Self Mutilation 2/2

One week later…

It’s morning at the start of my 48 hour shift as a paramedic intern. Having just checked out the rig I’m standing in the kitchen making coffee for the crew when the tones go off on the portable radios and the dispatcher comes up telling us the nature of the call and location. Taking a sad look at the stream of coffee just starting to drip into the pot I head out to the rig for the first call of the day.

Bouncing down the two lane rural highway with lights and siren I rush to put on my gloves before my palms get sweaty and make it nearly impossible.

As we take the side entrance into the mobile home park I get the feeling I’ve done this before. There’s the BRT and the neighbors in their bath robes in front of James’ mobile home.

I’m excited, this could be every intern’s dream – a call do-over. I’ll get a chance to ask the right questions in the right order, do my rule outs prior to medication administration, and not fumble while drawing up and connecting to the IV tubing. Redemption is within sight as I walk through the door.

Something is wrong. The fire crew isn’t taking vitals – they’re all just standing around the dinette. Seeing us walking in they part so I can see James. The fire captain shakes his head and picks up his clipboard. Walking out with the rest of the crew he looks at my preceptor and says, “DRT.”

I’m not sure what that means but I’m busy trying to figure out what’s going on with James. He’s sitting upright at his table, once again in boxers and flip flops, with a different bottle of wine sitting next to him with the ash tray overflowing with cigarette buts. One cigarette is still in his fingers, burned down to the filter. There is ash on the floor under his knee where his hand rests. He has new surgery scars on his chest with meticulously tied sutures.

I’d already seen a few dead bodies in my short career but never one that was my patient the week before or one that is my responsibility to pronounce. Okay, suck it up and do it by the book.

Tony has become a fly on the wall again, letting out the proverbial leash. I walk up and notice the mottled skin on his lower extremities, the ashen color of his face and torso, his glassy eyes with fixed and dilated pupils, lids still open from the fire fighter’s assessment. I grab his lower jaw as Tony had previously coached me. Rocking it up and down his torso follows the motion without the hinge of the mandible moving; rigor has already set in.

Now that I have hands on I notice how cold he is and how fresh the surgical scars are. He must have had surgery after last week’s trip to the ED. I place my fingers on his neck checking for a carotid pulse; nothing. I check for lung sounds in all fields and at the neck; no air moving. I place my stethoscope over his heart, no heat tones.

One last thing to do and I can leave.

I place the heart monitor leads on James’ torso; I need to record a six second strip of asystole (flatline) for my paperwork.

The room goes dark as I tunnel vision into the screen on the monitor. This must be what a vagal response feels like. Kneeling down to see the monitor better, or possibly because my knees just gave out, I hit print on the monitor. Where the flatline of asystole should be there is a perfectly spaced, consistent complex printing out of the machine at 72 beats per minute. What the fuck?!? That shouldn’t be there! Hell, that can’t be there!!

Now my vagal response has turned into SVT (supra ventricular tachycardia). I stand up to feel for a carotid pulse again. He’s cold and dead, there can’t be a pulse.

I move my fingers around thinking I may have the wrong placement and maybe I missed it. After ten seconds I’m positive there is no pulse.

As I pull my hand away from his neck my glove is tickled by fresh sutures on James’ left upper chest; the new surgical scar that wasn’t there last week. Underneath the skin is a small box the size of a matchbook. A pacemaker has been implanted to send out electrical impulses to the heart 72 times a minute in a futile attempt to stimulate dead cardiac tissue to contract, but it couldn’t overcome the damage that James had done with his habits and now it just served to trick the monitor into recording electrical activity in the heart.

My own SVT converts to a benign tachycardia and the lightbulb comes on: DRT means Dead Right There. I look over at Tony, who had never budged from his “fly on the wall” position. He saw the new pacemaker scars as soon as he walked in the door. I can only imagine his amusement at my momentary panic. Or maybe he’d already seen too many other interns react like I did and it was old hat.

On the slow ride back to quarters I’m going over the call in my head while sitting in the dim light of the back of the rig. I start to think about the coffee waiting for us and hope that it might actually still be drinkable. Then I look up at the radio in the front of the rig and wonder when the tones will go off again.

Self Mutilation 1/2

self

1: a person’s particular nature or personality

2: the identity, character, or essential qualities of any person or thing

3: the union of elements (as body, emotions, thoughts, and sensations) that constitute the individuality and identity of a person

 

mu·ti·la·tion

1: an injury that deprives you of a limb or other important body part

2: to physically harm as to impair use, notably by cutting off or otherwise disabling a vital part, such as a limb or vital organ.

 

 

As a paramedic intern I have three states of mind; call anticipation, call anxiety, and post call critical evaluation. During my 48 hour shifts with my preceptor I cycle between the three in a never-ending manic loop.

I’m standing in the kitchen of our quarters making coffee for the crew. It’s my routine after checking out the rig each morning.

The tones go off on the portable radios and the dispatcher comes up telling us the nature and location of our first call of the day; chest pain in the corner of the county at the far edge of our response zone. Unlike my current county which is mostly urban with a dozen hospitals, the county in which I interned was mostly rural with only three hospitals. Parts of that county were over an hour away from the closest hospital, and possibly even further from the closest most appropriate hospital. At least we’ll have coffee when we get back to quarters.

Siren wailing, strobes muted by sunlight, we speed across the two lane rural highway towards the water. I’m sitting in the back of the rig. My preceptor, Tony, is in the front holding the map book and directing his partner to the call.

Tony tells his partner to take the side entrance to the mobile home park by the water. With my call anxiety in high gear I look up through the windshield to see the BRT (big red truck) parked next to a mobile home, and neighbors in bath robes standing around the truck taking in the commotion like a Jerry Springer dinner theater. It’s a new experience for me as I can’t remember ever going into a mobile home park. Little do I realize how often this exact scene will repeat throughout my career in EMS.

 

Ambulances are drawn to mobile home parks by the same electromagnetic waves that draw ships into the Bermuda triangle. The same mysterious phenomena causes ambulances to be drawn to Walmart more so than other retailers.  I’m thinking there’s a correlation here…

Walking into the mobile home I see my patient sitting at a vintage 1960’s folding card table in the dinette; a bottle of cheap red wine sitting on the table, almost empty at 0915, and an ash tray overflowing with butts, one still giving off a slight stream of smoke.

The BLS (basic life support, meaning EMTs only, no paramedic) fire crew is finishing up a set of vitals and gives me a quick report as my preceptor becomes a fly on the wall giving me enough leash to run the call, but ready to cinch the choker if I screw up.

The patient presents with sudden onset crushing chest pain of 10 out of 10 severity, associated diaphoresis, non-provoked. Except for the cigarettes and wine.

James, my patient, is sitting at the table in boxer shorts and flip flops. His chest is scarred down the middle with an eight inch fresh surgical scar held together with staples. I will later come to recognize this as a “cabbage” (CABG – coronary artery bypass graft).

At this early stage in my experience I have to ask what it is. James tells me he had quadruple bypass surgery last week. The pain he’s feeling is exactly like the heart attack that led to the surgery.

As James is now on the heart monitor I print a strip: ST segment elevation in two of my three leads. I reposition the leads to get two additional views from S5 and McL1 as my preceptor taught me just last week. This rural county hasn’t adopted pre-hospital 12-lead ECGs so we have to do the “poor man’s 12-lead” by moving electrodes around the chest. More ST-segment elevation.

I may be brand new to the field but even I can do the math well enough to see this is a probable MI (myocardial infarction, also known as a heart attack).

We load James into the rig and start transporting. As with many other patients, we’re over twenty miles away from the closest hospital so we apply the common practice of “load and go” – start driving and treat en route to save time.

I run through my chest pain treatment protocol with staccato starts and stops. After running similar calls a few hundred times it becomes second nature, but the first few times it’s a conscious effort to remember everything. I ask about aspirin allergies before giving him an aspirin. I hold the nitroglycerine spray up to his mouth then quickly pull it back to ask if he’s taken Viagra recently. My hand fumbles while screwing the morphine vial onto the hub of the IV tubing. I have to do contortions to read the slash marks on the vial while cautiously pushing the drug into his vein. It comes loose from the hub so I have to screw it back on.

 

I also ask James how he could possibly keep smoking and drinking like he does after having heart surgery. “Don’t you know that your heavy smoking and drinking probably caused the heart attack that led to your surgery?” I asked. “Yeah, I know. But I just couldn’t stop.”

None of this goes overlooked by my preceptor. Sitting behind James in the captain’s chair I’m not really sure he’s even awake. He seems to have the uncanny ability to sleep through the siren noise, the bouncing of the rig, and the enormity of the fact that the cardiac tissue in James’ heart may be slowly dying. But of course he’s watching every move and saving his thoughts for the post call critique. Again, just enough leash and no choker yet so I must be getting it right – or at least I’m not getting it terribly wrong.

Arriving at the ED (emergency department) I stutter through a hand off to the RNs and MD that are waiting for us. They realize I’m an intern by the conspicuous lack of county patches on my uniform. The RN looks over at Tony silently confirming my report. He nods letting her know she has the full story.

Tony takes me aside after the call and runs down the entire event from start to finish. He gives praise on some aspects and well-meaning criticism on many others. Study points are identified and on the way back to quarters I practice with vials and syringes in the back of the rig to try to build the muscle memory.

Back in quarters I’m finally able to have my morning coffee. It’s two hours old and condensed to a bitter lukewarm shadow of its former self. I stare at the portable radios quietly sitting in their chargers and wonder when the tones will go off again.

 

Silent Alarm

Si·lent

1 : making no utterance : mute, speechless

2 : indisposed to speak : not loquacious
3 : free from sound or noise : still

 

Alarm

1 a call to arms <the angry trumpet sounds alarum — Shakespeare>
2 : a device that signals
3 : sudden sharp apprehension and fear resulting from the perception of imminent danger
Synonym: see Fear

Walking up to the car I can see he’s scared, eyes wide, head moving rapidly as he looks first at the fire medic, then at me, then back at the fire medic.
His compact car is perfectly parked in a parking space at an urban park, with no visible signs of damage. We have both of the front doors open. “Hey, what’s going on today?” he turns his head back in my direction and his eyes lock onto mine, but he doesn’t answer. Fear!

“Hey, what’s your name, can you talk to me?” No answer, head shaking side to side. I notice the cell phone sitting in the cup holder of the center console. Deaf guys don’t use cell phones, “Can you usually talk?” He nods his head emphatically. Now we’re getting somewhere.

I look over at the fire medic as he’s finishing up with a blood pressure and ask, “How did this guy call 911 if he can’t talk?”

“It came in from that jogger over there, he said this guy came up to him waving his arms, dialed 911 on the cell and handed it to him.” Strange. “I got a BP of 210 over 120, heart rate in the 130s” Crap, we’ve got a good idea where this is heading.

The fire medic walks around the car to help me transfer the man to the gurney. Standing next to the open driver side door, “You think this guy is stroking out?” We’re standing so the patient can’t see our faces. He’s already scared and things are about to start moving fast. “There’s a good chance, but I can’t run a decent stroke test while he’s sitting in the car. I’ll work him up in the rig.”

I have the man grab onto my hands so he can stand up out of the car and sit down on the gurney. No weakness on either side, at least not obvious weakness. Now I can see him from the front without having to turn his head. That might be a little droop to the right side of his mouth.

Closing the door to the car I see the cell phone again. I grab it and throw it on the gurney. I suspect this guy is going to be spending some quality time in the hospital for the next few days. This is a bad neighborhood and a cell phone in plain sight is reason enough to break into a car.

Once in the rig I start a Cincinnati Stroke Scale while my partner is getting him on the monitor and oxygen. Minor facial droop, no slurred speech as he’s not talking (aphasia), minor arm drift and leg weakness on the right side. Okay that’s good enough for a stroke. Blood sugar and 12 lead are all normal, but his blood pressure is still through the roof.

While I’m finishing up my assessment I’m doing rapid fire questions about medical problems and looking for head shakes to confirm or deny. Yes for diabetes, hypertension, and high cholesterol. Well there’s your trifecta that leads to everything that goes wrong in the head and heart. Of course the obesity probably kicked off the cascade but that’s a discussion for later when time isn’t critical.

One more question; “Did you stop talking right before calling us? This is important – I need to know exactly when this started.” He once again emphatically nods yes.

Okay, good enough for me. This definitely warrants a Code-3 trip to the CVA receiving hospital, which fortunately is just 5 minutes away. I have my partner call in a hot stroke activation and we get moving – everything else can be done on the way there. I have a three hour window where I can call it a hot stroke and the hospital still has the option of using thrombolytic drugs (clot busters) to break up the occlusion in the cerebral vasculature, assuming it’s not a hemorrhagic stroke (a bleed). But this is somewhat minor in presentation so I doubt it’s a bleed. I left my portable CT scanner at home again…

Bouncing through the downtown traffic, I can’t get an IV. He’s just too fat – his veins are too small and too far down to find, and I only give it one try. There’s a good chance this guy is going to a cath lab where they will need multiple IV access points and they don’t need me blowing all the obvious sites on a blind fishing expedition.

With all of my immediate tasks finished and just a few minutes out from the ED, I go through his wallet to get an ID so the hospital knows who they are treating and I have info for my paperwork. I decide to ask for a phone number and give him a piece of paper to write it down. Five numbers into it his brow scrunches up and the pen squiggles off to the side. He’s confused and can’t translate what’s in his head to the motor skills required to do a simple task. Crap, decreasing mentation!

I find his driver’s license and look at his name, “Okay Charles, couple of quick questions for you. How many quarters in a dollar?” Confusion, frustration, anger; wrong answer… “How many wheels on a car?” Eyes closed tight, left fist pounds the paper on his lap. He knows the answers, or at least he realizes that he should know them but he can’t make the intellectual jump from visualization to quantification – he can’t jump from right brain to left brain like he could just a few minutes ago. The insidious thing is he is fully cognizant of his deficit and still can’t make it work. Decreasing mentation and impaired cognitive ability. Crap, there goes my only reliable witness to time of onset!

Pushing the gurney into the critical care room filled with the stroke team I recognize the MD and start giving him my report as we’re helping Charles move over to the bed. I finish my report with the observations of the cognitive changes of the last few minutes. We both understand the ramifications of that finding. If Charles is not a reliable witness to his own condition then he could have been sitting in his car confused for the last 5 hours and doesn’t know the difference. The three hour window for thrombolytics is unconfirmed and the risks then outweigh the potential benefits of the treatment.

The nurses are hooking up their monitor, taking vitals, and unfortunately searching fat skin for any sign of a vein. Sorry guys, I couldn’t find anything either. The MD pulls some cards out of a drawer with pictures on them. The pictures are complex line drawings of scenes showing people, animals, cars, and buildings, with a twist. Every picture has elements that don’t make sense, like a three legged person or a dog with balloons for a tail. Charles doesn’t see the problems with the pictures. He can’t point to anything that is wrong with any of the pictures.

The MD turns back to me. “You sure you don’t have any other witnesses?”

“No, the only other person was a jogger but Charles was already aphasic when he approached him to call 911.”

My gurney is pushed up against the wall behind me. The MD reaches over and picks up the cell phone from the empty gurney. In the rush to get Charles moved over to the bed and all of the people in the room it got overlooked. “Is this his phone?” YES!

Flipping through the recent calls we see 911 and then another call made 25 minutes prior with a duration of 12 minutes. The MD hits dial for that number and gets a person on the other end. He’s able to confirm that Charles was acting normal and talking at that time. We now have a definite time stamp for onset of symptoms.

————

It would be nice to end with the MD pushing the magic clot busters and Charles thanking me as I strut out of the ED. Sadly, that’s not the case. I checked with the MD the following week and learned that they struggled for hours to get his blood pressure down to a safe level where the thrombolytics could work. They were never able to get it to a good range before exceeding the safe window of time. Charles regained speech eventually but still has minor right sided motor deficits. He may slowly recover in time but I’ll never know unless he calls 911 again and I’m in the area. Sadly that’s a real possibility also.

The experience of the MD and his insight to look at the history of the cell phone taught me an important lesson on using cell phone time stamps when dealing with CVAs. I honestly only grabbed the cell phone to keep the car safe. Now I realize the invaluable use cell phones serve in these situations and make it a point to find it in the house or car whenever I have similar patients. The good thing to come from this is that I’ve used them three times since with favorable outcomes. That doesn’t help Charles but I know that Charles has helped others. 

At the end of the day, that’s all we Paramedics can hope to have: the knowledge and experience that makes a difference.


Blunt Force Trauma

blunt

1: having an edge or point that is not sharp

3: slow in perception or understanding; obtuse

2: Slang: a cigar stuffed with marijuana.

 

force

1: cause of motion or change

2: an agency or influence that if applied to a free body results chiefly in an acceleration of the body and sometimes in elastic deformation

 

trauma

1: an injury (as a wound) to living tissue caused by an extrinsic agent

2: an agent, force, or mechanism that causes trauma

“Okay Ronald, you need to calm down and listen to me for a minute. Things are going to start happening very fast and I need you to focus. I know you can feel your heart beating way too fast and it hurts.” My cardiac monitor, sitting on the captain’s chair over Ronald’s shoulder, spits out a second 12-lead strip. Same interpretation as the first one: ***ACUTE MI SUSPECTED***
“I need you to chew up these aspirin while I explain what’s going on here. Whatever was in that blunt you smoked, maybe crack or meth, is making your heart beat too fast.”

He’s scared, staring at me with big, round, bloodshot eyes with that “doom” look that I’ve seen often with cardiac etiology. His heart is racing at 166 beats per minute, irregular, and his blood pressure is through the roof at 210 over 120. He smoked 20 minutes ago with some people he didn’t know and the weed came from an unknown source, so he has no idea what it was laced with.

When he told them he needed an ambulance they told him to “get the fuck out!” He called 911 from his cell phone a few blocks away.

Given the fact that he’s only 32 with no cardiac history it’s likely that his heart just can’t handle the fast rate and it’s causing some localized ischemia. Regardless of the etiology – whether it’s just the drugs or the unlikely occlusion of the coronary artery – I’ll activate him to the cardiac receiving center. They’ll have a cardiologist standing by when I get there to decide if he gets a trip to the cath lab or just monitoring until he calms down.

The siren starts to wail as we pull out of the parking lot where he sat waiting for us. I figure I’ve got maybe six minutes until we get there, just enough time to do what I can for him.

I hit transmit on the cardiac monitor and dial in the cardiac hospital. Bouncing down the road I place his hand on my knee and lift my heel up off the floor, making my leg an extra shock absorber so I can match the bouncing of the rig. As the needle finds a vein and gets a good blood flash I hear the monitor doing a modem handshake with the hospital to transmit my 12 lead.

Nitroglycerin and morphine are contra-indicated for his heart rate. It took a while to get used to that footnote in the protocols when I switched to working in this county because in my previous county it was part of our protocol. But so be it, I’ll play by the rules.

Fortunately we have decent sedation protocols for extreme anxiety, and I have just enough time to get two rounds of Versed on board before I get to the ED. Admittedly, I feel a bit strange treating a possible MI with a sedative but that’s what he needs right now. Ronald is really worked up, half from the unknown drug and half from the reality of the situation.

Versed is a decent drug – it’s used for procedural sedation in the hospital, like doing a reduction on a dislocated shoulder – give enough of it and you can put someone completely out, give just a little and it reduces anxiety. If you can titrate just right and walk the line between the two you can put someone in a very relaxed state yet they can still interact. It also has amnesia properties so people may not remember the pain they experience. That’s what I’m shooting for with Ronald but he’s a heavy guy so I don’t think I have enough time to get him there.

Backing into the ED another crew who heard us coming in code-3 opens the back doors and helps me unload the gurney. Walking into the critical care room the cardiologist comes in holding my transmitted 12 lead. I hand him the two follow up prints while I give a quick run down of the treatment I did and how Ronald responded.

They do a full cardiac work-up on him, and run their own 12 lead which comes out with the same interpretation. I always feel a little better when their machine and mine say the same thing.

They draw blood and send it to the lab to look for elevated troponin levels, the byproduct of distressed cardiac tissue. They’ll also run a tox screen to see what was in the blunt. Walking out, after giving a report to the staff I hear the cardiologist make an order for Ativan, another sedative. The ED has better drugs than I do but at least I got Ronald to the right place and started him in the right direction.

Off to the next call – my pager is buzzing on my belt and my dispatcher is chasing me out of the hospital for the calls that are stacking up.