Assault

We're called for a domestic in an apartment complex. Minor injuries. The police are already there.

They lead a man out of the front door. He is a big muscled man, six three at least with linebacker shoulders. Except he walks with a cane and I see a brace of his left foot.

"What happened?" I ask.

"She pushed me down," he says. "I had a stroke a year ago."

"Did you get knocked out?"

"I hit my head. I saw stars."

I feel his head and neck. There are no bumps or bruises. His eyes are wet.

One of the cops rolls his eyes as if to say, "that's bullshit. Be a man."

"You want to go to the hospital?"

"Yes," he says.

I have my partner bring the stretcher over and we help the man on it. His huge feet hang out over the end.

He is forty-eight years old. High Blood pressure, high cholestrol and residual left sided weakness from his stroke. He hasn't worked for a year.

He sits on the stretcher looking forward, looking nowhere.

Cath Lab

A lot of EMS is bullshit. People using 911 for runny noses, sprained wrists, and stomach aches from eating too much greasy chicken. Then there are the legitimate calls like strokes and traumas, but too often in those calls there is really not much we can do to fix them. They are dead from getting into an accident at 60 MPH or they are stroked out so bad they are just going to stay that way. That calls that make the most difference I believe are the cardiacs -- the chest pains. The patient is pale, diaphoretic, with nausea and chest pressure. You take their vitals, do a quick 12-lead. It shows an inferior MI. You put the patient on a non-rebreather, give them some ASA, put in a couple large bore IVs and fly to the hospital. You call ahead, this patient is having an MI. They need to go to the cath lab.

When all goes well at the ER, the doctor meets you at the door, glances at your 12-lead, and then while you are unloading the patient, he is calling the cath lab, and before you have even sat down to write up your run form, they have heparin running and are wheeling the patient out of the ER and up to the cath lab.

The cath lab is where a cardiologist does angioplasty. They run a catheter in through the patients groin and up through his artery into his heart, where they blow up a balloon to clear the blockage in the heart that is causing the MI. Time from door to cath lab is critical. I've brought in patients with ST elevations--the hallmark of an acute MI -- and had them code on me in the ambulance. I've had them code in the ER, and I have heard about them coding in the cath lab. If they can make it there and get the plasty done, they are often up and walking around within days.

Recognizing an MI and getting the hospital to take it seriously is criticial. Sometimes, you have to go and find a doctor and say, Doc, my patient is having an MI. He needs to go to the cath lab. They are busy with other patients and you need to get their attention. No disrespect to the nurses, who are also busy, sometimes you just have to bypass them in the interest of time.

Trauma patients get the trauma room, but its hard to fix them. Cardiac patients can be fixed, but the system isn't really geared to them yet. Even the ER doc's have to call a cardiologist to get the cath lab open. In an ideal system, paramedics could call for the cath lab as they do for the trauma room.

Here's what happened today. We get called to a cardiologist's office for an Acute MI. I sign on with dispatch to get an EMD update. "They wouldn't give us a sex or age," the dispatcher says, "Its a cardiologist's office, they have an acute MI. Paramedic hot response."

A nurse meets us at the door. "What's going on?" I ask.

"He's having an acute MI. We're running in saline. He just walked in. The doctors are in with him."

I find the man in an exam room. He looks to be in his fifties, a healthy male with good complexion. Good color. He is attached to a three lead monitor that is not reading. They have a 250 bag of NS running wide open through a 22 in his right AC. I ask him how he is doing. He says okay.

The cardiologist comes in and briefs me. He tells me the man is having an acute inferiorposterior MI and I'm to take him right to the cath lab where the doctor will meet us. He is leaving for the hospital right now.

Okay, I say. We hurry him onto our stretcher and take off lights and sirens. I put him on a cannula, take a quick BP - 130/80. HR - 100, then notify the hospital. Coming from a cardiologists office going straight to the cath lab, can you have someone there to lead us straight up.

In ten years I've never taken anyone straight to the cath lab from a scene. I don't want to take a wrong turn in the maze of corridors.

I ask the man how he is. He says, fine, maybe a little nervous. I tell him not to worry he is getting the best care possible -- going straight to the cath lab. I put in a another IV -- a 20 in his hand that runs great. I tried an 16 in his AC, but blew it, my ego got the better of me. It was only an 18 size vein.

I put him on the monitor. It is my first look at his ECG. They never showed me one at the doctor's office. Normally I would ask, but here I would basically be giving a report back to the guy who gave me the report.

I'm looking at II, III, and AVF. Maybe a tiny slight elevation in III, nothing in II or AVF. I don't doubt the doctor at all. It just isn't screaming MI.

I want to do a full 12 lead for my own edification, but the man has a shag carpet on his chest, and I can't get the leads to stick.

"You can shave me," he says.

"We're going over the Delmar Street Bridge," I say. "That's not a good idea." the Delmar Street bridge has been under construction for two years and is nothing but potholes and uneven bumps. "You'll end up in the trauma room instead of the cath lab. Besides we're just about out."

At the hospital, the tech leads us right up to the cath lab, where the doctor meets us, and we bring him right in and get him on the table.

I can't tell you how many times I have struggled to get patients up to the cath lab. Called ahead, said, this is an acute MI, I've got tombstone ST elevations. I've run through the ER showing doctors my 12 lead, screaming MI. But they have their procedure they have to go through in the ER, register the patient, assign a room, have the nurse assess the patient, do a 12-lead, get the doctor over, the doctor questions the patient, then he orders heparin, and calls a cardiologist and discusses the case. Sure, sometimes its quick. 20 minutes. Sometimes its an hour.

This guy was lucky to get such service.

You know what the deal was?

He was a golfing buddy.

I'm not saying I don't help my friends out. If I was the heart doctor and that was my buddy, I would have done the same thing. All I'm saying is if we can get a doctor up there at the snap of the fingers we ought to be able to get other people up there that quick. Cath's can save lives.

David

I got an email titled “Sad news.”

It is from my friend Tom.

"Hate to break this to you in an e-mail, but David died yesterday. He was found in his home when he did not report to work, dead of an apparent heart attack. I will forward funeral information in case you can attend. "

David and I worked together twenty years ago before my life as a medic. There were four of us. David, Tom, Rusty and me. We called ourselves “The Road Show” as our job was to drive our boss all over the state. Tom was the advance man, David and I the camper drivers, and Rusty the backup driver.

David’s parents were very wealthy, but he’d worked for awhile as a doorman at a ritzy hotel in Washington. He was good at taking care of details, making people feel important. He'd get up at five in the morning drive twenty miles to a small drug store newsstand that carried the boss's favorite juice, a concoction called Park Avenue Punch, so when the boss was thirsty, David would reach into the cooler and produce it for him. The camper was always immaculate, gassed, washed, and vacuumed. Even the shit tank dumped.

He was a good hearted, crazy guy. When he went out on dates, sometimes he'd rent a limo and take his date to the McDonald's drive through. He used to like to go into strip clubs, walk up to the dancer, hand her a ten, turn around with a spin, drop down and do a split, then walk out. He once innocently offered the boss's busty daughter five dollars if she would just show him her breasts. He went on a vacation at Hedonism, and came back with pictures of himself standing bare-assed on the beach with some women he’d met. His favorite movie was “Fast Times at Ridgemont High.” He could do dead on impersonation of Sean Penn as Spicoli. He also liked “Ferris Buelher's Day Off.” After we’d drop the boss off at night, he’d pop The Who's “Teenage Wasteland” into the tape deck, and he'd play a perfect Keith Moon air drums as he drove.

Some nights when we'd been on the road late and were scheduled for an early start the next morning, I'd crash at his parent's place. He'd stay up watching TV, a tequila bottle on the table next to him. I think he had insomnia.

In later years, he went to law school, and got a job in his father’s firm, but he had problems with drugs and alcohol. He quit and the last I had heard was working as a pool boy at a fancy country club. But Tom, when I spoke to him on the phone, said David had cleaned up and was working again as a lawyer and doing well for himself. He'd been living down in Florida.

I had completely lost touch with him.

How many times have I gone into a house and seen a cold stiff body on the floor?

I run the six second strip of asystole and note the time.

Precepting

I'm assigned a paramedic student. And while I love students, I’m not too happy to be precepting this one. She is as close to clueless as you can get and still be allowed to ride.

I precepted her a couple weeks ago. She talked a good game so I figured it would be an easy day. We did a call for a violent psych. We get there and find four mental health workers holding down a screaming fifteen year old, one adult on each junior, though muscled limb. I call and get orders for ativan and benadryl. I draw up the ativan and hand it to her, then turn my back to draw up the benadryl. When I turn back, there is blood all over the place. I look at the patient’s AC, and see that is where the blood is coming from. She gave her an IM shot in the AC. The other medic, who was at the call, watching, says he was going to say something, but thought maybe they were teaching a new technique in school these days.

Today she blows an IV on a chest pain, blows it bad enough that I switch places and do the IV myself instead of giving her a second shot. I run off the 12-lead and ask her what she thinks. She looks at me for an answer. I show her the inverted T's in the anteroseptal leads.

"Reciprocal changes," she says.

I shake my head and show her there are no elevations in the any of the other leads.

"Should we do a right-sided ECG?" she asks.

I shake my head again.

At triage she tells the nurse there are reciprocal changes.

We go over it after the call. She looks at me, almost coldly like she is pissed that I am semi-scolding her. I’m not scolding. I am just telling her some of the basics of cardiology.

Her assessments are poor, her IV skills are terrible. We do a shooting, 18 year old shot in both arms in a drive by. Right elbow, left proximal humerous. He's alert, warm and dry. Good pulse. We get him in back. I tell my partner to drive. The student is already trying for an IV.

"How about a blood pressure?" I ask.

After she gets that, she goes right back to the IV. She uses a 16, and gouges a hole in the kid's AC, and grinds it so hard, the kid who's right elbow is completely shattered, shouts at her to stop.

I switch places again and pop an IV in.

In the trauma room, I am showing the trauma doctor, the bullet holes. Right elbow, left proximal humerous.

"What about there?" the doctor says pointing to the left AC. "There's a third."

"No, no, no," I say. "That's an IV attempt."I

t’s almost time to head in for the day. The student reluctantly hands me her evaluation papers, then we get a call for an unknown, not far from the hospital.

We show up and see the telltale relatives standing outside, urging us frantically to hurry. The fire department has arrived just before us.

"Step it up," a fire fighter says.

We charge in through the old house. I can hear people yelling and crying. When I get in the room, I see a man doing mouth to mouth on a woman who looks to be in her thirties. She has a dialysis port coming out of her naked chest. The fire guys are putting the defibrillator on. Shock advised. Shock.

I hand the rider our monitor and tell her to attach it. I tell the fire guys to start CPR, as we ease the family member out of the way, and I get out an ambu bag.The woman is in V-fib.

"Go ahead and shock," I tell the student.

I get out the intubation kit, lay the laryngoscope to the side of the woman's head, then stick a stylet in a tube and attach a syringe, as the student shocks again.

"Ready to tube," I ask her.

She looks surprised like she didn’t think after how the day had gone I was going to let her tube."

Go for it," I say.

She scoots to the head, and sticks the blade in her mouth. She seems to struggle with it.

"You've got it?" I ask. I'm not giving her a second change if she can't pass it.

"Yeah, yeah, I do."

And I see her pass the tube. I hand her the ambu-bag and it looks good. Check the lung sounds and they are present and equal.

“Good job,” I say.

We work the lady hard. She's got no IV access, and its dark in the room, so we move her out to the ambulance, where I put in an EJ, and we slam some IV drugs. She's still in and out of v-fib, and then settles into ventricular asystole. They work her for a little while at the hospital.

The student is ecstatic. She is wired, running around the ER like she just scored the winning basket in the NCAA championships, telling everyone about it in detail.

I see the family coming down the hall. They look distraught. I ease the student outside where she can do her funky chicken dance out of the family’s sight.

The truth is I am happy for her. She had a shitty day, then she got her code, got her first field tube. I remember when I got mine. I was just as excited.

I've been doing this for twelve years. The truth is I was clueless once too.

In the Dark

We're called for a stabbing.

Its dark and when we pull up on scene, we can see officers with guns drawn. We stage and wait the word to go in.

It's hard to tell what's going on, then another cop comes running out into the street right for us. We step out. "You're going to need your stretcher," he shouts, "and, and disinfectant, lots of it. Give me the strongest stuff you got. I got blood on me. He got HIV and he bleeding all over the place." The officer is hopping up and down and moving his hands like he's got posion ivy, but can't itch himself.

I grab a couple trauma dresssings and a box of vionex, which I hand to the officer.

We go down the hill behind the house and find six cops standing in the dark. They attack the box of vionex, shining their flashlights on each other as they scrub their hands.

I look around and see a body lying face down on the ground, handcuffed. "Can I get a light over here?" I ask. "Is this guy alive?"

"He's fine," an officer says. They are scrubbing each other like surgeons.

I shine my tiny pen light on the man. His eyes are closed, but I can see a little chest movement. He's got some lacerations about his head. His hair is matted with blood. Smells like etoh. He's got a nice steady pulse in his neck. Rate of 80. "You okay, buddy?" I ask.

He opens one eye, looks at me like he's bored, then closes it.

I look back at the officers. "You missed a spot," one says, shining his big mag light on the other's hands. "Right there."