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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.
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