Sore Throat

We get sent for a choking downtown. We find the fire department standing around a guy on a low cement wall that is part of the landscaping. A tree looms over him. Even in the dusk I can see the man is purple. He looks dead. I am about to say, check for a pulse and start CPR, when on a sternal rub, the man takes one big deep gasp. I pull out the ambu bag, and hand it to my partner. I look at the man’s eyes. Pinpoint. Okay, I’ve got it now. It’s a heroin OD. I draw up 1.2 mg of Narcan and jab him. I am expecting him to wake up fairly quickly, but I get no reaction. Well, now his respirations have gone from 1 a minute to maybe 8. But he is still out of it. I draw up another .8 and hit him again. Still no response. He does have some alcohol on his breath, maybe there are other pills on board and his color is crappy. I decide to intubate him. I go in and can’t see the chords; I think I see them, when my partner gives me cric pressure. I try to pass the tube, but he says I am in too deep. I use the bulb syringe detection device and it confirms I am in. I bag once listening to the belly, and I hear the rumble of air down there, and quickly pull the tube. So much for the bulb detector device. I go in again, but can’t quite manipulate the chords into view. I reposition his head, and go in a third time. This time I see the chords, but no sooner have I passed the tube, then I look down and see his eyes are open, and he starts fighting me. I think what an idiot I am for tubing him before I have given the narcan time to work. I pull the tube. He raises his head, and mutters something. A passerby goes, “Good bless you people, you are terrific” I am thinking “right three tries to get a tube on someone who doesn’t need one. Impressive.”

Down in the ambulance, he drifts back off and starts snoring again. I try to rouse him with no success. I put in an IV, and give him an additional .8 of Narcan. That does the trick and he is alert and able to carry on a conversation. He did heroin, percocets and alcohol. He says it is only the second time he did heroin. He is very apologetic.

When I describe the call to the nurse, she tells the man, these guys saved your life. He thanks us again.

I am thinking. It is true we saved his life, but it was one of those calls where any paramedic with some narcan could have saved his life provided they recognized it soon enough. Not every paramedic will leave him with a sore throat, however.

I was surprised at how long it took the narcan to work. I did find this recent article suggesting that alcohol combined with heroin requires a larger dose of narcan.

The relationship between naloxone dose and key patient variables in the treatment of non-fatal heroin overdose in the prehospital setting.


I talked with a doctor about it later and he said maybe the initial narcan just didn't hit the receptors quick enough because the patient was so shut down. Maybe.

The sad thing is it isn’t the first heroin overdose I have intubated and had wake up on me with the tube in their throat. You are supposed to be aggressive with the airway, but sometimes patience is prudent. Years ago I used to always give Narcan IV, then I ready a study, which said IM was a better route because it worked just as fast as IV (when you allow for the time it takes to get an IV)and it is easier on the patient's system.

Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose.


Not to mention the number of times I have given Narcan IV, had the person wake up and rip the IV out of their arm before stalking off. Some would argue, better to put them in the ambulance, and then wake them up as they are coming in the hospital door so you don't have the problem of the patient's walking off, and then later succombing to the heroin when the narcan wears off. But again I read a study that suggests the reoverdose just doesn't happen all that much if at all.

Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport.

Hurricane Wind

I stopped at the State armory and unloaded five bags of clothes for the hurricane victims. I was ruthless going through my closet. Every Christmas I get a sweater from my father and his wife. They sit in my closet because I rarely wear anything besides my work clothes and then jeans or workout clothes when I am off. I piled a bunch of them into the bags. When I got to the armory, I felt good, but thought I should go back and get the rest of my clothes and bundle them up to.

I'm on a list at work to be sent down to Mississippi/Alabama to help out, but don't know if I will get deployed. They are sending five people every five days. I think the problem with me going is I work six days a week so it is like having to replace two people. We'll see.

It is my understanding that the company has sent an extra hundred ambulances and five hundred EMTs and a paramedics to the area where they have a base of operations. There is something to be said here for the benefits of a big ambyulance company in their quick ability to mobilize resources.

***

I have a large number of unexpected expenses lately. The columns in front of my house and the trim have been rotting so I have had to replace the columns and am getting the trim vinyl covered. My front teeth fell out a week ago, leading to a $2000 dental bill (and I have insurance) to get the proper dental work done and a replacement bridge put in. My computer died. I feel bad whinning about it in light of the situation down on in the Gulf states. It all demands a certain perspective.

I just read an excellent column this week from USA Today:

"Stuff" Doesn't Matter

I am regoing through my house to find anything -- clothes, canned goods, blankets -- anything I don't truly need that I can donate.

***

I have been upset by the government's priorities in recent years and by its complete bungling of the situation in New Orleans and the area both before and after the hurricane hit. By misusing resources, appointing unqualified people to key posts and just plain not showing needed leadership -- it has failed the American people. But I have to say my faith in the country has been renewed not by the politicians, but by the common men and women of the country. The number of people volunteering and giving freely is staggering, and being down at the armory, you couldn't help but be swept up by it. Clearly the storm has taught us that people matter. I'd like to see this lesson passed on beyond the moment and imbedded in our government policies permanently.

Here's a few other editorials and articles that I have found interesting.

New Orleans Growing Danger -- an article from the Philidelphia Inquirer last October forecasting the threat and possible damage from a killer hurricane.

New Orleans Crisis Shames Americans -- an early (September 4) BBC view of the crisis.

United States of Shame -- a scathing indictment of the government's bungling.

Americans Give Record Amounts -- an account of American's generosity.

Before the Flood -- a column about how Americans responded to the 1906 San Francisco Earthquake.


***

Later I read an interesting article in the local paper. The basic premise is that where have all these kind souls(donating clothes, food, and shelter) been when in our own city people are drowning in poverty. Shelters are overflowing, people are homeless and needy here.

"It's easier to drop off a check, a case of water or a few bags of diapers for the victims in New Orleans and feel like we did our part. Easier to avert our eyes when the calamity is just the daily drip, drip, drip of poverty all around us."

Sort of puts a damper on my self-congratulatory clothing donation at the armory. The writer has a point.

Drowning in Poverty Closer to Home

***

I think the hurricane is not yet done with us. I hope that it reshapes our national and local thinking. I sense a growing anger in the public as the days go past. I don't buy the latest spin that this is not the time to finger-point after the same people have just been finger=pointing themselves trying to deflect the critisim against them. You need to finger point. You need to find the blame, find the problems, and fix them so they don't happen again, even when the finger is pointing at your own nose -- our own noses.

Here in this state for decades we have been talking about the shape of our EMS system, and we say -- it is going to take a tragedy to get people to pay attention. They say to the people in New Orleans -- you knew this was going to happen and what did you do? You knew there were problems.

A month or so ago there was a big accident in a nearby town, a truck barrelled down a mountain and smashed into a bunch of cars. Several people were killed, many more injured. Even though the top administrative commanders all got medals from the Governor, the word from the street people was the scene was a disaster -- complete chaos. Nobody was talking to anyone else. Here in this state, you have many different local services, many chiefs, many chiefdoms.

It's been 4 years since 911 and I have recieved no relevant training in that time. I haven't been to one mass casualty drill nor given any new equipment. Something blows up in this town today, I will be the first one on scene, and I will be acting by the seat of my pants.

The EMS system, for all the good people working on it in this state is fatally flawed because it is not regional, but town by town. There are over two hundered ambulance services in an area smaller than some large state's counties.

By the way, how is San Francisco's disaster plan? Are they prepared for their version of a category 4 or 5 Hurricane in the form of an earthquake? Or like New Orleans or this state's EMS, do they just throw up their hands and say, well, let's hope it veers off at the last minute, let's hope we're lucky, let's hope its not when I'm on duty.

***

Breaking news: They have finally just now relieved the political hack running FEMA, relieved him not from his job, just from the hurricane relief effort.

FEMA Head Relieved of Katrina Duties

How does a man with no emergency management experience get to run FEMA?

Roommates

A woman in a nursing home is in severe respiratory distress. History of COPD. Her lungs are decreased with an expiratory wheeze. Her SATs are in the 80's. The nurse's aide who gives me her paperwork says she is a DNR, but the papers haven't been signed by her doctor yet. I give the patient a breathing treatment but it doesn't help much. Her breathing is very labored and irregular. At the hospital, the doctor peers over his glasses at the patient's respirations then looks at the unsigned DNR I have handed him.

"Well, I think we should get this signed," he says.

We clear the hospital and five minutes later get sent back to the same nursing home and the same room. The patient in the other bed is an obese woman having a full seizure. She is bleeding from the mouth where she has bitten her tongue. She has a CVA and IDDM history, but no seizure history. Her blood sugar is fine. I give her two milligrams of Ativan, which stops the seizure. She remains unconcious.

When we get to the hospital, she starts seizing again. It turns out she has a massive bleed in her brain. While she is a full code, her roommate now a few rooms over has gotten her DNR signed.

Both patient's families gather by their sides in vigil.

One a DNR. One a full code. Roommates.

Variance

I've been playing poker seriously for over five years. When I say seriously, I don't mean I play for big money, I mean that I am a student of the game. I read books about it, discuss the game with friends, run simulations, constantly try out new strategies. I started out playing in the local casinos, although now I mainly play on-line where the game is quicker and you can play multiple tables at the same time and the "rake" the portion of the pot the casino takes for itself is much smaller. To date, I consider myself a modest long-term winner.

Poker is a great instructor in life. It is a game that has three components: patience, skill, and luck. It is very much like life. If you are patient and skillful, you should be a winner in the long term, although short term anything can happen. You'll have streaks where you run well, and then vicious streaks of being beaten -- streaks that cause you to question yourself deeply. You have to stay focused on the goal -- playing each hand the proper way, putting your money in only when you are getting the best of it, not letting emotion overwhelm your better judgement.

One of the more interesting lessons in poker is variance. In Texas Hold'em, the best starting hand is AA. The odds of being dealt that hand are 1-132. But that doesn't mean you will get that hand once every 132 times. You might not get it for 500 or 1000 hands. Or you could get it three times in a row. And just because you get it doesn't mean you will win alot of money with it or even win at all. You might get aces, raise and everyone folds or you might get dealt aces, and your opponent, who has kings will catch a third king on the last card to take the big pot that you have pounded your money into, and you will lose more than if you had been dealt 2-7, the worst hand, a hand you almost always fold at the start. Getting beat when you have bet with the better hand is called a bad beat. You might have everything going for you, then that last card comes -- maybe the only one in the deck that will beat you, but the one feared card falls on the green felt, and you lose.

I think about EMS in poker terms sometimes. Right now I'm sort of in the dolldrums, waiting to catch a hand. I'm sitting at the table, I get my calls (my cards), nothing very interesting to play. Everything routine -- nursing home falls, old people feeling weak, psychs, minor motor vehicles. No big hands for me to show my stuff, no big hands to win or fail.

A few days ago I was covering a suburban town, when we got sent for a pneumonia. Not a minute later the next call came up in that town. As we headed south going lights and sirens we saw several police cars race north at unusual speeds. A two year old run over by a car -- his own mother backed over the boy in the driveway.

The crew that responded took him lights and sirens to the hospital, but he was dead. Nothing they could do. The medic on the call has kids of his own -- a tough memory for him to carry home to them.

I think about the mother -- how everything was probably going great for her -- sitting at the table, enjoying a good run of luck, she's healthy, has a nice home and family, the child has just had a birthday. Then she goes out and gets in the car. Imagine the sound or the feel as she encounters something unexpected as she starts to backup. She gets out of the car. The paper this morning quotes a neighbor hearing her scream, saying the only thing capable of making such a sound is a mother in distress over her child.

What kind of horrible hand was she dealt? The random events of a day all leading to the worst beat a person can ever take. What does the future hold for her? Will she be able to recover? Will she understand that there is only so much you can do to protect yourself and your family? That sometimes the cards just aren't on your side no matter how well you've played the game so far.

What does the future hold for her? What does the future hold for any of us?

***

Variance is a parameter that measures how dispersed a random variable’s probability distribution is. -- statistics website.

Honey, I Love You

I come in at six and find the night crew is out on a call. A few minutes later they clear their scene with a refusal, but then are dispatched to a possible dead body/overdose at a local business. They ask me to respond in the second ambulance to meet them there in case it is a workable code.

I am almost there when they slow me down, telling me it is a 10-45 -- a presumption.

The address is a local transportation company that relies on contract workers as their drivers. I find the night crew standing in the doorway of the hallway bathroom. I glance in. A large naked man is sitting on the toilet, bent forward, his head down by his knees. His body is mottled and rigorous. There is a syringe on the ground next to him. While we are standing there, his cell phone starts to ring.

You have the urge to pick it up and answer it.

We're thinking "What do you say?"

1. Uh, hello...
2. Fred's phone.
3. Hades.
4. Lucifer.
5. He's not available right now, he's ahhh... he's still being processed.
6. He's in the can.

We just let it ring.

Maybe it was his dealer.

Maybe it was his girlfriend.

***

A number of years ago there was a business where an angry employee came to work with an assault rifle and killed several of his co-workers and injured a number more. A medic, who was there, told me how as he walked through the room past all the cubicles, phones were ringing everywhere, and as he was presuming one man, he could hear the guy's wife on the answering machine, leaving a message saying, "Honey, are you okay? I've been watching the news. I just need to know you're all right. Honey, I love you, honey..."