own doing some good. I look forward to his fresh, insight posts.
Sunday, July 01, 2007
Summer Fiction
I haven't written many scene stories lately. Maybe I'm in a rut and have shut down my human vision as I go through the calls. Or maybe the calls just seem repetitive to me. Old folks slip and fall, convalescent home pneumonias, minor MVAs, or if they are trauma room MVAs they are the typical evaluate for mechanism types -- nothing that has really stood out.
The few funny calls I had involved fat patients with large breasts that they weren't afraid to show and I didn't want to write about them because they were sort of typical fat person with large breasts calls and they made the fat person with the large breasts seem sort pathetic, and the only thing more pathetic than a fat person with large breasts story is the person writing to get a laugh about fat people with big breasts.
I did another call that involved a patient who didn't want an IV, but whose heart was going at 200 a minute(which I did write about), and we were trying to convince him to trust us and let us put in an IV, all the while our new employee driver was taking one wrong turn after the other and the patient with the 200 heart rate was trying to tell us the right way to go. I could have written about the new driver getting lost angle, but we've all been there, and I didn't want to pick on someone being there for the first time, although at some point I may write a general post about all the times I've looked up out the side window and wondered what the heck are we doing over in this part of town or crossing the river going the wrong direction. Hey, it happens.
Anyway, in response to some reader comments, I am reposting my novel Diamond in the Rough. I took most of it down awhile back because I was unhappy with it. I remain unhappy with it. While I have received many favorable comments, I have had some negative ones, including from a reader/friend who I respect very much, and that has sort of put a damper on my enthusiasm for it, so I haven't reworked it yet. But for those who read what I had up, here's how it all comes out.
Also available online is my novel Mortal Men, which I have been rewriting and I do feel much better about. My rewrites are not reflected in what it is posted, but I still think it is a good read, and hopefully one day I will have it in a form that I feel is publish worthy.
So while TV shows are showing summer reruns, here's some summer fiction reruns.
Thanks for reading, and I hope to have some new scene stories soon.
The few funny calls I had involved fat patients with large breasts that they weren't afraid to show and I didn't want to write about them because they were sort of typical fat person with large breasts calls and they made the fat person with the large breasts seem sort pathetic, and the only thing more pathetic than a fat person with large breasts story is the person writing to get a laugh about fat people with big breasts.
I did another call that involved a patient who didn't want an IV, but whose heart was going at 200 a minute(which I did write about), and we were trying to convince him to trust us and let us put in an IV, all the while our new employee driver was taking one wrong turn after the other and the patient with the 200 heart rate was trying to tell us the right way to go. I could have written about the new driver getting lost angle, but we've all been there, and I didn't want to pick on someone being there for the first time, although at some point I may write a general post about all the times I've looked up out the side window and wondered what the heck are we doing over in this part of town or crossing the river going the wrong direction. Hey, it happens.
Anyway, in response to some reader comments, I am reposting my novel Diamond in the Rough. I took most of it down awhile back because I was unhappy with it. I remain unhappy with it. While I have received many favorable comments, I have had some negative ones, including from a reader/friend who I respect very much, and that has sort of put a damper on my enthusiasm for it, so I haven't reworked it yet. But for those who read what I had up, here's how it all comes out.
Also available online is my novel Mortal Men, which I have been rewriting and I do feel much better about. My rewrites are not reflected in what it is posted, but I still think it is a good read, and hopefully one day I will have it in a form that I feel is publish worthy.
So while TV shows are showing summer reruns, here's some summer fiction reruns.
Thanks for reading, and I hope to have some new scene stories soon.
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