Vicissitude

vi·cis·si·tude

1 – one of the sudden or unexpected changes or shifts often encountered in one’s life, activities, or surroundings

2 – a difficulty or hardship attendant on a way of life, a career, or a course of action and usually beyond one’s control

3 – unpredictable changes or variations that keep occurring in life, fortune, etc.; shifting circumstances; ups and downs

4 – a difficulty that is likely to occur, esp. one that is inherent in a situation

We walk up to the front door of the house. The diesel engines of the ambulance and the fire engine rumble behind us and their strobes light our way — and the rest of the quiet residential neighborhood. “This should be our last call. Let’s just bang it out fast so we can go home.” As soon as I said it I got that familiar sinking feeling in the pit of my stomach. Why the hell did I just say that?

It’s late at night in my mostly urban county and Louis and I have been working the last four days straight. To top it all off we’ve been held over every day due to the high call volume associated with the sudden heat wave. It’s not like we can just clock out when our day is done. If there are calls pending and not enough units in are available to take them then our dispatcher will hold us over. After the exhausting week that we just had we are finally seeing the light at the end of the tunnel with the idea that this could be the last call of the day.

That is of course until I said what I did. EMS personnel are some of the most superstitious people I have ever met aside from possibly baseball players. I resisted it for years until I just couldn’t ignore the trends. If I’m sitting in the front of the rig just passing the time and talking about a really bad code that I worked last year I’m practically guaranteed to get a really bad code on the very next call. When that happens once it’s coincidence. When it happens continuously for five years you start to respect the EMS gods by paying homage and doing everything possible not to piss them off. Well, I just pissed them off with a simple comment and I’m starting to get nervous as I walk through the front door.

It takes a second for my eyes to adjust as I enter. Standing in the front room of the house I know this is going to be a challenge. The multi-colored strobes from outside are casting harsh shadows in the poorly lit and cluttered living room, which is deserted. I’ve been inside the houses of ‘hoarders’ and this isn’t too far off; not the worst I’ve seen but the clutter is starting to pile up. I hear voices from the back bedroom and head that direction. Why is it always the back bedroom?

Standing in the bedroom are the LT and engineer. LT is writing down medication names on the run sheet and the engineer is just standing there. Their bags and monitor are sitting by the bed, still closed. They haven’t done anything for the patient yet. Down a tiny hallway is the fire medic standing outside of the bathroom. Finally I know where the patient is — the furthest possible location from the front door.

I can hear the fire medic doing an assessment down the hall as the LT brings me up to speed. “That’s Susie down in the bathroom there. We ran on her about four days ago for a lift assist after she fell. She refused transport last time. Today she’s been on the toilet for six hours because her legs are so weak that she can’t stand up. She was basically trapped back there until her sister came by to check in on her. So, first off, we have to figure out how to get her out of there because she’s really big. Second, we need to get social services involved because it’s obvious she can’t take care of herself anymore.”

I thank LT for the heads up and walk back to talk to the fire medic. I’ve run calls with him before and we have a casual familiarity. Turning the corner to the bathroom I see Susie sitting on the toilet. She’s maybe five and a half feet tall yet I estimate her weight to be 350 pounds.

Todd, the fire medic greets me, “Hey, how’s it going? This is Susie — she’s 81 years old. Basically, she doesn’t have any complaints — just increasing general weakness since the fall a few days ago. Her legs are too week to stand up right now and she needs a lift assist. But she said it’s okay to go to the ED to get checked out for the weakness.” Looking at her I can see that’s a great idea.

She’s pale — one might even say ashen — or it could be the harsh florescent lights in the bathroom. I’ll reserve judgement on that one. She has skin tears on her arms and legs with the discoloration of many bruises in various stages of healing. She’s breathing a little fast but otherwise seems to be in good spirits. There’s no visible distress. One of the skin tears on her leg looks fresh with the bright red sheen of an undressed wound.

I ask Louis to get the stair chair from the rig and he takes off to get it. There aren’t any stairs in this house but I can use it as a wheel chair to try to navigate the piles of clutter with Susie instead of trying to walk her out of here. I saw the walker sitting next to the bed on the way in so I know she doesn’t walk too well by herself.

The bathroom is very tiny so when she sits on the toilet the door is held open by her knees and she takes up the whole room. The firefighters haven’t really been able to access her to do an assessment because of the confined space. We’ll have to extricate her from the house as there isn’t any floor space available here, and get her to the rig before I can check her out. That’s fine by me — I work better in the comfort of my own rig. But it would be nice to have a set of vitals before we attempt to extricate her. Just as I’m thinking that Louis shows up with the stair chair.

Todd an I are able to assist Susie to transfer from the toilet to the stair chair. It must have been a comical sight as we’re doing our best to support her while reaching through the door. Once on the chair it’s up to Todd and I to do all the work and drag it out of the house — because of the clutter no one else can reach in to help us. Eventually we get her to the gurney that waits outside the front door. We now have a few more hands to help as we transfer Susie to the gurney and finally into the ambulance.

I throw some packs of disinfecting wipes to the firefighters — I know everyone feels dirty after being in that house — and then I start to assess Susie. This is the point that everything starts to go downhill as the EMS gods have their final say in the matter.

I clip a finger probe to her finger to read her oxygen saturation and heart rate but I can feel that her hands are too cold — so it probably wont give a reading. I put the stickers on her limbs to get a look at her heart and immediately see that she’s in a very fast rhythm — it’s not lethal but it’s not good either. I need to check her blood pressure as it can’t be too high with that fast of a rhythm. I can actually hear the EMS gods laughing at me — like gremlins in my stethoscope — as the needle coasts below 100 without the slightest hint of a systolic auscultation. Pulling the stethoscope off of my ears I hear the fire engine accelerate away from us. That’s just great!

In the last thirty seconds this call went from a simple lift assist and social services call to a Code-3 trip to the ED. With my assessment done I tell Louis to light it up and get moving towards the ED that’s only a mile away. Susie has a blood pressure of 92/64 with a heart rhythm of Supra Ventricular Tachycardia (SVT) at 172 beats per minute. She’s stable for the moment but she actually may have been this bad for the last six hours. I’ll need immediate attention as I get to the ED. That’s the only reason for the Code-3 return — if I do a Code-2 (without lights and siren) I stand the chance of getting stuck in triage for an hour waiting for a bed. At this point it’s more of a statement to the ED than a way to blow through traffic faster.

As we start to pull away from the house I lean down to try to reassure Susie that this is all just precautionary. Her smile and jovial attitude from before has been replaced by a frown and morose mood. I was careful not to voice any concern as i was discovering one bad vital sign after another, but she knows something is wrong. With siren blaring in the background she knows that her life has just changed. She may never be able to return to her house or to live alone again. The simple act of sitting on the toilet may be the single moment that will affect the rest of her life, and she knows it. I can tell from the look on her face that she knows life will never be the same again.

As much as I would like to talk to her right now I have work to do and only two minutes to do everything I can for her. I can attempt to convert the rhythm to a slower one if I can get IV access. A quick look at Susie’s arm tells me that’s not going to happen. She’s too fat and the veins are buried under an inch of bruised and torn skin. So I abandon the search and check my vitals again.

The finger probe still hasn’t registered her oxygen saturation. I pull out a tape-on probe and tape it to her ear lobe in the hopes of getting a reading by the time we pull into the ED. Taking my hands away from her ear I see an external jugular (EJ) vein that looks good enough to sink an IV into.

I don’t usually start EJs as most times I can get an IV started on a peripheral vein and I don’t like sticking needles into people’s necks, especially in a moving ambulance. But this looks like my only access. I tell Louis that I’m doing an EJ and not to bounce me around too much. I can hear the siren change tones as he’s navigating through intersections. I put the head of the gurney lower which allows the blood to distend the EJ making it a better target for my needle. I turn Susie’s head to the side and sink the needle in and disconnect the catheter. At this point I’m holding pressure just below the catheter in the neck so I don’t get sprayed with blood. I look over at the monitor which is right next to my head as I’m kneeling at the head of the gurney. The rhythm starts to fluctuate and drops to 60 beats per minute. What the hell! As I’m connecting the IV tubing and taping it down I see the rhythm on the monitor speed up again and resume it’s previous rate. I’ve got a little smile on my face as I realize what just happened but I don’t have time to dwell on it right now as I hear the beeping sound of the rig while we back into a parking space at the ED doors.

I reach in a cabinet and grab a preload of 6mg of Adenosine and a 10ml flush. Hitting print on the monitor I clamp off the IV tubing and fire off the Adenosine followed by the flush just as a nurse opens up the back doors of the rig.

“Did you convert her?” She’s standing at the back door with another crew that was at the ED; they are there to help us out if we need anything as they saw us come in with the lights on.

“I don’t know, we’ll find out in a second.” All eyes are on the monitor as the fast and regular rhythm starts to get uneven and finally goes to Asystole — flatline. As the last organized complexes trail off the left side of the monitor everyone holds their breath waiting for Susie’s heart to start working again. Adenosine induces a few seconds of Asystole in an attempt to restart the heart’s electrical impulses in a slower rhythm. It’s like rebooting a computer. It’s also the longest five seconds in anyone’s EMS career as you stare at the flat line and hope the EMS gods are in a good mood.

On the right side of the monitor a few organized complexes start to march across the screen, followed by a few more, and then like someone stepped on the accelerator they speed back up to the 170s. I look back to the door as four people let out a collectively held breath. “No, I guess I didn’t convert her.” I pull the cables off of Susie and the other crew helps us get her transferred into a critical room as I’m giving a report to the MD who’s waiting for us.

After filling out my paperwork I go back into the room to drop it off. They’re still working Susie up. I suspect the more they look the more they are going to find that’s wrong with her. I found out later that she finally converted after two more rounds of Adenosine.

I’m sitting in the front of the rig watching the full moon rise over the city and listening to the dispatcher dishing out calls every minute or so. We’re already an hour past our off duty (OD) time but I recognize the call signs of other units getting sent to calls who are over two hours past due to go home. I can tell this is going to be a long night.

I have a bit of a laugh at myself as I recall the drop in heart rate when I started the EJ. After spending 25 years practicing Chinese Kung Fu my fingers sometimes have a mind of their own and place them selves where they are needed. We did extensive study in acupressure both for healing and in knowing which points on the body affect different aspects of physiology. When I was holding the IV catheter down on the neck to prevent blood from spraying me I actually had my finger on a fairly reactive acupressure point called Stomach-9. It happens to be the one spot in the body where the vagus nerve is closest to the surface and vagal stimulation is actually possible from the outside. I’ve watched people get knocked unconscious as Stomach-9 was struck in a sparring match. Academically I know that vagal stimulation drops the blood pressure and heart rate through vasodilatation. Yet this is the first time I’ve ever watched this effect inadvertently stimulated while someone was on the heart monitor.

I feel a little sad for Susie as her life has just changed. I can only hope it’s for the better and she’s able to find herself in a decent place where she is taken care of. I ask the EMS gods to look out for her as I’m watching the full moon rise.

The dispatcher comes up on the radio again, “Medic-40, you’re clear for OD, have a good night and drive safe.” The EMS gods have been appeased…

 

Sexual Tension 3/3

Louis and I are taking a slow drive into the “killing fields.” That’s what we call this neighborhood since so many people die here from gunshot wounds and gang violence – cops, kids, bangers – they all die in this area. We just received the call – Code-2 – for penis pain. Now, you have to imagine that we see all kinds of stupid and tragic stuff all day long. Yet when penis pain comes over the MDT (mobile data terminal) in the rig we just have to laugh. I’m sorry but that’s the normal response. If my penis hurt I would go to my doctor or drive to the ED myself. Why the hell would I call 911?

But this is the poor neighborhood where people don’t have a primary care physician or any other avenue to the healthcare system other than by way of an ambulance to the ED. It doesn’t surprise me anymore, it just makes me sad. Code-2 also means that we are responding alone; no fire department to back us up. As we find the apartment building, not four blocks from a recent cop killing, we see bangers hanging out in the common area. We’re used to this – we always lock the doors to the rig, and have our heads on a swivel as we approach the building. Radios on our belts are on and we’re watching each other’s back as we walk up the stoop. Were I walking up here off-duty I would be missing my  wallet in less than a minute. Yet as they see we are EMS and not PD, the bangers are ready to help. They know we are only here because someone called and they look out for their own.

“Hey, you know where apartment F is?” The closest banger in his white tank top puts down his malt liquor and points up a stairway. “Thanks man.”

I’m walking up like I own the place – it’s better than letting my knees quake like they want to – and Louis has my back as we find the apartment. Knocking on the door, “Paramedics!” Louis pulls me back so I’m not standing in front of the door swing – or potential bullet trajectory…

A tall African American man in his sixties answers the door and motions for us to come inside. “Hey, what’s going on today?” I offer my typical greeting as I reach down and grab the remote to turn off the TV that is a little too loud.

“It’s my dick man, it’s hurt’n.” Before I can say anything else he unzips his pants and uses two hands to unfurl the most enormous penis I have ever seen. Sometimes I really have to take a step back and reflect on my career choice. I mean seriously, I just walked into a stranger’s house and he just exposed himself to me. Now I’m supposed to deal with whatever medical problem happens to pop up. Paramedics have an interesting mandate – whether we walk into a house with a blue baby, a dying grandparent, a choking sibling, or a wife who was beat up in a domestic violence, we MUST maintain the same expression on our face. People are relying on us to fix that which is beyond their own abilities to fix. And we do it day in and day out. Yet this is stretching my ability at the moment.

He unfurled maybe 14 inches of two inch diameter penis cradled in both of his large hands. “Okay, so what’s up, is this more swollen than it should be?” What the hell else am I going to say?

“Hell yes it’s more swollen and I can’t pee; nothing comes out!”

“So how did this happen, what were you doing?” Why the hell did I just ask that…

“See, I was have’n sex.” He lowers his voice. “And she kept saying, harder, harder, so I did and I guess I just rammed it in too hard!”

So I’ve pretty much got nothing left to figure out on this one; “So what hospital do you want to go to?”

He tells me that he goes to the County Hospital and starts walking back to the bedroom talking to someone saying he’s leaving. As soon as he turns away Louis and I look at each other – big mistake! We both double up in silent laughter and have to turn away from each other to regain composure before he returns.

I walk him out past the bangers, who ask if he’s okay, and into the rig. There’s not much I can do for this one so I give him an ice pack to stuff down his pants and just load him up with Morphine. Call it a male sympathetic response but if there’s anything wrong with a guys package then he deserves as much Morphine as my protocols allow me to push. It helps him, of course, but it also helps me get through the call without having to cringe every few seconds.

On the way to the hospital I do a quick lookup on my iPhone as I can’t remember the name of this condition. The result comes back quickly – paraphosis. It’s where the foreskin gets stuck on the proximal side of the head of the penis and constricts due to trauma. It constricts the penis and prevents urine from passing and creates a swelling of blood. It sounds painful and he’s only marginally better after the medication.

I get him through triage quickly by telling the nurse this is a matter of “life and limb” and it’s a damn big limb! I finish my paperwork and go back to his room for a signature. Sliding back the curtain I look in to see the MD injecting his penis with Lidocaine. UGH – another image I’m going to have to try to erase from my mind!

The MD tells me he’s going to numb the penis, clip on with a forcep, and pull the foreskin over the head. He’s using the Lidocaine as a local anesthetic and he’ll do a procedural sedation with Versed just before doing the deed. AHGGGHHH! Cripes, too much information.

Before leaving the ED, I decide to make a quick stop at the restroom – I learned early in my EMS career to never pass up an opportunity since I never know when I’ll get another. I have to let Louis know where I’m going, “I’m going to depress myself and hit the head,” I tell him. He replies, “Yeah, I think I’ll wait – I’m not ready for that kind of let-down just yet.” I wouldn’t even want to be as “well-hung” as my patient, but there’s still that male ego thing…

I go back to the rig to finish my lunch and hope for a nice and simple cardiac arrest call to erase the images of the last call from my head.

 

 

Sexual Tension 2/3

As we’re pulling up behind the BRT, Louis and I recognize the SRO from last week. This time we were called for chest pain – one of the EMS bread and butter calls. Standing in front of the lobby is a man in his late sixties wearing a camouflage jacket with a heavy-set woman standing next to him. A few firefighters are standing with him while the engineer sits in the cab. He’s old-school – he doesn’t go on medical calls.

Walking up I catch the eye of the fire medic. He tells me it’s a chest pain call and asks our unit number for his paperwork. Seconds after giving him my number their engine is pulling away. The patient and I are still standing on the sidewalk. That’s the way it is sometimes in the Big City – fire crews are tired of medical calls and take off as soon as they can.

I look at the fire sheet that the LT handed me before they bugged out to get the patient’s name. “Hey Jessie, so what’s going on today?”

“It’s my chest man, it just don’t feel right.” Louis is getting the gurney because if this is an actual chest pain call I don’t want to walk the patient and put more strain on the heart.

“Okay, so how bad is the pain?”

“No pain, man, it just feels like it’s thump’n too fast.”

I reach down and feel his radial pulse. Just a quick look but it’s upwards of 150 beats per minute. Would’ve been nice if the fire department had actually taken some vitals.

I’m getting Jessie settled on the gurney, “So what were you doing when this all started?”

“I was having sex man!” He’s got a big smile on his face; he’s proud of this proclamation. His wife, standing next to him holding his medications in a bag, hits him on the shoulder. “Hey cut it out!” he chides her, then back to me, “It’s the first time in a year.”

Despite the fact that this is an “emergency” he’s in a good mood and joking around with us and his wife. He knows something is wrong but he’s a playful man and won’t let it get him down. “Well, I’m sorry you didn’t get to finish you’re business.”

“Oh, I finished my business, don’t worry about that. I called y’all after I was done.” We all have a laugh as we’re wheeling him towards the ambulance.

I look over at the wife as we’re about to load the gurney in the ambulance. “Can’t you see this is a fragile old man, don’t you know you have to do all the work?” I’ve got a mock-accusation tone to my voice – I’m having fun with them as I sense they’re okay with it.

In the way that only a heavy set African American woman can pull off with credibility, she puts her hands on her hips, leans towards me, and with head bobbing for emphasis, “I WAS doing all the WORK, just ASK him!” Jessie just smiles…Louis and I are attempting to maintain our composure, but we’re only half effective.

I put Jessie on the heart monitor and run a 12-lead EKG. He comes back with Atrial Fibrillation with Rapid Ventricular Response at 162 beats per minute – no chest pain and no heart attack that my monitor can see. So basically, he’s got a fast and irregular heart beat – the electrical impulse reaches the ventricles of the heart and starts over sooner than it should. It’s not really a lethal rhythm that would require shocking him right now as his blood pressure is fine for the moment. It’s a rhythm that will either subside on its own or persist until he fatigues and becomes unstable. I can help it start subsiding by administering a sedative to help him relax. Some counties have beta blockers and anti-disrhythmics for use in this situation but unfortunately we don’t have that in our protocols. If he becomes unstable I can shock his heart back into a decent rhythm, otherwise it’s just best to help him relax and hope that it’ll resolve on its own.

As we’re driving to the hospital I start an IV and give him four milligrams of Versed to help sedate him and relax the heart. Because of his age and potentially unstable condition, he gets immediate attention at the ED, and a room close to the front where the nurses can keep an eye on him. The 12-lead that the ED runs comes back the same as my monitor’s interpretation and they pretty much just keep an eye on him until he calms down.

After a few more calls I take a patient back to the same hospital and get a chance to check on Jessie. He’s smiling and putting on his camouflage jacket as he’s getting ready to go home. “You doing a’right Jessie, ready to head out?”

“Oh yeah, I’m all good. I got me a fine woman to go home to!”

Sexual Tension 1/3

sex·u·al

1 – of, characteristic of, or involving sex, the sexes, the organs of sex and their functions, or the instincts, drives, behavior, etc. associated with sex

 

ten·sion

1 – the act or process of stretching something tight

2 – a force tending to stretch or elongate something

3 – mental, emotional, or nervous strain: working under great tension to make a deadline

4the interplay of conflicting elements in a piece of literature, especially a story

Louis and I are taking a leisurely drive to the call as it came in as a Code-2, which means no lights, no siren, and we obey the traffic laws. Being sent to the call Code-2 doesn’t always mean it’s non-emergent; it just means that the call taker in the 911 center was unable to find any critical problems during a brief conversation. I’ve had many Code-2 calls that resulted in a Code-3 trip to the ED. This happens either because the caller is unable to fully convey their problem to the call taker, or the call taker is unable to interpret what is really going on. I don’t fault anyone for this. I mean seriously, I sometimes have a hard time understanding what’s going on even when a patient is explaining it to me in-person. If anything, I’m surprised that calls aren’t mis-lebeled more often than they are.

This call came in as a possible dislocated shoulder. Now granted, this isn’t the most critical of calls, but I would think it deserves a full response of Fire and EMS running Code-3. But I have to follow the directions of the dispatcher; I can’t go upgrading or downgrading a call based on my intuition. I’ll just have to apologize to the patient for taking fifteen minutes to reach him if it turns out to be a real emergency.

We roll up to the converted hotel in the middle of downtown Big City. The address is for an SRO (single room occupancy) and the room is on the fourth floor. When tourism dropped off the older hotels became vacant as people wanted the newer, more modern ones. Developers came in and converted the older hotels to SROs and classified them as low-income housing, for which tenants pay by the day, week, or month. Having been in the majority of them in the city I know what to expect – dirty, unkept hallways and tiny little rooms with a hot plate and mini fridge. There’s a shared bathroom on every floor.

Fortunately, as we drive up to the lobby, it appears my patient made it down to the street and is walking towards the ambulance as Louis puts it in park. My new patient seems to be a man in his late forties being supported by a woman in her mid thirties. I hop out of the ambulance and walk up to him.

“Hey, what’s going on today?”

“I think I threw my shoulder out. It hurts like hell!”

I take the coat off that’s draped across his shoulders so I can get a better look. Sure enough, anterior rotation with deformity. “Yeah, looks like it’s out, this ever happen before?”

“Yeah, just last week; same thing. It happens a couple times a year.” The woman is just standing there holding his coat and caressing his head as he’s in pain. Louis is pulling the gurney out to bring it to us so my patient doesn’t have to walk any further.

“What were you doing when it went out?”

“We were fix’n to have sex!” She slaps him on the good arm. “Hey, stop it! The man asked.” He’s just a little bit proud of the situation; she’s a little embarrassed, at least I think that’s what’s going on. “I was about to climb on top, supporting my weight with my arms, when I felt it slip.” She actually starts to push him to the gurney as Louis is almost here.

We get him loaded into the rig and Louis looks at me with anticipation. “Yeah, go ahead, it’s all you.” Louis dives into the cabinets and grabs the triangle bandages to make a sling and swath to support the shoulder. We’ve had a couple of shoulder dislocations in the last week; it’s a common injury in late summer as the first few football practices start up at the local schools. Louis has been working on his sling/swath technique so he’s excited to get this one perfect.

I take a set of vitals and start getting set up to administer some Morphine for pain and some Versed for sedation. If I can relax him now the muscles will stop pulling against the shoulder and make the reduction a little easier when we get to the hospital. In his current state the muscles and tendons are actually contracting to apply tension to the shoulder, and that keeps it out of the socket. It’s got to be excruciating! 

Just making conversation while I’m getting things set up, “Is your wife going to be coming to the hospital with us?” I noticed that she kissed him while we loaded him in the rig but had since disappeared.

“No she’s not coming, and she’s not my wife. But she might as well be – I’ve been seeing her for about eight years.”

Louis finishes up the sling and swath with an ice pack on the shoulder about the same time as I sink the IV in the vein on the other arm. Louis did a great job; it’s always a good feeling to get the same call just a week apart so you can do things better the second time.

As we’re leaving the curb for the five minute ride to the hospital I inject the pain killer and sedative. My patient is feeling much better now and he asks for his coat so he can get his cell phone. I have the lights turned down and I’m just working on my paperwork as I hear him on the cell phone.

“Hi honey…yeah I’m going to be a little late tonight, my shoulder went out again and I’m on the way to the hospital…yeah, I love you too.”


Distraction 2/2

Walking into the entertainment center I see the jumpy house with it’s bright yellow entrance which matches the yellow of my gurney. Sitting on a bench is a woman holding  a small girl who’s bleeding from the foot. The firefighters walked in maybe 30 seconds before we did. I’m in the more affluent neighborhood of my mostly urban county. The fire crews are more pleasant here as they don’t get run as hard as the inner-city crews. They are quick to break out the bandages and stop the bleeding.

Fortunately I’m able to get a look at the wound before it’s completely covered. It’s a one inch evulsion (skin torn away from underlying tissue) to the top of the small girl’s right foot; muscle and adipose tissue are visible where the skin should be. It looks as though someone just carved away the skin with a knife. The girl, whom I come to find out is named Kimberly, is crying. It’s more of a sad constant cry than a hysterical outburst. She must be quite a mature little lady not to be flipping out right now. Her mother, on the other hand is very distraught; brow furled, talking quietly in her daughter’s ear, she’s holding on by a thread. While inspecting the foot I notice that Kimberly’s pants have a thick quilted lining sewed into them; obviously a modification. I start to ask the mother questions; I want to take her mind off of her daughter as much as I need to understand what happened here.

“I really don’t know, I mean I only turned my head for a second.” Her brow is furled, voice cracking under stress, trying very hard to hold back the tears; very emotional. “One of the other children must have landed on her. She has Ehlers-Danlos Syndrome so she’s susceptible to skin tears.”

There are so many syndromes out there, I may run into the same one every few years or never see one in an entire career. I have to be honest with her. “I’m not familiar with that syndrome. How does it effect the skin?”

“It’s genetic, I have it also and passed it down to her. We’re missing the gene that creates collagen in the skin so the skin and connective tissue have no elasticity; even a simple bump can create a tear.”

Now that she’s focusing on me and not the compounded levels of guilt about her daughter I see that she’s a well spoken, educated woman. She has lived with this syndrome for all of her thirty something years and is fully versed in all of it’s intricacies.

I’m not going to be able to do much for Kimberly other than understand the nature of the syndrome a little better then treat the symptoms. Genetic repair hasn’t made it to the pre-hospital bag of tricks yet. “Are there any bleeding, coagulation, or clotting issues associated with the disorder?”

“No, it’s strictly collagen, it doesn’t effect the blood at all. That’s why I made the padded cloths and protect her as much as I can but they said she had to be bear foot in the jumpy house. I knew I shouldn’t have let her go in but it’s a special day.” She’s doing her best not to loose it in front of her daughter. The firefighters have finished wrapping the foot and Kimberly has stopped crying; just sporadic whimpers as she’s held in her mother’s arms.

Their both on the edge of cracking, I need to keep them focused on me to avoid a negative emotional feedback loop. “Okay, so Kimberly’s foot is protected now that it’s wrapped, how about you let me take you to the hospital? Their going to need to close the wound, either with sutures, or possibly a glue, to protect against infection.”

“No, I’ll drive her myself, God knows, I’ve done it before.”

“So, here’s the thing. She’s perfectly stable right now and I have no problem letting you drive her. But you’re very emotional right now. It would be much better if you had someone else drive so you can take care of her on the way. The last thing I want is to get called to a traffic accident and find the two of you there. Is your husband around or can you call him?”

“No, he’s out of the picture, I’m here alone.” Her non-emotional response tells the whole story. Paramedic opens mouth and inserts foot; news at eleven…

“Then it’s definitely a good idea to let me take you, it will keep the both of you safer and I can give Kimberly some medicine to help with the pain a little.” She agrees with a bit of a relieved look on her face. With all of the issues that she’s dealing with right now at least this is one less thing to worry about and she can focus on her daughter.

Once in the rig I tell my partner that we can start moving; all of the necessary treatment was done on scene by the firefighters. Kimberly is laying on the gurney in the back of the rig with mom sitting next to me on the bench seat. Kimberley is still letting out a soft stream of whimpers.

While I’m explaining to mom that I can give Kimberly some morphine for the pain I reach up to the front of the rig and grab my iPad. I don’t like to dope kids when their parents are present without a good explanation. I’m planning on using the iPad to keep Kimberly busy while I draw up the morphine and explain the effects to mom. I launch an app and hand it to Kimberly, after surreptitiously checking for blood on the hands.

“Kimberly, this is Talking Carl, say hello to him.” She looks at the screen to see an animated character waving at her. He looks like a short fat sibling of Gumby.

In a tentative voice, “Hi Carl.” Two seconds later in a slightly higher pitched voice Carl’s mouth moves and he mimics Kimberly, “Hi Carl.” bobbing back and fourth he waves at Kimberly. She starts giggling, “Mommy, he talked to me!” two seconds later Carl starts giggling and moving his mouth and in his exaggerated high pitch voice, “Mommy, he talked to me!

This goes on for ten minutes of giggles and laughter as we drive to the hospital. I show her how to tickle Carl on the screen and Carl starts laughing then she laughs and Carl mimics it and it starts all over again. It looks like we just created a positive emotional feedback loop. As Kimberly is now busy and mom is actually starting to smile for the first time since I met them I have a minute to look up the syndrome on my iPhone. It’s exactly what mom described.

With Kimberly fully engrossed in playing with Carl I see a relieved look on mom’s face and we have a few minutes to talk. Quietly so as not to distract her daughter mom confides in me. “I didn’t want to take off her shoes but they said she had to be bear foot in the jumpy house. I just wish I could wrap her in bubble wrap for the next ten years..” She’s conflicted with emotion; she wants to protect her daughter but at the same time she wants to let her explore, have fun, and be a normal child. She remembers her own childhood all too well and wants to do good by her daughter.

I’m pulling out my iPhone again, “Have you ever seen the shoes that martial artists wear to protect their feet when they spar? It covers the top of the foot with a half inch of foam dipped in a rubber coating. It’s bare foot on the bottom so it might be okay for the jumpy house.” I pull up a picture on my phone and mom sees how it may be applicable to her little girl. It’s not bubble wrap but it’s a good idea. We spend a few minutes browsing the site and looking at the different protective padding options that may be applicable.

As we arrive at the ED they are both a little more relaxed. Walking into the room, pushing the gurney, to get Kimberly settled in the bed I realize that I actually had two patients on this call; Kimberly with her foot and her mother with her anxiety. I didn’t lay healing hands on either of them nor did I open up the drug cabinet or perform any paramedic skills. Rather I treated with compassion, conversation, laughter, and a little distraction.

Distraction 1/2

dis·trac·tion

1 : a thing that prevents someone from concentrating on something else

2 : the act of distraction or the condition of being distracted

3 : something, especially an amusement, that distracts

4 : extreme mental or emotional disturbance; obsession

Kimberley always new she was different, ever since she was young. Now that she’s older she’s starting to understand it better. Mommy says that she can get hurt easier than the other kids so she has to be extra careful. But this is a special occasion; today Kimberly turns six years old.

Kimberly has her padded pants, her thick long sleeve shirt, the squishy headband around her head, and a big smile on her face as she enters the jumpy house. All of her friends from school are here; brightly lit faces and laughter as the primary colors of the inflatable castle illuminate everyone in a surreal light. The smell of kettle corn and pizza speak to the treats that await them when play time is over.

Outside the jumpy house Kimberly’s mother nervously talks to the other parents as the inflatable castle deforms from the constant jumping of the kids inside. She had reservations about bringing Kimberly to this place today but she wants to let her beloved and sheltered little girl have a special day. She paces outside the jumpy house, holding her breath at every fall.

She carries the weight of the world on her shoulders. Being a single mother of a fragile little girl she is on constant vigilance for Kimberly’s safety. She carries the guilt for her contribution to Kimberly’s condition and the roll that it may have played in her father taking himself out of her life.

One of the other parents brings her a soda as they all know she wants to stay close to the jumpy house. As she turns to accept it the smile of gratitude turns to alarm as she hears the sound of Kimberly cry out in pain. It’s a primal instinct that all mothers are programed to respond to; the sound of their child in distress. Spilling the drink on her shirt as she rushes to the clear observation panel of the jumpy house she knows what what to expect from her own experiences.

Laying in the corner of the jumpy house is Kimberly. Blood smears the bright yellow inflatable fabric, children scatter away from her daughter as they don’t understand what’s happening. How can such a happy experience go bad so fast? Kimberly’s mother knows exactly how it can happen; from personal experience and from the lengthy explanations from the geneticist.

Candy Man 2/2

The dispatcher comes up giving us a call back in the “Flowers.” We call it that because all of the streets are named for different flowers. It’s also on the list of spots to avoid today. “Medic-40, respond to 1055 Rose St. for the 242, unknown assault. Please stage, your scene is not secure.” Fabulous!

Louis punches the address into his GPS and starts driving. I reach back into my bag and pull out my body armor. We’ve been partners for a few weeks but he hasn’t seen me pull this out yet.

“Oh that’s just great dude, where’s mine?”

“Sorry man, I think yours is at the store waiting for you to buy it.” We have a fun banter throughout the day — our way of releasing some stress. Maybe it sounds twisted but everyone I’ve worked with is like this; we make snide comments, totally inappropriate observations, and have some pretty dark humor before and after a call. Once we’re on scene and in the public’s eye we are 100% business. It’s a coping mechanism that seems to work.

Before entering the Flowers our dispatcher tells us that the scene is secure and we’re clear to enter. That didn’t take long; probably because the whole police force is mobilized right now.

Covering the last few blocks to the call I can see people standing in front of houses for maybe four blocks. The whole neighborhood is outside to see if this is the guy from the manhunt. I’m sure everyone in the city knows what’s going on right now.

As we pull up I can see firefighters on the corner treating a person with blood on his head. Louis and I have already talked about how we’re going to handle this one. Despite what the dispatcher says, there is nothing secure about the city today. So we’re going to hold our scene time to a minimum and treat every call as a “load and go.”

Walking up I see a small pool of blood on the sidewalk, an eight foot pole with cotton candy bags tied to it, and a man in his twenties getting put on a back board. The fire medic tells me that this is one of the street vendors that walk around selling stuff (usually ice cream or candy) in the urban neighborhoods. He has a bicycle horn tied to his pants with a string — he honks it as he goes up and down the streets to let the kids know he’s around. Two guys jumped him for his cash — a totally random act of violence, and particularly low considering that this guy probably only makes $50 or $60 per day. Looking at the pole with the candy on it I’m even more disgusted — the pole is still half full, so they couldn’t have gotten more than twenty or thirty dollars.

As we’re strapping him to the board I just can’t help myself; I honk the horn. Well, I guess I’m not always appropriate on scene. That seemed to lighten the tension a little with the other firefighters and PD that are standing around us. I get questions about the vest and nods of approval; today it’s very appropriate.

We load him in the rig, I jump in after him, and I tell Louis to take off. Eight minute scene time — not bad! It’s not a trauma activation but we don’t want to hang out in the hood any more than we have to today.

We’re driving out of the Flowers without lights or siren; it’s a Code-2 trip to the closest hospital. I do my secondary assessment which reveals nothing new — just the minor bleeding from a laceration to the left orbit and some swelling to the cheeks. I’m doing my assessment and talking to Jose, my new patient, in my pigeon medical Spanish. I learned to do a pretty good Spanish assessment when working in the rural county where I interned, which had a large migrant field worker population.

I give Jose an ice pack and he’s able to hold it to his cheek as I put a sterile dressing on the laceration. As I’m reassuring him that everything is fine and this is all just precautionary he starts to cry; he’s getting very emotional and scared. I think I see what’s going on here.

“Señor, soy un paramédico no un policía, todo es bueno.” I look out the window to see that we’re out of the Flowers so I pull the Velcro straps on my vest and take it off. It says Paramedic in big letters on the front and back but even still I look like a cop to him. I want to take it off to make him feel a little better.

I still remember being in the rural county with my preceptor on Halloween. We thought it would be fun to hide in the ambulance, parked in front of our quarters, and wait for the trick-or-treaters to ring the bell. Then I hit all of the lights on the rig and my preceptor jumped out and scared the kids. It had an unexpected result as the children of the migrant farm workers ran off screaming, “AAAHHH policía, policía!” Poor kids, I really felt bad about that — we forgot about the badges that we wore in that county. No way in hell I’d wear a badge in this county — it’s already too dangerous.

¿Medicamento para el dolor, la morfina?

He declines the Morphine. No candy for the candy man today. He’s still pretty emotional but at least it hasn’t gotten worse. I suspect I know what’s going on. I’m going to assume he has a questionable immigration status. Most of the people that work this type of job do — not all, but it’s a high probability. These are the kind of people who want to fade into the background and not be seen by the authorities. The new laws in Arizona have made a lot of people in my state very nervous. Then, through a random act of violence, this hard working man is all of a sudden looking up at three flavors of uniforms from the light bar fraternity — pretty much his worst nightmare. Possibly that’s why he declined the Morphine — he wants to keep his wits about him as he’ll be answering a lot of questions for the next few hours.

He was also evasive when I asked his address. I need it for my paperwork as we picked him up from a random corner. I was thinking my pigeon Spanish wasn’t working so I typed the question into my iPad and it spoke it to him in a very suave Spanish voice. It practically scared him to death. I don’t think this guy has much contact with technology. And to have an iPad ask him where he lives was too much.

We roll him into the same trauma hospital where the officer is still in surgery upstairs. Sitting in the triage room I get the attention of the triage nurse by squeezing the horn which is still attached to Jose’s pants. She gives me the coldest stare possible. Crap, I’ll be blackballed on the nurse network by the time I clear the hospital.

As we roll him into the room we are met by his nurse. She’s a traveler that I haven’t seen here before. We have a nursing shortage in the state so many temp workers from other states — and even out of country — are paid a premium to relocate and work in our hospitals for six months at a time. She’s probably brand new to the city, and she has a thick English accent. She greets him and he shakes his head.

“He doesn’t speak English.”

“Well what language does he speak?”

“Welsh…” I can pull off a deadpan delivery pretty well.

She stares at me with a confused look for a while until I tell her it’s Spanish. If she sticks around she’ll eventually get my humor and she’ll be speaking pigeon medical Spanish. I tell her what happened and finish by telling her that he’s very scared right now and what I suspect the cause may be. She calls for a translator to reassure him that his immigration status has no bearing on our treatment and we do not share records with INS.

On the way out I get an update from the underground nurse network that the officer is in critical yet stable condition. The news from dispatch is that the shooter is still at large. Back at the rig there are a few clean cut guys in casual clothes standing by the ER entrance.

One of them asks me how to get in to the ED. I ask if he’s with East Side PD; he nods. My heart goes out to these guys. It was just like this last year when the four officers were shot. All of the off-duty guys showed up at the ED. You need a uniform to get past security to the ED so I escort them through the hospital to the area where they usually set up a room for these guys.

What does it say about the city that they actually have a protocol in the hospital to accommodate this kind of tragedy?   

24 hours later the shooter was taken into custody without incident as he attempted to cross the Mexican border. It appears that the officer may recover.

 

 

Candy Man 1/2

can·dy

1 – a rich sweet confection made with sugar and often flavored or combined with fruits or nuts

2 – cotton candy; a large soft ball of white or pink sugar in the form of thin threads, which is usually sold on a stick and eaten at fairs and amusement parks – UK see candy floss

3 – verb; to sweeten – make pleasant

 

man

1 – an individual human; especially : an adult male human

2 – one of the distinctive objects moved by each player in various board games

3 – verb; to supply with people – as for service – man all stations

4 – a male pursued or sought by another, especially in connection with a crime: Inspector Bull was sure they would find their man

“Hey, look out the back window at the other side of the freeway!” Louis yells to me from the front of the rig.

Looking across the freeway I see at least 10 police cars, lights blazing, speeding back to the neighborhood we just left. I have a patient in the back of the rig with me but he’s stable so it’s just a routine call. He threw his back out when he attempted to move the dresser, chasing a mouse. It’s a flair-up of an old injury. After some Morphine for pain and Versed for anxiety he’s resting more comfortably and I’m working on the laptop. Considering he was curled into a fetal position and resisting any effort at movement when I met him this is quite an improvement.

Louis and I have been partners for a few weeks now and he’s pretty much the best EMT partner I’ve ever had. We get along great and have a lot of fun at work. He jokingly calls me The Candy Man because I use so much Morphine in my treatments. He says that he’s watched more Morphine use in the last two weeks than in his previous two years on the job. He seems to think that I’m single handedly responsible for the nationwide Morphine shortage.

Hey may have a point, but it was burned into me by my FTO (field training officer) when I switched to working in this county. “In this county we treat pain!” Okay, copy that. The protocols are flexible enough to allow it and I honestly feel better being able to help someone. It’s not uncommon to spend an hour waiting to see a nurse — even when transported by ambulance — so I can at least make that wait a little more comfortable.

Louis yells back over his shoulder again. “Officer involved shooting, turn your radio on.” I always keep my radio on my belt with the mic clipped to the front of my shirt. Usually when I have a patient in the back I have it turned off as Louis can monitor the radio for anything that may pertain to us.

I hear the tail end of the dispatch. “Medic-20, Medic-44, respond to 1059 Tulip Street for the GSW, possible officer involved, multiple vics. Please stage out, your scene is not secure.”

We listen to the trauma drama play out on the radio as we drive to the hospital on the other side of town. The Highway Patrol is setting up observation posts at the bridges and major freeway connections. The County Sheriff is crossing jurisdiction to back fill the Big City with officers as everyone is on a man hunt for the shooter who is still at large. His description — including some very distinguishing tattoos — as well as the license plate number of the car he stole at gunpoint (car-jacked) are paged to all of the EMS staff.

By the time I finish my paperwork at the hospital we have a little more information as the underground nurse network has been mobilized. Many of the ED nurses work in more than one hospital in the city so they have cell numbers to people all over the city. In less time than a teenage girl can text her BFF, a network of texts spreads information across the city. I think it’s actually a little more reliable than my dispatcher sometimes.

Apparently, two detectives from a neighboring city in the county were attempting to serve a warrant on a known gang member in our Big City. He shot one of the officers and tried to car-jack a car. When that person attempted to speed away he shot at the car and then successfully car-jacked a different one. The injured detective’s partner threw him in the cruiser and took him directly to the trauma center without EMS. Gutsy move, but considering we would have been staging at least 10 blocks away until they could secure the scene for us, it was probably the right move. It’s hard to have a secure scene when the shooter is at large. Two of our units treated and transported the two car-jack victims. We were only 20 blocks away, ten minutes prior to the incident, helping out my last patient with the hurt back.

This city is starting to get even worse with the summer heat and the bad economy — there’s a feeling of desperation. Not too long ago we had a series of riots because of an officer involved shooting of a suspect. We had a sniper shooting at officers maybe a month ago; they never caught him. The Highway Patrol had a prolonged gun battle with a suspect on the freeway a few weeks ago where the shooter was wearing body armor. And no one can forget the four officers that were gunned down last year. My old partner, Brent, actually pronounced the shooter on scene. Brent couldn’t even count the holes the guy had in him. If City PD catches up with this guy I suspect one of us will be pronouncing him later today.

We have multiple SWAT teams running searches throughout the afternoon with their EMS standby teams. Our pager keeps us up to date on which areas to avoid although that’s not much help when the dispatcher sends us to those same areas for a call.

Through the underground nurse network we keep tabs on the officer throughout the day; he’s been in surgery for the last four hours, one GSW to the thigh, one to the pelvis, lacerated femoral artery — it’s critical.