Storm Watch

 A month ago, I swapped out of my Sunday shift for Saturday. Of course I had no idea then that a hurricane would be forecast to strike our state on Sunday. (My reason for swapping was so I could enter a mile open water swim in Boston Harbor called “Sharkfest.”) I will admit like most in EMS to being somewhat of an action junkie, but instead of being upset that I might be missing out on the hurricane action, now that I am older and have a family to protect, I was quite glad that I could spend the day at home instead of out on the road battling the elements. (Sharkfest was cancelled).

The weather media machine was in full hype for storm Irene, and having witnessed first-hand the damage done by Hurricane Katrina, I have learned to respect weather, regardless of the possibility of any storm turning out to be less than advertised. I dutifully joined others in the grocery stores, buying bottled water, canned goods, charcoal for the grille, and other provisions to tide us over through what we were warned was the possibility of being without power for up to a week. On Friday (while at work on the ambulance) the day before the storm, I even managed to secure batteries, a flashlight, candles, a lighter, and a precious manual can opener – all items I had either forgotten to get or that were sold out from the larger Home Depot stores. Through searching all the little gas station convenience stores, I managed to get what I needed. I then bought 2 bags of ice at the 7-11 right before we were sent in for the day, and thus had my emergency provision list fully completed.

That night I gave the three girls the game plan for the storm. Eat the perishable food first, don’t use the flashlights unless necessary, etc. I had them help me finish the laundry and get all the dishes done so we would be in a good state of preparedness. Their mom was working late that night and since she had to work again the next morning, she had plans if the storm was bad enough to stay at the hospital. Little Zoey got in bed with me and I gave her a heart to heart about what the storm might bring. The howling wind, driving rain, sound of trees crashing. I told her not to be afraid, that I would protect her.

“Daddy, I’m scared,” she said.

“Don’t be, it’ll be all right.”

“I think I’m going to sleep with my sisters.”

So with that, she got up and scurried down the hall.

“You can come back if the storm gets too bad,” I called after her.

I slept through the night, rising with the first sunlight. It was raining hard, but nothing truly torrential. The power was still on. I saw no damage in the yard, no water in our basement, which is usually dry after storms. I had my Diet Coke and watched some of the news. The full brunt of the storm hadn’t quite reached New York yet, still to our south. The next six hours were forecast to be our worst. I was glad to be on guard at home. I didn’t even think how if I hadn’t switched, I’d be out there in the rain, battling to get to patients through flooded streets and downed limbs.

Zoey and I made pancakes and read books while watching the news in the background. There were the traditional shots of weathermen standing in knee deep water with trying to keep their rain hoods on as the wind buffeted them.

By two in the afternoon the rain had stopped and the now Tropical Storm had passed. I put Zoey in the running stroller and Lauren rode her bike alongside us as we ran throughout our local neighborhoods, inspecting the damage. A lot of leaves and small branches down. A low-laying bridge on the golf course over a stream was now underwater. No big deal at all.

For dinner we made meat balls and spaghetti, adding our secret ingredient – whipped cream – to the meat balls. We watched the nightly news and saw all the storms highlights, washed out roads in North Carolina, demolished houses along the Connecticut shore, torrential flooding in Vermont. We also learned scattered lives had been lost and millions were without power. We were grateful we had been spared the worst of it. Zoey fell asleep watching her favorite TV show – King of the Hill (I think this is why she often greets me "Hey Dude!" -- and I carried her to her room and set her head on the pillow, and pulled up the covers.

This morning I got up, showered and dressed, turned on my pager and saw the previous night's pages asking for additional crews to come in and help out a division of ours on the shoreline and later a page for crews to help evacuate a hospital whose generators had failed. Finally there was a page thanking everyone for working so hard during the storm. Making us all proud.

My family still asleep, I walked out the front door into a beautiful late August morning. The air was fresh with ozone. I drove in for my scheduled 12-hour shift.

Doctor's Offices

Doing calls in doctor’s offices can be tricky. “Do you start working the patient in the office or wait till you get out to the ambulance?”

Here are the assumptions. You are a transport medic so you have the stretcher with you. The patient is not in cardiac arrest or so sick that they will crash if you don’t do something right away. At the same time, they are sick enough that you will likely have to give them an IV and medicine once you get into the ambulance. Here is a scenario I have had three times -- a patient with an PSVT in the 180-220 range who has come to the doctor's office for an emergency visit because he is feeling uncomfortable. Here is how it played out each time.

1. I am a relatively new medic. After getting a report from the doctor, I say, “Do you want me to give him some adenosine?” He says “No, wait for the ED staff to do it.” Deflated, I wait for the ED staff and the ED Doc gets mad at me for not having given it.

2. I am a more experienced medic, I keep my mouth quiet. I nod, put the patient on the stretcher, get them down in the ambulance, where I do my thing, give them the adenosine -- the rhythm breaks and converts to a sinus in the 80 range, the patient feels much better, and all is good.

3. Just recently, the doctor tells me the patient is in an SVT. He already has an IV line, and has done a 12-lead. This time, it is a little different. The doctor asks “Do you have adenosine?” I say, “I do. I can give it here or out in the ambulance.” “Your choice,” he says. I think a moment, and then say, “Let’s do it here.” I give it, and it all works out great.

Let’s analyze all three situations.

Situation 1. You have a doctor who doesn’t appreciate EMS. The problem with these doctors is if you ask them in front of their patient about treatment, you run the risk of a clash of wishes. I once had a 35-year-old patient having a severe allergic reaction-- hives from head to toe with crazy itching. I asked the doctor what he had done for the patient. He had given Benadryl PO. “What about epi?” I asked. “No, it is contraindicated,” he said. “She is hypertensive.” “What is her pressure?” “140/90.” Okay, so now I have boxed myself in. Once I get out in the ambulance I have to convince my patient to let me give her epi against her doctor’s wishes.* Another time I had a patient having an asthma attack, I gave the patient a breathing treatment in the doctor’s office – no issue here – but then I tried to also get an IV in the doctor's office. When I missed my first attempt, the doctor began yelling at me for wasting time and to get the patient to the ED now. Not a comfortable situation.

It has never happened to me, but I have heard many stories of medics starting care in a doctor’s office and getting into huge fights over the direction of the care. Sometimes the medic was right and sometimes the medic was wrong. Conflict like that doesn’t serve anyone well. One of the worst cases I heard of and this one sounds unavoidable, was a cardiac arrest in a foot doctor’s office in which the doctor insisted on running the code, using his own algorithms. The medic was new and wasn’t able to seize control back. I am always uncomfortable when calls become territorial, which is why I like to get on my ground.

These experiences have all led me to the general approach of situation 2. Get the history and get into your office – the back of your ambulance. This doesn’t mean that there aren’t situations where you have to stand your ground and do what you have to do. It is just that there are some cases where it might be easier for all to just vacate the doctor’s space. Some doctors do it for you. They leave the patient in the waiting room with only the receptionist or family member to give a report. They don’t want the patient taking up an exam room. I have taken care of patients unresponsive with head bleeds slumped in their waiting room seats clutching their CAT SCAN photos.

Situation 3 is relatively rare – a doctor both knowledgeable of prehospital care, engaged in the patient’s care, and respectful of prehospital’s domain. This situation, when it presents, should be seized upon. I have only had this happen one other time in a doctor’s office – where I was encouraged to work the patient right there before the doctor. That was for a semiresponsive hypoglycemic patient. The doctor was fascinated and very complimentary as we put in an IV and gave the patient D50. He had treated diabetics in his office for years, but this was the first time he had actually witnessed a patient crash in front of him and then seen the effects of D50.

None of all of this is to say that the majority of EMS interactions are not professional and courteous. Most of the cases involve getting a report, putting the patient on the stretcher and getting on the way. I have seen doctors who did not seem competent to me and I have had doctors pick up subtle ST elevation that I might have missed that turned out to be STEMIs.

As anything in EMS, whether to start working a patient in a doctor’s office (beyond 02 and a monitor) all comes down to the great saying, “It depends.” The point of this post is just to say to newer medics to beware of some of the drawbacks to doing your thing on the doctor’s turf, and unless necessary, it may be best to just get the report, ask any pertinent history questions you might have, thank the doctor, and get on your way.

* At the time epi was in our protocols as standing orders for this, now we would withhold epi and just treat with Benadryl unless the patient developed wheezing or become unstable. 

Working Man

 I’ve been fighting a respiratory infection for the last week. Every now and then I have a coughing fit that brings up lingering mucus from my chest. I have some medicine I can take to keep the cough under control if it gets too bad -- when my cough is so rough patients offer me their spot on the stretcher. I am actually feeling much better today. I even went running this morning before work -- just a short 2.4 mile neighborhood run to get my legs and air back.

Normally, the first thing I do once we put ourselves on-line with dispatch is get a large Diet Coke on ice at one of the local 7-11s. I could get a bottle from the vending machine in the crew room, but something about the Diet Coke on ice makes it taste so much better and helps relax me and tells me everything is all right with the world. I imagine it is how an alcoholic must feel when they pour their first drink of the day. I just sip that Diet Coke slow throughout the morning. If I have my cold, that’s when I pop the cough pill or a decongestant if I need one. Some mornings I don't get my Coke until after a call or two, and today, I go four deep before I finally get it. It has been busy.

I’m seven calls in already and this is the first chance I’ve had to get my netbook out and start recording. I started the day off with an unknown that turned out to be a guy who turned his ankle getting into a police car a couple days ago (I didn't ask about that story) and said it was swollen now and hurting him. He met us on the stoop outside his apartment building. My partner started to pull the stretcher, but the man said he was fine and would walk over to where we had the ambulance parked. When we got to the back of the ambulance, I offered to pull the stretcher again so he wouldn't have to climb in the back. But again, he said he was fine. I told him to watch his head as he climbed in. Once in the back, he at least agreed to lie down on the clean sheet we spread out the stretcher and be strapped in. At the hospital, the triage nurse told us to put him in a wheelchair and take him out to the waiting area. All of a sudden he made a big deal about how his leg was killing him and why couldn’t he have a room instead of having to sit in the waiting room? He walked out to the ambulance, my partner told the nurse as the man went through his theatre. She just shook her head at him and said "Waiting room."

As soon as we got back in the ambulance, we were dispatched for a stroke at a group home. Patient found that morning leaning to her right. Last time that happened the hospital diagnosed her with depression. She was depressed so she leaned to her right, instead of sitting up straight. She had no facial droop, clear speech, equal grips and no pronator drift. But she was leaning to her right. "Are you depressed?" I asked. "Yes," she said. She looked like someone leaning to her right because she was depressed rather than someone leaning to the right because they were stroking out. She was on a lot of heavy duty psych meds and lived in a small spare room with not much light in the home. If that was me, I'd probably lean to the right, too.

No sooner had we cleared that call then it was off to a surburbantown for a headache. Girl with severe left-sided head pain and an aversion to the light. She said she had two prior episodes recently with negative cat scans. BP was 120/60. Pulse 60. She wouldn’t open her eyes to let me look at her pupils. “”What do you think it is?” she asked. “A migraine,” I said.

There is a new ED at one of the hospitals and while it is an awesome ED, it is hard to get to the cafeteria now and for some reason my security badge isn’t working so if I go, I often have a hard time getting back to the ED. I have to wait for someone to come along and swipe me in. So instead of getting my Coke, I went back on-line figuring I could get my Coke at a 7-11 or fast food restaurant before we got another call. Wrong.

Man down behind the motel. Unknown. On the way there, I have a coughing fit and try to resolve it with a stick of gum, lacking any beverage to wet my throat. It is getting very hot and muggy out, which does not help. One moment, I am fine, the next I can’t breathe, but I manage to get it under control before we arrive.

The patient is intoxicated -- crawling on the ground looking for his glasses. He says he just got locked out of his room. I can smell the alcohol on his breath. We pick him up and put him on the stretcher. He takes a half-hearted swing at my partner, and when I tell him to cut it out, he takes a swing at me, which I easily deflect. He calls the police officer some names and says he still wants his glasses. The officer says he has looked for them and can’t find them so he is out of luck. As we load him into the back, he looks at me and spits. The spit doesn’t reach me, but I caution him.

“Please don’t spit at me,” I say. “I’m just a working man.”

I am getting the glucometer out to try to check his sugar when the cop opens the back door and says, "You’re in luck, I found your glasses." He hands them to me. I consider leaving them by the patient’s feet, but instead hand them to the patient. I'm willing to let bygones be bygones. If I treat him well, maybe he will reciprocate. He puts the glasses on, looks at me, and then launches another goober in my direction. Now just because I was willing to offer an olive branch, doesn't mean I have left my guard down. And I have been in EMS a long time, and like most who have been in EMS a long time, I have acquired a Matrix-like ability to evade bodily fluids, including spit. I do my best Keenau Reeves impression and for a brief second find my eyeball a bare millimeter from the spit gob. But I slowmo evade it. It falls back to earth, landing on my computer screen.

“Again, not cool,” I say.

He spits again, but this time the glob lands back on his face. “Looks like you misfired,” I say.

I get a towel and with a straightarm wipe it off his face, and say, “I would appreciate it if you would stop. Nobody likes having spit on their face.”

He looks at me blankly and then I see him start to work on getting another mouthful of spit.

It is stuffy in the back of the ambulance and the switch for the AC is on the patient’s side of the ambulance. To hit it on, I will have to come again into his range. He senses my intention and spits again. I deflect it with the towel.

Suddenly, just then, a coughing fit comes on me. It begins with three asthma like gasps to get some air in, and then, four staccato, deep rattling coughs. If this blog had sound, imagine an old homeless man with a long greasy beard coughing up a deep aqualung wad of phlegm. That's what it sounds like. I can feel the mucus detaching itself from my lungs and shooting up in my throat. Now, let me just say here that I try to always be a gentlemen and subscribe to the highest ethical standards of professional conduct. As I cough, the patient suddenly looks quite uneasy. I would never spit on a human even in retaliation. I don't understand how a human could spit on another. But I suspect his view of human nature is different than mine. If he is capable of spitting on another human being, maybe he thinks I am capable of spitting on him. He doesn’t know me. He doesn’t know how I roll.

With a terrible sound, I hawk the mucus up into my mouth to keep from choking on it. The man is now clearly frightened by this display. I wonder if he is thinking about the positional advantage I have over him. I wonder if he is thinking just how nasty that mucus is in my mouth. In normal polite circumstances, I might force myself to quickly reswallowthe mucus. Instead I find myself raising the towel to my mouth and depositing my phlegm into it. “Forgive me,” I say,” “I’ve got this lingering respiratory infection. I 've been coughing up some serious phlegm. Green, yellow, very purulent.” Here I am exaggerating. It is clear mucus, but instead of showing it to him, I lie about its qualities.

He doesn’t take his eyes off me, but he doesn’t try to spit again the rest of the way. I wonder if this is how nuclear deterrence with Russia worked for so many years.

After the call, I make certain to wash my hands and carefully clean off the computer. I also borrow my partner’s badge so I can go down to the café and finally get my Diet Coke on ice.

The Diet Coke (with Lime) tastes good, and I sip it slow as we head off to a doctor’s office for a seizure. We find the man on the floor of an exam room. The doctor says the patient had four gran mal seizures without waking up. The patient has his eyes open looking at the ceiling. The man has the end of an OPA sticking three quarters out of his mouth that he is holding with his teeth. I pick one of his arms up and can feel he has good control over it. I question the doctor about what was observed, and then put the patient on the stretcher and transport. I work him up like he had a real seizure, check his sugar put him on the monitor. The transport is uneventful I tell the nurse at the hospital, no incontinence, no tongue biting. Seizure described as tonic-clonic full body lasting 30 seconds, repeated every three minutes until our arrival. I tell her I caught him watching me out of the corner of his eye when I got ready to do the IV. Then it’s off for another unknown which turns out to be a 24 year-old who tried to kill herself by slashing her wrists. Never mind that she failed to break the skin. She is upset because her boyfriend broke up with her. I feel bad for her. She has a big tattoo on her arm that says "Enrique" with a big heart around it. I hope Enrique is her son (if she has one) and not her boyfriend. She goes in the psych wing in the room next to the spitter who is now sound asleep, snoring.

We do a dialysis transfer and then stage for a psych, awaiting PD. The cops are very busy today also, but eventually an officer arrives and we and the firefighters follow him into the house where a woman says she wants her thirteen-year-old son brought to the hospital. She doesn’t want him in the house anymore because he doesn’t pay her any mind. It takes awhile to figure it out, but that is just it. She just doesn’t want him in the house because he doesn’t do what she asks. He isn’t out-of-control. He is not suicidal. She just doesn’t want him in the house. Meanwhile he is in his bedroom playing with his PSP and listening to music on his IPOD, turned up so loud I can hear the beat. Maybe the hospital can talk some sense into him, she says. The officer asks her if she has tried to discipline him. "I can do that?" she says. "Yes, you can." "Well, good, then, you can go. As soon as you leave I’m going to whoop his little behind." "Just don’t leave any bruises or marks," the officer says. "Show some judgment." "Oh, I will," she says. "He's going to feel my judgement all right." While the officer (aka social worker) further clarifies what as a parent she can and cannot do, we clear, no patient.

Then it is off to a doctor’s office for a man with chest pain for two days, skin warm and dry, normal 12-lead. I give him some ASA and then apply a tourniquet for the IV. “I have bad veins,” the man says. “That’s okay,” I say, “if I see one, I’ll try for it. I’m pretty good at it.” "Why don’t you wait until the hospital,” he says. This is a situation I encounter fairly often. Most of the time, I sink the IV and the patient says, “Wow, you’re great.” I love it when that happens. This time I try a 24 in the wrist and while I get a small flash, the line blows up when I push the flush. The man looks at me and shakes his head. I can tell he just wants to be at the hospital and out of my ambulance. I don't press the IV issue. I put a 4 X 4 on my miss, and then pick up my computer and start typing out my PCR. You can’t be a hero everyday.