Strike Out 2/2

We’re driving in the middle of the city after having just stopped at Starbucks to grab some caffeinated motivation for the day ahead of us. It was a long night yesterday as I was on the SWAT standby for an hour past my regular off-duty time. After the anti-climactic end to the situation I was able to go home and almost got enough sleep to make it through the next day. The hot coffee in my hand is helping to fortify my resolve as the morning commuters are exiting the freeway and the busy urban downtown area starts to come to life.

My coffee-inspired day dreams are interrupted by the computer on the console as it gets toned out and a call location drops almost on top of the icon representing our ambulance. The dispatcher comes up and tells us we have a patient with a laceration at the city police department on the second floor in the interrogation rooms. I’m actually looking right at the city police department building as the disembodied voice of the dispatcher is giving me the call information.

We pull up to the front doors as I load the gurney with all of my equipment and bid farewell to my warm coffee. I know we’ll be up on the second floor and the interrogation rooms are quite a ways on the other side of the building. Coming back to the rig for a Band-Aid could take a long time so it’s best to just take everything with us on the first trip.

A detective is waiting for us and proves to be a decent escort through the maze of the police intake and booking area as we make our way back to the interrogation rooms. The detectives aren’t really saying much but I can read their body language enough to know that something bad happened.

The detective opens the door to the little room and I’m faced with a complete blood bath. The tiny room looks like a set piece for the TV show Dexter with blood spatter covering the walls, desk, and floor. There’s a man sitting at the table with his hands cuffed to a metal ring on the desktop. Under his hands there is a fresh pool of blood.

I turn to the detective. “What the hell happened?” This is obviously the kind of high profile situation where Internal Affairs will get involved because someone messed up really badly. That explains why the officers were being so quiet and not telling me anything. The less I know about the facts the better it is for everyone when the investigation finally gets going.

The detective has a quiet voice as he fills me in. “So, did you hear about the hostage situation last night? Well, this is the perp from that scene. We had him in the room all night waiting for the morning shift detectives to come on duty. He asked for a soda. Someone gave him a can of Coke. He drank it, tore it in half, and cut his wrists with the sharp edges. We found him like this an hour later.”

“Wow!” That’s all I can say. I mean really, this is such a jacked up situation on so many levels I just don’t know where to start. The officers know how bad this is and they really don’t need the Paramedic to point out the sequence of stupidity that led to this bloody outcome. Whatever, I’m not here to judge, I’m just here to clean up the mess, as usual. But seriously, paper cups might be a good idea.

The man at the table hasn’t moved since I entered the bloody room but I can tell it’s the same man I talked to last night through the bars of the police cruiser. “Hey, are you okay?” Fine, it’s a stupid question but I have to start somewhere.

“Fuck you!” Seriously, are we going to play this game again?

Last night I could walk away from this guy based on the fact that he wasn’t visibly injured and refused all assessment. Today I can’t do it. I’ve got to check his wounds, bandage up what I find, and get him over to the hospital for medical clearance. He will eventually return here and be put on suicide watch.

I’m in the interrogation room and my partner, Anna, is handing me supplies to clean him up a little so I can see how bad the cuts are. As it turns out he missed the artery and all of the blood is just slow trickle stuff from the veins. He’s going to need some sutures and he’ll have some very impressive scars in a month or so when it all heals. Regardless of his medical outcome he just accomplished his third strike last night. He’ll be seeing the inside of a prison for the rest of his life, whether or not he manages to end his life a little early.

Three Strikes Laws are statutes enacted by state governments in the United States which mandates state courts to impose life sentences on persons convicted of three or more serious criminal offenses. In most jurisdictions, only crimes at the felony level qualify as serious offenses and typically the defendant is given the possibility of parole with their life sentence. These statutes became very popular in the 1990s. Twenty-four states have some form of habitual offender laws.

The name comes from baseball, where a batter is permitted two strikes before striking out on the third.

The three strikes law significantly increases the prison sentences of persons convicted of a felony who have been previously convicted of two or more violent crimes or serious felonies, and limits the ability of these offenders to receive a punishment other than a life sentence. Violent and serious felonies are specifically listed in state laws. Violent offenses include murder, robbery of a residence in which a deadly or dangerous weapon is used, rape and other sex offenses; serious offenses include the same offenses defined as violent offenses, but also include other crimes such as burglary of a residence and assault with intent to commit a robbery or murder.


Strike Out 1/2

strike

1 -  to try to hit or attack something

2 – Baseball; a pitched ball judged good but missed or not swung at, three of which cause a batter to be out

3 – Collective refusal by employees to work under the conditions set by the employer, a work stoppage

4 – to be unsuccessful in trying to do something

 

out

1 – to a finish or conclusion; the game played out

2 – a means of escape; The window was my only out

3 – used in two-way radio communication to indicate that a transmission is complete and no reply is expected

As the car passes the officer he recognizes the driver as a known felon. They’ve been briefed on this guy – armed and dangerous, two strikes down in a three strike state, gang affiliations with narcotic distribution. The plates on the car come back as stolen and the officer calls for backup before attempting a felony traffic stop. The man in the car knows that he’s been made so he speeds up, trying to outrun the officers. Every officer in this part of the city starts to converge on his location. When he finds himself boxed in he exits the car and starts shooting at the officers in their cars as he runs down the quiet neighborhood street. Seeing another officer blocking his escape route, he realizes that he’s trapped. He makes an abrupt turn and runs up to the nearest house. One kick to the front door and he makes entry into someone’s home. The officers hear screams as he takes a few hostages and yells threats through an open window. The officers surround the house but pull back as they initiate a SWAT call-out for a hostage situation.

The Bear Cat rolls past me and slowly drives up the street to park in front of the house where the suspect has barricaded himself. The six SWAT officers in the armored truck are positioned to report on any changes in the house and they will be used as a rapid reaction force if the suspect does something stupid like killing a hostage. Their job is to hold the scene at a forward position and react as needed to buy the rest of the team some time to formulate a plan.

From my vantage point in the incident command center I can see the SWAT commander setting up his game plan: floor plan of the house on a white board, arrows showing expected direction of attack, frequent radio communication and the occasional cell phone call. The SWAT snipers, dressed in woodland camouflage, begin the long and solitary walk to disappear into the neighborhood, with Remington-700 Police Sniper Rifles slung on their backs and a M4 duty weapons slung in the front. They quickly vanish from sight, undoubtedly taking up overwatch positions from rooftops a few streets away.

The SWAT Medic that is embedded with the team comes up to my rig and we make a game plan on various extrication scenarios and transport options. We’ll work under force protection protocols and enter the warm zone if necessary to initiate prompt treatment and extrication of wounded. If the suspect decides to force the officers into shooting him I’ll go in afterwards and make a field pronouncement. If he’s really stupid and starts shooting the hostages I’ll handle the initial triage and treatment while my partner calls for the appropriate number of units for transport. I’ll utilize the SWAT members to help extricate victims to the curb for the responding units to transport to the hospital.

The police helicopter finally shows up and starts doing lazy orbits of the house from 800 feet in the air. The pilot has the FLIR (forward looking infrared) turned on the house so he can see any movement. It’s sharp enough to pick up a hand on a window and discern our uniforms with the patches on the shoulders or the characteristic lack of heat signature where the ballistic vest insulates the torso. Unfortunately it’s not sharp enough to pinpoint heat signatures in the house. By now the snipers are in their overwatch position and I hear their quiet radio transmissions as they report on activities in the house as seen in their magnified scopes atop the rifles.

The rest of the SWAT officers start showing up to the command center that was hastily carved out of this quiet street in the middle of the hood. Their duffle bags of gear have been laid out like dominoes on the sidewalk. Officers who drove their personal vehicles into the hood stroll up to the duffle bags and begin their transformation from average citizen to door kicking SWAT officers. Black uniforms, heavy ballistic body armor, communication ear buds placed under headphones, and finally weapons loaded and made ready. The SWAT commander walks around to the troops showing a picture of the suspect as they prepare for the final showdown.

Whoomp! Whoomp! Whoomp! The continued noise of the forty-millimeter grenade launcher has been rhythmically pounding the house with tear gas for the last ten minutes. They systematically hit the house room by room – filling the interior with gas – until they have the suspect and hostages pushed to a back bedroom where there is no escape. I count 35 gas grenades before it finally goes silent.

The SWAT officers – who have collectively just heard a dispatch on the radio – turn in unison to walk down the street towards the house for the final assault. The K9 officer falls in with them and someone grabs a Halligan tool for door breaching. I’m going over scenarios in my head for possible outcomes in the next few minutes. I may end up with more patients than I can handle, with trauma that I can’t fix here on the streets. I could end up with wounded SWAT officers or a dead suspect or a random bystander shot in the mix. Maybe an officer twists his ankle on entry or gets a dog bite while going through back yards or a sniper falls off of a roof. Hell, anything could happen, I’ll just have to wait here and deal with the consequences as they come.

The tear gas grenades have been quiet for fifteen minutes now and the bulk of the SWAT officers turned the corner towards the house ten minutes ago – it’s been quiet since then. Out of the darkness from the direction of the house comes a lone patrol car backing slowly towards my rig. The officer steps out and walks up to my window. “Hey, we’ve got the suspect here, can you check him out real quick before we take him downtown?” Really, just like that and it’s over?

I walk around the back of the police cruiser to the back window which is rolled down. I can see a man in his mid-30s, hands cuffed behind his back, calmly siting in the back seat. I can talk to him through the bars on the back window. “Hey, are you hurt?”

“Fuck you!” Not exactly the response I was looking for but okay I guess it’s something.

“Did you get taken down hard or is the tear gas hurting your eyes?” It’s not the first medical assessment I’ve done through the bars of the back of a police cruiser.

“I said FUCK YOU!” Maybe I’m just asking the wrong questions.

“Are you saying that you don’t want any help from the Paramedics and you just want me to go away?” I think they call that a leading question.

“No, I don’t want anything from you. FUCK YOU!” Okay then. Somewhat of a limited vocabulary but he’s made his wishes quite clear.

I stand up from the window and address the officer who has been standing by waiting for me to complete my medical assessment. “He’s all yours.”

 

 

System Status

sys·tem

1 – a condition of harmonious, orderly interaction

2 – a group of interacting, interrelated, or interdependent elements forming a complex whole

3 – a set of principles or procedures according to which something is done; an organized scheme or method

 

stat·us

1 – a social or professional position, condition, or standing to which varying degrees of responsibility, privilege, and esteem are attached

2 – a state of affairs or a change in social standing

Beep, beep, beep. “Medic-20 copy Code-3. Respond Code-3 to 123 Main Street for the three year old unconscious.” The dispatcher’s voice comes across the radio interrupting me as I am filling out my status report. I glance at the computer to see where the address is in comparison to where Medic-20 is posting. Medic-20 is about a mile from the call location and I’m another mile further than they are from the call. I put the SUV in drive and start heading that direction. There is a certain advantage to having the entire system status on my computer in the supervisor’s rig.

There’s a sixth sense to interpreting the description that the dispatcher gives to a call and actually knowing what is going on before arriving on scene. The wording in this call and the location put the little hairs on the back of my neck on end and I feel it’s something that I should get involved in today. For one thing, a three year old doesn’t know how to fake going unresponsive. We see it every day with adults who just plain decide to shut down and let EMS pick up the pieces. But a three year old isn’t quite that devious. Besides that, the address is an indoor swimming pool and water park and there is nothing good about a kid who’s unconscious near water.

I’m catching too many red lights as I head in the direction of the call so I remedy the situation. “Dispatch, S-4, can you attach me to Medic-20’s call and show me en-route?” The dispatcher comes back at me in a monotone response, “S-4 copy, showing you en-route.” The computer on my console starts making tones and a green line is routing me to the location where I’ve already started driving. Now that I have clearance to run hot to the call I can turn on the lights and siren and make better time. I take my little SUV through the red lights without a partner to help clear intersections. It’s still a bit unnerving to drive Code-3 without someone to help navigate, but it’s necessary. The traffic backs up in front of me and I switch tones in the siren to activate the rumbler; a low harmonic pulse that literally rattles the inside of the vehicles in front of me until they pull to the right. Unbelievably traffic clears, allowing me to make good time to the call. As I’m pulling into the parking lot I see my crew walking through the doors at the main entrance with a gurney and the fire engine is already sitting in front of their rig. I park my little SUV behind all of the big boy toys and casually stroll into the building without any equipment and not wearing my gloves.

It’s a strange experience to enter the scene of an emergency without equipment or protection, but the fact is that I’m not here to work on a patient or bring tools to the scene. There are two Paramedics ahead of me and the entire complement of advanced life support equipment has been carried in by others. My job is to support the team and ensure that patient care is seamless in regards to agencies and environment.

I walk solo through the water park and just keep the others in sight as I follow in silence. Screaming kids and teens are playing in the water and on the slides, lifeguards are watching from elevated chairs, chlorinated water splashes my boots. Finally I catch up to the crew in the lifeguard office where the child is sitting in a chair.

I know the paramedic from my service who is Medic-20 today. She was a new Level-1 Paramedic that was assigned to mentor under one of my old partners last year. My old partner was assigned to mentor under me a number of years ago so it seems the cycle continues. My teachings have passed to my partner who passed them to this wide eyed young Paramedic standing in front of me who is now on her own and making her own calls. She takes the report from the fire medic as I listen over her shoulder.

“So, apparently the little girl was pulled out of the water without a pulse and not breathing. They did CPR on her and then someone brought her here when she started breathing and they called us. She’s doesn’t speak English, her parent’s aren’t here, and all we have is a neighbor who is basically no help at all. Right now she’s just lethargic but she’s alert, at least, as much as I can tell she’s alert, but she’s really not talking much at all.”

I’ve been looking at the little girl while listening to the report. It seems to fit her presentation. With all of the strangers poking her and taking vitals right now I would expect her to be a little more agitated. Yet she’s looking like she just woke up from a nap. I slip an ungloved finger up to her eye and touch her dark skin while pulling her lower eyelid down a bit; bright white. Okay, good enough for me, she had a hypoxic event and she’s recovering. The mucus membranes of the eye shouldn’t be that white yet if they are the person is either very dehydrated or recently had a hypoxic event; that seems to fit the story. As the EMT from Medic-20 and the firefighters are transferring the patient to the gurney I catch the eye of the Paramedic. She looks over with big round eyes and a bit of a question.

I quietly lean into her ear. “You have to treat it like a near drowning with return of spontaneous circulation. Your only question is do you want to drive close or far away and how fast to drive.” With kids you don’t take chances. Presumably the life guards have their CPR cards and should know what to look for in terms of breathing and pulse. If the kid truly had neither and now she does she needs a full work up and some chest x-rays looking for water in the lungs and ensuring that the CPR didn’t displace any ribs. The driving close or far away only refers to which hospital to go to. The kids’ specialty hospital is 45 minutes away in rush hour traffic. The local hospital is just seven minutes away.

She looks undecided for just a few seconds and then comes to a decision. “I want to drive close and I’ll start off Code-2 and upgrade if I need to.” It’s half a statement and half a question as she looks to me for approval in her decision.

“Sounds good to me. I’ll run interference with the neighbor so you can get out of here.” I would have said any decision sounds good right now. The patient is doing fine and she, as a new medic, just needs the exercise in making a decision and sticking to it. But in this case she made the same decision that I would have made – I guess my old partner taught her well.

As the Medic-20 crew starts to push the gurney with the patient towards the front of the building I step in front of the neighbor and start asking her questions. She’s a heavy set woman in her late forties who walks with a walker and moves slowly like she’s in constant pain. As I question her she’s distracted as she looks over my shoulder at the patient disappearing in the crowd as they head towards the rig. I know the Medic-20 crew just wants to transport as soon as possible. All medics are the same when it comes to kids in this situation. If the kid is fine they just want to get them to the hospital and out of their charge before something changes for the worse. Had I let the neighbor follow she would have delayed them another ten minutes on scene with her slow moving and a long production of climbing into the truck. Not to mention the liability of helping her climb out of the truck on the other end and the overall delay in getting the kid to a doctor is unacceptable in this situation.

Having intercepted the neighbor long enough to give Medic-20 a clean getaway I walk over to the head lifeguard and ask to talk to the lifeguard who pulled the girl out of the water. I want to get a better understanding of how things happened. She’s a very emotional fifteen year old girl. She can barely catch her breath from the sobs and stuttered gasps for air as she attempts a retelling to me. After three or four minutes and a few stops for tears I finally have a story that makes sense and I feel I can leave.

Pulling out of the parking lot I glance down at my computer on the console. Medic-20 is about half way to the hospital and they are still driving Code-2. So the kid is probably doing fine. I punch the Medic-20 identifier into my cell phone and get the driver.

“Hey, so I finally got a good story and some contact info for the family. The little girl was on a water slide between two bigger kids. They went down the slide and the two big kids came up but the girl didn’t. She was under water for approximately twenty seconds when a nurse pulled her out, found her to be pulseless and apneic, and started doing CPR on her at poolside. After 30 seconds of CPR she started breathing again and was taken to the lifeguard room. All I have is a first name for the kid and the parent’s first name and phone number – the neighbor really didn’t know much. I called the father who speaks enough English to understand what’s going on and he said he’s on the way to the hospital.” She thanks me and hangs up. No doubt she is now relaying the information over her shoulder to the medic in the back of the rig so she can tell a better story to the doctor when she does a hand off.

I take a slow drive to the hospital and once I arrive I see Medic-20’s rear doors open and the patient compartment trashed with all sorts of bins and wrappers strewn around with a disheveled monitor propped in the corner with all of its wires hanging out. I spend ten minutes wiping down the interior and putting everything back into place. I then walk over to my little SUV and pop the cooler open to pull out two ice cold gatorades and prop them in the front cab so the crew will find them once they get out of the hospital.

I drive off before they can get out of the ED so they don’t think I’m interfering in their day too much. It’s a fine line to be involved in the call and supportive of my crews yet still allow them to function as the independent Paramedics and EMTs that we value in this service. I try to tread lightly and reward often. If I do my job right they may even forget that I was on the call yet they will remember that everything ran smoothly. I find a quiet corner of the parking lot in some shade and go back to updating my status report.

 

 

Field of Honor 2/2

To the fire lieutenant as we’re loading up the ambulance, “Can you please call PD and have the poor steed put out of its misery?”

He laughs as he’s closing the rear doors to the ambulance, “I was thinking a mechanic might be more appropriate.”

I tell my partner we can start transporting and since it’s a fairly non-emergent call I’m chatting with my patient as I double check all of his vitals.

“Seriously, Segway polo? When did you start playing that?” I’m still having a hard time not laughing at the whole spectacle of the last few minutes. All of the participants were pale skinned, greasy haired, tech workers, looking like they just escaped from the cubicle jungle for a few hours of sunshine. Or possibly their employer kicks them out at lunch to prevent the workforce from succumbing to a vitamin D deficiency. My patient is a little older and has the look of a middle management office worker who was trying to keep up with the younger guys and inadvertently took a spill.

Segway polo is similar to horse polo, except that instead of playing on horseback, each player rides a Segway PT on the field. The rules have been adapted from bicycle polo and horse polo.

“We’ve been playing for maybe a year now. There’s a company that sponsors the event and they deliver the Segways to the park every Friday. We’ve had a pretty solid group of guys for a while now so we’re thinking of setting up a match against another company.”

I put the capnography nasal cannula on him to track his quality of breathing. Given his body style – tall and thin – I want to keep an eye out for the possibility of developing a tension pneumothorax. I can see that he is in a significant amount of pain by the waveform and the shallow tachypnea that I’m seeing on the monitor.

The Segway Polo world championship is the Woz Challenge Cup, sponsored by Steve Wozniak of Apple Computer. The first match was played in 2006 when the Silicon Valley Aftershocks played the New Zealand Pole Blacks in Auckland, New Zealand. The result was a 2-2 tie.

I start an IV and administer some Morphine to reduce the pain level a bit. After a few minutes I can see it’s working as the respiration waveform on the capnography monitor is starting to elongate to a normal shape. My patient eases back into the gurney in a more relaxed position as I turn the lights out and move to the chair behind his head so I can tap away at my computer to document the strange events of the last few minutes.

The spectacle of the Segway Polo players sticks in my head not so much as an oddity yet more as a somewhat sad evolution of a noble and practical sport – the sport of kings has beed usurped by the nerds. At one time the elite military horsemen of kingdoms would compete against each other to hone skills for warcraft. Now, with the advances in technology making personal conveyance machines more practical and the global economic woes making horse ownership less practical, the original sport is in rapid decline as the anachronistic adaptation gains traction.

The whole episode makes me think of other areas of warcraft that have evolved over the centuries. At one time a skilled archer would put countless hours into honing his skills with the bow in the hopes of defending his homeland from invasion and putting dinner on the table. Today any random gang-banger sticks a Glock out the window of a moving car and indiscriminately takes a life with the pull of a trigger finger.

Ultimately, the whole episode makes me just a little sad – not so much for this individual episode of life gone wrong – yet more so for the social commentary that can be extrapolated from my overall observations of the evolution of our society.

My patient did in fact have separated cartilage in two ribs and a hair-line fracture on one rib. He was sent home a few hours later with instructions to limit physical activity for a few weeks and a prescription for pain medication.

His trusty steed, the Segway, made a full recovery after a tune up by the mechanic. 

 

 

Field of Honor 1/2

field of hon·or

1 – a scene of a duel

2 – a region where a battle is being, or has been, fought

3 – the scene of the final battle between the kings of the earth at the end of the world

Polo strategy on hitting: Get your hand high for a long shot. Hit through the ball. Keep your arm straight until it passes forward and above the shoulder. Give yourself space hitting the ball – not too close to the horse. Take your time on the ball. Ride your horse before your hit the ball. Set your horse up for the shot.

Jamie Le Hardy – Polo Champion

He lays in the field of battle next to his trusty steed, writhing in pain and struggling to breathe; diaphragm spasming to the point that the lungs can’t function. Other combatants stand around him swaying in the awkward forward and backwards rocking motion that is unique to their mode of transportation. His polo mallet lays nestled in the grass next to him after causing the accident. His steed lies nearly lifeless just a few feet further away.

The origins of Polo date back to the 5th century BC in Persia where elite calvary units of the king’s guard used the game as simulated horseback battle.

As I walk up to the players on the polo field they canter away in their awkward little leaning motions to give me more room to inspect my new patient. We arrived with the fire fighters so our little entourage is trudging across the field while we carry bags and push a gurney to the crumpled man in the middle of the “field of honor.”

As with any injury of this nature one of my first concerns are the integrity of the neck and the neuro-function of the extremities. I run my patient through the battery of simple neurological tests while one of the other polo players recounts the events leading up to the injury.

Sultan Qutb-ud-din Aibak, the Turkish Emperor of North India, ruled as an emperor for only four years, from 1206 to 1210. He died accidentally in 1210 playing polo.

“Jim was shuffling the ball towards the goal and one of the defenders started to crowd him. It was totally legal and everything, he was just defending. So Jim went to score and took a big wind up with the mallet. When he took the shot his mallet got caught in the undercarriage of his mount and he got thrown. He didn’t pass out or anything but it looked like he couldn’t breathe so we called you guys.”

After all the neuro tests come back with no issues I sit Jim up and assess for any obvious abrasions, bruising, or swelling that would indicate a problem. Nothing really looks out of place until I encircle his rib cage with my hands and have him take a big breath. Jim practically jumps out of his skin with painful sensations shooting from his flank to the middle of his back. A closer inspection shows that the ribs are stable enough but it’s very likely that he separated some of the cartilage where the ribs connect to the spine. It’s not a critical injury but it’s worthy of some x-rays and sign-off by a doctor. Once I listen to his lungs I’m satisfied that the injury is probably localized to the ribs and not involving a collapsed lung – I’m ready to transport. I’m just worried about his poor steed laying in the grass, barely moving, with pitiful whimpering noises coming in small gasps.

To the fire lieutenant as we’re loading up the ambulance, “Can you please call PD and have the poor steed put out of his misery.”

Military officers imported the game of polo to Britain in the 1860s. The establishment of polo clubs throughout England and western Europe followed after the formal codification of rules.

 

 

Stagnation

stag·na·tion

1 - the condition of being stagnant; cessation of flowing or circulation, as of a fluid; the state of being motionless; as, the stagnation of the blood; the stagnation of water or air; the stagnation of vapors

2 – in acupuncture: a pattern of excess that occurs when the smooth flow of Qi is stuck in an organ or meridian – the primary symptoms are pain, soreness, or distention, which characteristically change in severity and location

3 – in western medicine: the retardation or cessation of the flow of blood in the blood vessels, as in passive congestion or occlusion

“My mind rebels at stagnation. Give me problems, give me work, give me the most abstruse cryptogram, or the most intricate analysis, and I am in my own proper atmosphere. I can dispense then with artificial stimulants. But I abhor the dull routine of existence. I crave for mental exaltation.”

Sir Arthur Conan Doyle – Sherlock Holmes

Officer Leung arrives at the Chinatown police sub station early every morning. He has a personal sense of ownership in that he opened up the station sixteen years ago and he’s been walking the streets of Chinatown ever since. After checking last night’s crime reports he sets out on his morning rounds of getting out to interact with the community. He’s a familiar face to the locals and he can’t walk more than ten yards at a time without saying hello to someone. Being a native Cantonese speaker he easily communicates with the locals and they feel the ability to approach him with everything from neighborhood concerns to telling him about the birth of a son.

It’s an experiment in community policing that started decades ago and is only now beginning to take hold and show results. Many people living in ethnic enclaves of our mostly urban city seldom venture outside of their comfort zone. They may have a mistrust of police and authorities and an inability to easily communicate in English. Because of this they are many times the victims of crimes that go unreported. The community policing model is an attempt to put a familiar face on the authorities and give the people in these areas the ability to thrive in a safe environment. Officer Leung is that face in this community and he loves his job – he feels he gives back to his community every day.

Chinatown is in the midst of its morning wake-up routine: produce trucks double parked and offloading fresh goods, vendors stacking baskets of fruits and vegetables partially in the sidewalk, succulent looking roasted duck and pork hanging in windows. Quickly following the produce trucks are the professional recyclers – men in small pick-up trucks, stacked high with cardboard, providing a service to the vendors and a small income for their family.

Jin has been doing this for years and he knows all of the vendors on his street. As he methodically breaks down the cardboard boxes and stacks them in the back of his truck his shoulder continues to hurt from the strain and the cold morning. He’s thankful he wore extra layers of clothing as it’s a cold day but he seems to be working up a sweat faster than usual today. as each layer of cardboard gets added to the pile in the truck the strain on his shoulder increases. Finally he drops to one knee, holding on to the side of the truck, and grimacing in pain as he sees Officer Leung stop next to him.

I really don’t like running Code-3 through Chinatown. The public cliché about Paramedics and EMTs is that they are adrenaline junkies who love to drive fast and live for the blood and guts of a gory scene. In truth, just about every co-worker I know is really happy when a call gets downgraded to Code-2 and we get to shut down the lights and drive slower. We get far more satisfaction from a complex medical call than a bloody trauma.

But running Code-3 in Chinatown is its own special kind of hectic. Putting aside the normal stereotype about Asian drivers, the real problem is the one way streets with delivery trucks double parked on either side and the intersections where pedestrians can cross in all directions at the same time. It’s a very confusing place to drive – much less Code-3. Fortunately, my partner is handling it pretty well and I just have to help keep an eye out for the random jaywalker.

When we pull up to the scene I open the door and I’m hit with the smell of Chinatown. It’s not unpleasant yet it is unique in the city. The fresh pastries from the Chinese bakery have a sweet smell that blends well with the roasted meat from the next storefront. Layered on top of the food smells is pungent odor of Chinese medicinal herbs that waft from the herbalist’s store. All of this mixes in with the closest and least appealing smell: burning brakes from our rig.

I walk over to the officer and the man sitting on the curb. “Hi Officer Leung, what’s going on today?” Over the years I’ve seen Officer Leung walking the Chinatown beat. He’s a refreshing fixture of the Chinatown landscape.

“Not really sure. Jin collapsed while stacking his truck. He said his shoulder hurts and he saw a doctor for it yesterday but it’s worse today. He only speaks Cantonese but I can translate for you.”

“Okay, how about we move into the rig so I can check him out. Ask him to have a seat on the gurney. Thanks.” The rig has plenty of room and Officer Leung is able to sit at the foot of the gurney without getting in the way. He’s easily able to translate all of my questions pertaining to the onset of symptoms as I try to figure out what’s going on and my partner sets up the monitor to take vitals for me.

Jin has the skin signs that scream MI: pale/cool/diaphoretic, wincing in pain, holding his left shoulder, respirations coming in small gasps. My priority is to set up the 12-lead and have a really good look at the heart. Yet as I open his shirt I’m surprised to see evidence of trauma – he has bruises all over his chest. I’m a little confused as this was presenting like the perfect MI; I remove his shirt so I can fully appreciate the bruises.

As I step back to get the overview of his condition it all comes into focus. He looks as though he was just attacked by a giant squid. He has maybe a dozen circular bruises on the front and back of his left shoulder – they look like giant hickies. Turning to Officer Leung, “Can you ask him to clarify, did he see a doctor yesterday or an acupuncturist?”

After a quick exchange of Cantonese I can rule out the giant squid theory and replace it with the likelihood that he is the recent recipient of fire cupping. It’s an acupuncture technique where a piece of flash paper is lit inside of a bulbous cup which is quickly placed on the skin. The fire sucks the oxygen out of the interior of the cup which then pulls the skin into the cup as it creates suction. The result is a number of circular bruises on the skin that look like a giant squid attack. The theory is based on the principlel that stimulating areas along a meridian will release the stagnation of energy and restore normal circulation. It’s a treatment that’s been around for millennia yet as I look at the results of the 12-lead ECG printing out of the monitor I can see it’s not the treatment he needs right now: ***ACUTE MI SUSPECTED***

 

 

Backdraft Postscript

post·script

1 - a paragraph added to a letter after it is concluded and signed by the writer; or any addition made to a book or composition after it had been supposed to be finished, containing something omitted, or something new occurring to the writer

As it turned out, Missy was a WUS. That’s not a disparaging comment about her intestinal fortitude – it’s a classification of stroke known as a “Wake Up Stroke.” According to a recent article in the American Heart Association / American Stroke Association entitled Thrombolytic Therapy for Patients Who Wake-Up With Stroke, approximately 25% of all strokes are WUS. Given that people may sleep 25%-30% of their life it can only be expected that a stroke will happen during that time in a proportionate number. EMS currently deals with a short (4-hour) window of time to rush a patient to a stroke center for thrombolytic therapy – if a stroke has a known onset of four hours or less, the patient is eligible for thrombolytic therapy. Outside of that window it is considered a “cold stroke” and thus ineligible. If the onset time of the stroke cannot be verified, such as in the case of a WUS, the patient is automatically ineligible for thrombolytic therapy. This latest article, however, states that the therapy may be safe in longer periods of time from onset of symptoms. Further studies are being conducted to explore the possibility of an extended time period for this treatment.

I recently attended a lecture series by a panel of neurologists on strokes and the latest trends in therapy. During the session the extension to the thrombolytic window was explained in greater detail. To paraphrase four hours of lecture, in the event of an ischemic stroke there is a proportion between necrotic (dead) brain tissue and the surrounding ischemic (under-perfused) brain tissue which can be visualized with a Functional MRI. With a proportion of 80/20 thrombolytic treatment would have very little effect. With a proportion of 25/75 thrombolytic treatment may have a greater effect and the potential benefits of extending the window would then outweigh the possible risks. The ramifications of this line of research is that every patient has their own personal window of opportunity for thrombolytic therapy which can only be viewed once that patient reaches a stroke center. This same research is showing that an extension of the window to as long as sixteen hours may be safe in some situations.

In the case of Missy I took her into the hospital running Code-3 because of the smoke inhalation and potential for an airway that may be in the process of closing. Yet I transported her to a stroke center, bypassing a regular ED with no specialties, to ensure that neurologists would be on hand to quickly evaluate her recent stroke symptoms. Unfortunately the extension to the thrombolytic window is still in the research phase and has not progressed to cover the WUS scenario at the local hospitals. The deficits from Missy’s stroke did not immediately resolve and she was not a candidate for thrombolytic therapy. She will undergo extensive physical therapy in an attempt to regain some of her left-side functionality.

Meanwhile, Stacy, the fire medic/RN who got caught up in the excitement of the fire to the point that she missed an obvious stroke in her patient, has since been promoted to Lieutenant…

 

 

Backdraft

back·draft

1 – a reverse movement of air, gas, or liquid

2 – an explosion that occurs when air reaches a fire that has used up all the available oxygen, often occurring when a door is opened to the room containing the fire

Missy woke up a little early and from the start she knew something was wrong. She just didn’t feel right and the world seemed just a little more confusing than usual. She tries to get up out of the bed but the weakness is just a little more pronounced than usual and she never makes it all the way out of bed. Thinking maybe it would help to bring the world into perspective Missy reaches for a morning cigarette with her left hand, but finding she can’t quite make that work she finally reaches across her body with her right arm, grabs the cigarette, puts it between her lips, and lights it while laying in bed. With the smoke inhaled deep into her lungs she starts to relax again and nod off.

There’s shouting from outside the house – someone is yelling at her. She opens her eyes and sees the flames overhead – gently rolling across the ceiling with the smoke starting to burn her lungs on every breath. She tries to get up but again the weakness is stopping her from getting out of bed. Suddenly there is light in her bedroom, as the door opens, this is quickly followed by intense heat as the flames erupt as if seeking the oxygen from the open door. Strong arms grab Missy and start to drag her out of the house. Once on the front lawn she can see the flames well above the roof as firefighters are breaking windows and drenching her house with water.

As we roll into the neighborhood my partner and I stop following street signs and just follow the smoke to the location of the medical call. We have to park a block away as the small residential street is full of fire apparatus and supply lines. We roll the gurney closer to the house, avoiding the standing water and six inch fire hoses that snake across the road. Sitting in front of a burned-out house is my patient, leaning forward in a tripod position, sucking hard on an oxygen mask, with both arms being held out to either side.

Stacy, the fire medic, is supervising two Explorers who are simultaneously taking blood pressures, one on each arm. Our county has a Fire Explorers program for youth who someday want to be firefighters – it gives them the opportunity to volunteer with a local fire unit and learn the basics of the job. Both of the Explorers seem distracted by the commotion of the fire; they glance repeatedly from the blood pressure dial to the flames. It’s obvious they would rather be squirting water than taking care of this woman.

Finally, Tracy has had enough and asks each of them for their findings – she knows I’m not going to hang out here all day waiting for kids to check a vital sign that I’m going to recheck regardless of their findings. The kid on the left gives us a report of 90 over 60, the kid on the right tells us it’s 180 over 110. I have a dead pan stare on my face as I wait for Stacy to give me a report.

Stacy is writing the two sets of blood pressures on the patient care form and handing it to me. “Yeah, I know, you’ll have to check the BP again. Basically she was smoking a cigarette in bed and fell asleep. The blinds caught fire and the whole house went up. She got caught in a backdraft when they went in to get her. She had moderate smoke inhalation without any visible burns. That’s about it. Are you good?” Am I good? Hell no I’m not good. But I’m absolutely ready to leave.

Having moved Missy onto the gurney we start the long trek back to the ambulance. We have to double back a few times because of standing water creating small lakes in the street and fire hoses blocking our way. Throughout the ordeal I’m grumbling to myself about the poor treatment of Missy. Yeah, great, they got her out of the fire, but her treatment stopped there. Stacy knows better, she’s also an RN at a local Emergency Department, yet she released her helpers to let them fight the beast while the Explorers tried in vain to take vital signs. She didn’t have a history and knows almost nothing about this patient except she was in a fire.

Once we’re back in the rig I can start over and give Missy a proper check-out prior to going to the ED. Looking her over I can’t see any obvious burns but I’m more concerned with her breathing and airway at the moment. I slip the oxygen mask off and shine a flashlight in her mouth and nose and find singed nose hairs with soot extending the visible length of the nares – not good. Soot in the mouth and on the lips – not good. Oxygen saturation of 86% on room air – not good. Wheezing in the apex of each lung with a stridorous noise starting to come from the throat – really, really not good!

As my partner prepares the Albuterol and Atrovent nebulizer to affix to the mask I put an end tidal carbon dioxide nasal cannula on her nose so I can keep a good record of her respiration trends and quality of breathing, but looking at her face something just isn’t right.

“Missy, we’re going to give you a breathing treatment to help you breathe a little better but I have to ask about your medical problems. First off, have you ever had a stroke?” I’m seeing the telltale facial droop on the left side with an eyelid that looks like it’s being pulled down in the corner.

“Yeah, I had me a mini-stroke a while ago. They said it’s because of the A-fibs. But I all better now.” Now that I hear her speak I can tell there’s a bit of a slur to her speech.

“So you’re saying you didn’t have any lasting deficits from the stroke; like facial droop or weakness on one side?” My partner just finished setting up the nebulizer but I need to finish this line of questioning before putting it on and obscuring her face with a mask. He moves up to the front and starts getting us out of the neighborhood; I haven’t given him a destination yet – we both know that destination will be critical with this woman – yet we need to get moving.

“You know, now that you say it, it feel kinda like that mini stroke right now. I could’t get out of bed and my arm jus’ seem like it don’t want to move like it should.” That’s enough for me. I run Missy through a series of stroke tests; facial droop, slurred speech, left side weakness, change in sensory appreciation from left to right side and minor cognitive disassociations (how many wheels on a tricycle, what color is an orange, that kind of thing).

I glance out the front window as I place the mask over Missy’s head and see that we’re just exiting the neighborhood. Rechecking her blood pressure I discover that the Explorer on the left was closest – she’s 84 over 48. I start to set up the Sodium Thiosulfate drip for the IV.  “Okay, you ready for this?” I yell up to my partner.

“Yeah, go ahead, where we headed?” He yells over his shoulder as he lights up, turns on the siren, and heads for the freeway.

“Well, you already guessed we’re going Code-3. We’re going to Hilltop ED; 44 year old female, moderate smoke inhalation, hypotensive, tachycardia, tachypnea, Albuterol/Atrovent/Sodium Thiosulfate running. She’s also got a cold stroke, unknown onset time, left side weakness, with a history of.”

“Seriously?”

“Yeah, seriously, that’s what started the fire.”

 

 

Dead Space Postscript

post·script

1 - an extra piece of information about an event that is added after it has happened

The patient in question did in fact have a massive pulmonary embolus known as a Saddle PE. Because the embolus lodged in the pulmonary artery at the bifurcation between the left and right branch, much of his lung capacity was not actively engaging in gas exchange. He was not able to offload the EtCO2 or fully oxygenate the blood. His altered state was actually a hypoxic event even though his lungs were clear and had perfect tidal volume. The EtCO2 reading was the only finding, other than skin signs and oxygen hunger, that pointed me in the right direction.

Upon turning him over to the MD at the ED I concluded my report with my findings and a differential diagnosis of PE. This bought me a raised eyebrow from the MD as a PE is a very difficult thing to diagnose without the help of a CT. That same MD seemed a little more on board with my findings when the patient flat lined ten minutes later and subsequently three more times before they pushed thrombolytics to dissolve the clot.

Later that night he was moved to the ICU and extubated the next day. He recovered with no lasting deficits yet he remained in the hospital for two more weeks as they continued to administer blood thinners and observe for any reoccurring emboli.

The bifurcation of the cherry tree is a beautiful analog for the inner vasculature of the lungs. Nutrients are carried along the trunk to the blossoms where gas exchange occurs and photosynthesis creates energy that is then carried back along the trunk. When a branch is injured the blossoms die and create a dead space. The cherry tree has the advantage of many bifurcated branches to continue the cycle – we only have one.

Dead Space

A decrease in perfusion relative to ventilation (as occurs in pulmonary embolism, for example) is an example of increased dead space.[3] Dead space is a space at which gas exchange does not take place, such as the trachea. It is ventilation without perfusion.

Saddle Pulmonary Embolus

A large thrombus lodged at an arterial bifurcation, where blood flows from a large-bore vessel to a smaller one. The ‘classic’ saddle embolus—which occurs at the bifurcation of the pulmonary arteries in fatal pulmonary embolism secondary to a centrally migrating venous embolus—is distinctly uncommon.

Segen’s Medical Dictionary. © 2011

Massive pulmonary embolism

As a cause of sudden death, massive pulmonary embolism is second only to sudden cardiac death. Massive pulmonary embolism is defined as presenting with a systolic arterial pressure less than 90 mm Hg. The mortality for patients with massive pulmonary embolism is between 30% and 60%, depending on the study cited. Autopsy studies of patients who died unexpectedly in a hospital setting have shown approximately 80% of these patients died from massive pulmonary embolism.

The majority of deaths from massive pulmonary embolism occur in the first 1-2 hours of care, so it is important for the initial treating physician to have a systemized, aggressive evaluation and treatment plan for patients presenting with pulmonary embolism.

 

 

Dead Space

dead

1 – having lost life, no longer alive

2 – having the physical appearance of death; a dead pallor

3 – not circulating or running; stagnant: dead water; dead air

 

space

1 – the infinite extension of the three-dimensional region in which all matter exists

2 – an empty area which is available to be used

dead space – a calculated expression of the anatomical dead space plus whatever degree of overventilation or underperfusion is present; it is alleged to reflect the relationship of ventilation to pulmonary capillary perfusion

Walking back into the ED room to get a signature from the nurse I’m momentarily surprised at the level of commotion surrounding the man that was my patient just a few minutes ago. I look up to the overhead monitor that displays his vitals and see the obvious cause for excitement – asystole, the most stable heart rhythm in the world, is marching across the screen and slowly erasing the beautiful complexes of normal heart beats as it fills the screen with the flat line of death. The Paramedic Intern pulls a short step stool out from the corner just as the attending MD makes the call for him to begin CPR. Well, I guess my differential diagnosis was correct, small comfort considering he’s dead now.

There’s a question in paramedicine that is useful to the Paramedic in deciding a course of action on any given call – is this person big sick or little sick? The speed at which we can determine the acuity level of any given patient helps us in determining how fast we move through the call. On occasion the first look at a patient can tell you everything you need to know in terms of acuity. As I walked into the bedroom I could see that this is one of those times. My new patient looked up at me from the bed and it’s obvious that this is big sick and I’ll be moving fast today.

The firefighters arrived just a few seconds before us so they’re still attaching the monitor  leads and trying to get a blood pressure. I know what they’ll find based on the patient’s skin signs alone. The term – pale/cool/diaphoretic – gets overused in our business but it still surprises me when I see these skin signs manifest on a patient. A man of his ethnic background would be hard pressed to look pale so the fact that he looks ashen tells me all I need to know. My first thoughts on a call like this are about extrication. I want to get this guy out of here, into my ambulance, and start driving. Everything else can be figured out on the way to the hospital but the main priority is getting him from the bedroom to the ambulance. The problem is that he’s over two hundred pounds and there are three flights of stairs between me and my ambulance.

I send my partner back to the rig for a stair chair as I start to take in the vital signs and patient history to see if I can paint a picture of the last few hours that led to this big sick presentation. It seems that he and his wife were out running some errands and he started feeling sick about an hour ago. He vomited once and now he’s presenting with an altered mental status, very low blood pressure (72/48), fast heart rate (118 bpm), clear lung sounds, and skin signs that are screaming “heart attack” at me. Of course that was until I ran the 12-lead for the second and third time. The results keep showing nothing even remotely concerning in the cardiac department. In his altered state the only intelligible uttering I can make out from him is, “I…can’t…breathe…”

I put a non-rebreather oxygen mask on him and start the trek of three flights of stairs to the ground floor and the relative comfort of my ambulance where I can start to figure this thing out. The new stair chairs with the revolving treads make quick work of the stairs while preserving our backs in the process. It seems we’re on the ground floor in just a minute or two and headed towards the ambulance.

Finally inside the ambulance, I have decent light and all of my tools at hand so I can try to analyze his condition while driving to the closest hospital. I’ve already ruled out the possibility of a STEMI (S-T elevation myocardial infarction – a.k.a. heart attack), which would require a cath-lab, so I am free to head to the nearest hospital. As I check his 12-lead a fourth time – on the right side this time, still looking for the elusive STEMI – the firefighters decide it’s a good opportunity to leave. Figures. Looks like I’m on my own on this one.

With lights flashing and the siren singing a duet with the air horn I bounce down the road while starting two IVs in my quickly fading patient. Once that’s done I set up two bags of warm saline flowing wide open to drop as much fluid on him as possible and try to keep that blood pressure out of the double digits.

I slip the non-rebreather off of his face and put on a nasal cannula that has a receptacle for reading the exhaled breath and measuring the end tidal carbon dioxide (EtCO2). I actually do a double take as the reading comes back as 8 when the normal reading should be between 35 and 45. Hell, I’ve stopped CPR and pronounced people dead with higher EtCO2 readings!

A number this low just doesn’t make sense. I listen to lung sounds again and they are still coming up clear. I check his blood sugar to rule out a DKA (diabetic ketoacidosis)  presentation and it comes up perfect. Sepsis could possibly take the reading this low and explain the presentation but not with an onset of just one hour. There’s only one other differential diagnosis that is making sense to me right now and when that flashes into my head I’m more relieved than I can admit to see the bright lights of the ED out of the back window as my partner backs us into a spot by the double doors and I prepare to give my findings to  the doctors on the other side.

In these days when science is clearly in the saddle and when our knowledge of disease is advancing at a breathless pace, we are apt to forget that not all can ride and that he also serves who waits and who applies what the horseman discovers. 

Dr. Harvey Cushing