Decreased

 I pride myself on my assessment skills, my finely tuned senses -- the ability to see, hear, touch, smell, taste, and whatever the sixth sense is – I do that one well too. But lately, I must confess I have been having some issues with the hearing. I auscultate the patient’s lungs and hear nothing. I say to my partner, "You listen. Tell me what you hear."

“Fine rales,” he says.

“Ah, precisely,” I say as fine rales squares with my other senses that this patient seems to present with mild CHF. “But a bit decreased?” I add, trying not to sound too questioning.

I have noticed in recent years more and more of my patients have decreased lung sounds and I think this is more because of my hearing than their conditions. Twenty years of sirens have taken their toll. I find myself out at dinner or other functions having to say, “What? Speak up.” It is even worse with patients. “You have to speak up,” I say. “It’s hard to hear over the engine.” Oh, how I hate patients who whisper because they are too sick in their minds to talk at a normal level. I try to be polite. “Speak up,” I say. “Use your full voice. I can’t help you, if I can’t hear what you are saying.” I am beginning to sound like a crotchety old man. I remind myself of my old partner Arthur who was always scolding people to speak up. There have been days when I have put the stethoscope in my ears and held it out to the patient and said, "If you can’t speak up, talk to this.”

But I must confess in the last week, even that trick was failing me. Every lung sound I listened to was decreased. I thought it might be the stethoscope itself. I tapped against the diaphragm with my finger to make certain I didn’t have it turned off. It was on. But then I would listen and hardly hear a thing. "Decreased," I would say to the nurse. "But my hearing isn’t so great."

So anyway, the other day, I go into the hospital and approach a particularly attractive nurse. I stand over her in my paramedic uniform with my stethoscope dangling around my neck. “Hey there, beautiful,” I say. “You are looking fine today. How about you come home with me tonight?” The other nurses laugh. The nurse I am talking to of course in the mother of my daughters. All the nurses know this except for a new one who appears astonished by my confidence, my forwardness. She has heard (been warned perhaps) about paramedics and here she is witnessing one of this bold breed in action.

The mother of my daughters looks up at me and smiles. “Your stethoscope is broken,” she says.

“Huh,” I say as it look at it. “I’ll be.” The plastic diaphragm covering and rim are missing.

“Here,” she says, pulling another stethoscope out of drawer. “I have an extra.”

Later that day.

“How were the lung sounds?” The doctor asks as I give my report. “Fine rales,” I say. "with a slight expiratory wheeze.”

He listens as well. “Yes, yes,” he says. “Precisely.”

Backing In

 I was in a parking garage over the weekend when my exit was held up by a woman in a SUV who took about five minutes to make all he turns necessary to back into a parking space. I was thinking why not just drive in straight? Why do you have to be parked for the quick getaway? It can’t be harder to back out then it is to back in.

While watching this and shaking my head, I was reminded of many times over the years, I have been driven lights and sirens hurtling through traffic to provide light-saving care (or not) to people who called 911 in distress, only to have to wait while my partner executed the same multiple turns to back into the driveway for the planned getaway.

This has never made sense to me. We drive lights and sirens for one reason -- to get to the patient more quickly. We drive to the call with lights and sirens far more than we drive away lights and sirens. So why do we delay arriving in order to park the car for the getaway when we seldom need the quick departure? Why not just drive in straight and back out later after the emergency is over?

I have wanted to write about this for awhile and since now I am either in a fly car or have partner du jour, I run no risk of offending any current partner.

I am mild-mannered and easy-going. If something bothers me, I tend to not let it show. But now after all these years, here it is: Park the damn ambulance already!

Routine

 It never ceases to amaze me when it happens. When routine saves you.

I was talking with another EMS Clinical Coordinator recently, and he said he did not understand why some medics seem to check the blood sugar on virtually everyone. Why don’t they do it only when it is indicated? I argued that medics don’t do it on everyone, just likely everyone within a very wide net. Almost any medical patient who gets an IV and some trauma get their blood sugar checked by many of us. Why? Well, the hospital often asks what the patient’s blood sugar is, and you look like you are on top of your game when you can fire back a number. And two, and more importantly, it is just prudent care. Now when I speak of checking the blood sugar, what usually happens after I get an IV, is I take the catheter and using my pen push against the back of it, causing a small drop of blood to come out the front, and I press that against the glucometer strip. What I am testing is not the capillary blood from the finger tip, but venous blood, which is often slightly less than the capillary blood. I am not too concerned with 10 points here and there. I am looking to see if there is a big issue. Is the sugar abnormally high or abnormally low?

The other day, I had a patient with weakness, who’s caregivers said she was not herself, and had been deteriorating, and was much worse this morning. They mentioned her blood sugar was 150. In my head, I ruled out hypoglycemia. I did my assessment. We carried her out to the ambulance in a stair chair. In the ambulance I did a 12-lead and put in an IV. I checked the sugar almost as an afterthought, and there was the number – 43. I now rechecked it with capillary blood just to make sure – 37. Okay, now I understoodd. She was hypoglycemic and her glucometer was not working properly. Some D10 (we are trying not to use the concentrated D50 now) and she was now chatting with me. How stupid would I have looked if I hadn’t checked it? In my almost 20 years as a paramedic, when expecting a normal result, I have gotten a surprising diagnostic result probably 20 or 30 times. You are not thinking hypoglycemia and bingo, there it is. I don’t have to face the “You know that lady you called the stroke alert for? Her sugar was 20 ” from a know-it-all ED staffer. I have caught hypoglycemia as late as the ED parking lot. “You know the stroke alert I called in,” I tell the triage nurse, “Never mind.”

I get called for a seizure. Patient history of seizures, not taking her meds, had a seizure last night and another one this morning. They are described as nonconvulsive seizures with altered mental status. A BLS crew is on scene with patient. The address is not more than a mile from the hospital. The BLS crew will likely be fine to take her in, but I decide to ride it in, just as a precaution. With seizures, you never know, and I am by nature, cautious. My routine with seizures is I ride in with them and I do them ALS. Again, I put in an IV just as a precaution. The lady is a hard stick, but the IV gods are with me, and I snake in a 22 in her forearm.

We go on a non-priority. Then just as we get to the ED, the patient’s eye starts twitching. By the time we have her in the room, she is now full blown, tonic-clonic, earth-quaking, bed shaking seizure. They thank me for the IV, through which they push Ativan to control the seizure.

Why did I ride it in? Why the IV? Did I know she was going to seize again, and this time have a full-blown seizure. I did not. I did it because it was my routine. It’s what I have taught myself to do.

I get called for a man with weakness. He is diabetic and has been feeling light-headed this morning. He has trouble walking, no strength in his legs. I follow my routine. I pop him on the monitor, put in an IV, check his sugar – its 187. I do a 12-lead. The machine spits it out. If the ST elevations by themselves aren’t enough to open my eyes, the machine is screaming it out as well -- ***ACUTE MI SUSPECTED***. Oh, my gosh. I radio ahead. Get the cath lab ready.

There are some medics who can walk in a room and in one glance tell you what is going on. I can do this sometimes, but I am not always right. Nor do I need to be. I just need to not tunnel vision on my first impression. I need to keep an open mind and follow my routine, which casts a wide net for all possibilities – hypoglycemia, recurrent seizure, STEMI.

There was no brilliance involved on these calls, just following a day to day routine. You never know when it will save you.