Improbable

im·prob·a·ble

1 : Having a probability to low to inspire belief

2 : Not likely to be true or to occur to have occurred

3 : Too improbable to admit of belief

We must fall back upon the old axiom that when all other contingencies fail, whatever remains, however improbable, must be the truth.

Sir Arthur Conan Doyle; His Last Bow, 1917

My pager is giving my hip an annoying tickle as it goes off for the third time in quick succession. Having just printed my paperwork out for the hospital I’m on my way back to the rig as Scottie comes through ED the doors.

“They’re screaming for us. We got a call on the west end.”

“Yeah, I know, let’s do it.” I throw my hood up to brave the rain from the ED to the rig. It’s been raining for the last three days and I’m starting to get a little tired of it. The rain seems to bring a special kind of stupid to the urban streets that are my workplace.

“Medic-40, we’re en route, please show us delayed for time versus distance and weather conditions.” Scottie’s being just a little cheeky to dispatch; they know we’ll be delayed to the call – hell we’ve been delayed to just about every call today. The freeways are parking lots, the roads are slick, and we’ve been level zero (no available units) for the last four hours. We’re responding to calls that are way outside our zone and it just takes a little longer to get there safely.

Scottie’s taking surface streets to the call as getting on the freeway would be an exercise in frustration. It’s been dark now for a few hours and the traffic is starting to get better as we drive through the hood. The rain is keeping the regulars off of the street and it looks a little deserted. Strange how sometimes I almost miss the normal funk of the hood.

With every surface covered in water the urban landscape is reflecting our strobes back at us in a thousand little twinkles that is suggestive of the current holiday spirit. Some houses even have holiday lights up – though here in the hood it’s not as prevalent as it is in the more affluent parts of the county.

It’s taking a long time to get to this call and it’s interesting to have so much time to think while on the way to the call. I recall the idiocy of my last patient who had a toothache. She lived less than a mile from the county hospital and she called 911 for a ride to the ED. Unbelievable! I was happy to escort her straight to the chairs in the lobby. I hope this call isn’t as benign as I look at the MDT for call information; you are responding to a 46 year old male who is dizzy. Awesome! Over half of my patients are dizzy. I’ve actually stopped asking people if they feel dizzy when they stand up because I always get the same answer – yes.

Scottie weighs in with his pre-arrival diagnosis of “straight up fucking drunk,” and I go with drug use as we near the call location. We call this neighborhood “the weeds” because of some of the street names. It’s actually a pretty scary place to go – there’s only one way in or out of the neighborhood, and it’s guarded by armed gang bangers. Even the local PD doesn’t go there unless they have more than one unit responding. We usually stage outside the neighborhood until they tell us it’s okay to come in but this is just a medical call so it shouldn’t be too bad.

We pass the liquor store with gang bangers standing outside oblivious to the rain. They call it “posting” – they observe the cars that enter their turf to make sure no one from the outside is selling drugs in their area – and to spot rival bangers. They see our rigs come in a few times a day so they don’t even turn an eye as we pass. Turning on to the street we see the fire engine with its lights blazing quietly parked in front of a house.

“I’m just going to walk up and see what we have. Let’s not take the gurney out unless we have to.” Working in the rain affects every aspect of doing our job – from driving to protecting our equipment to patient care.

The fire crew looks exhausted as I walk up to the stoop of the house where everyone is trying to stay out of the rain. I know they’ve been getting run as hard as us or even harder – they can run calls faster than we can since they seldom go to the hospital with patients.

“Hey guys, whatcha got?”

“So, this is Lester, he’s forty-six. He’s been feeling dizzy since yesterday, falling down, having trouble walking, and slurring his speech.” Looks like another win for Scottie… “He’s also got a little swelling to the left arm but otherwise vitals are stable. Are you guys good?”

“Yeah, we got it. Stay dry.” They want to get out of here and back to the fire house. I can’t blame them and this seems like an easy call. Granted, I’ll have at least a dozen things to rule out on this patient; stroke, trauma, overdose, cardiac, diabetic… But I won’t need to take their medic for a ride as I can do whatever treatment is needed by myself.

There’s no porch light on the house so I move out of the way of the street light so I can see Lester a little better. In the dim light I can see he’s what I call an urban outdoorsman (homeless). He’s pretty wet and very tired looking – his eyelids droop like those on a sleepy hound dog. He’s had a rough life and it’s taken a toll on his body.

“Hey, Lester, I’m going to be taking you to the hospital. What do you say we walk over to the ambulance so I can check you out a little more?”

“Okay, but I’m a little woozy, don’t walk so well.” That’s some serious slurred speech, I hope this guy didn’t stroke out yesterday when this started. I’m really hoping Scottie nailed this one as a drunk.

Just watching him stand up it’s obvious that we’ll have to get the gurney wet and use it to get him to the rig. As Scottie is going back for the gurney and the fire engine is leaving I kneel down to look at Lester a little better and see if I can smell any alcohol. His face is emotionless but he just smells like a homeless guy – I don’t get the smell of recent alcohol at all.

Scottie and I load Lester onto the gurney and into the rig where we have a better environment for an assessment. Scottie is working on the computer as I go through my normal routine of assessing vitals and starting the rule-out process.

Top of the list is stroke but Lester has no weakness on one side or the other – he’s just all over weak. His blood pressure, blood sugar, heart, breathing, lungs are all good. All of his vital signs are within normal limits. There’s no head trauma that I can find but there is an untreated cataract in one eye, making pupil assessment difficult – but from what I can see his pupils look fine. Next I get to the arm and ask him questions as I compare the two arms.

“Has this happened before, I mean the swelling?” The left arm is easily thirty percent larger than the right and when I touch it I can tell there are ridged lumps and pressure under the surface – almost like it’s going to burst. The skin is absolutely stretched to the max and doesn’t give at all when I press down. The skin temperature is hot – noticeably hotter than the right arm.

“Yeah, it comes and goes. Sometimes it swells up for a week or two then it goes down. This is pretty bad though.” His slurred speech is making it difficult to understand him but he’s answering appropriately and showing no signs of intoxication or being altered.

I roll his shirt up to expose his shoulder and see the inch long surgical scars from multiple cut-downs. It’s a sign of heroin use. As people inject heroin to the veins over time the veins atrophy to the point that the user will eventually run out of veins and resort to injecting the heroin into the muscle. The impurities of the heroin will cause an abscess to develop in the muscle and because of reduced circulation the body can’t purge the abscess. This leads to sepsis as the infection spreads. The only solution is to have a doctor cut into the muscle and clean out the infection. The result is a multitude of perfectly straight white scars covering Lester’s shoulder.

“How long you been shooting up?”

“Maybe twenty years. I’ve been using heavy the last three or so.”

“You right handed?” If he’s shooting up with his right hand then the left shoulder would be the more infected.

“Yeah, but I switch it up.” He understands my questioning and where I’m going with it.

I expose his right arm and feel the muscle. Sure enough there are some abscesses in the upper arm but nothing like the left one. He may switch it up but he hits the left shoulder more than the right. As I’m switching between shoulders I notice the scar just below his Adam’s apple – a sign of a tracheostomy.

“Why did you get a trach?” I’m really starting to feel bad for Lester as I continue to find evidence of a hard life on the streets. His drooping eyelids, lack of emotion in his face, dizziness with frequent falls, and slurred speech are starting to add up to a very sick man – quite possibly one of sickest people I’ve seen in a long time.

“I had botulism two years ago. Spent eleven days on a machine that breathed for me.”

“Were you dizzy with slurred speech when you had botulism?”

“Yeah, pretty much the same thing.” Well, there you have it, looks like he’s got it again. I seem to remember a doctor saying that diagnosis is 75% history taking and right now that seems to be the case.

Historically the toxins that cause botulism have entered the body by contaminated food – usually a byproduct of improper canning methods. Yet recently there has been a notable increase of botulism cases in intravenous drug users – specifically the users of black tar heroin that shoot up in the muscle.

Botulism is a paralytic illness that initially affects the twelve cranial nerves causing paralysis of voluntary muscle groups starting at the head and working to the feet. The drooping eyelids, slack facial muscles, slurred speech, and uncoordinated extremities are all classic signs of the impending paralysis. Eventually the lungs are paralyzed and the patient can’t breathe on their own. That’s why Lester was put on a ventilator last time. Once the antitoxin is administered it can still take a few weeks to eradicate the bacterium – during which time respiratory failure is a very high probability.

I was already feeling bad for Lester but the reality of his situation is even worse than I had anticipated. It looks like the next few weeks are going to be hell for him. He’ll have another round of cut downs to clean out the festering abscesses on both arms and he’ll probably end up on a ventilator for a few weeks during which time they’ll be administering methadone to prevent him from going into withdrawals from heroin while his body recovers.

I can’t do anything substantive for him except make sure he gets to the right hospital. I’ll take him to the county hospital because they are prepared to deal with this kind of patient. Some of the other hospitals might find it easy to turf him with a referral which he’ll never make. At least I know county will see him through the next few weeks.

Sitting in triage at the county hospital Lester looks really sad. Granted, his face is partially paralyzed but the reality of the situation is starting to sink in. There’s a violent person restrained to the gurney next to us and she’s causing quite a commotion. Three county sheriffs are helping the paramedics to hold her down as the nurse injects a sedative. She’s swearing at everyone and screaming about how her rights are being violated. How about my right not to get my eyes scratched out while trying to help you?

“Hey Lester, it’s a little crazy in here today because of the rain. You gotta trust me though – this is the right place for you to be.”

“I know.” The slurred response is a sad acceptance of reality.

Lester was placed in critical room #2 – basically the lower the room number, the more critical the patient – it doesn’t get much more critical than Lester. I was back to the same hospital 24 hours later and saw his name still assigned to the room. I walked up and had a chat with his nurse because I’ve never had a patient still in the ER a day later. Usually they either get turfed, sent to the regular nursing floor, or to the ICU.

His nurse tells me they are treating his condition aggressively as it is an advanced presentation of botulism. He has had a decreasing respiratory drive and they’ve been keeping him in the ER to wait for respiratory failure. They are better prepared to keep and eye on him and put him on a ventilator when the time comes. They don’t want to  risk sending him to the ICU too early. They gave him the antitoxin last night but he still has a long road ahead of him. 

According to the CDC:

In the United States, an average of 145 cases of botulism are reported each year. Of these, approximately 15% are foodborne, 65% are infant botulism, and 20% are wound-based. Adult intestinal colonization and iatrogenic botulism also occur, but rarely. Outbreaks of foodborne botulism involving two or more persons occur most years and are usually caused by home-canned foods. Most wound-based botulism cases are associated with black-tar heroin injection, especially in California.

The respiratory failure and paralysis that occur with severe botulism may require a patient to be on a breathing machine (ventilator) for weeks or months, plus intensive medical and nursing care. The paralysis slowly improves. Botulism can be treated with an antitoxin which blocks the action of toxin circulating in the blood. Antitoxin for infants is available from the California Department of Public Health, and antitoxin for older children and adults is available through the CDC. If given before paralysis is complete, antitoxin can prevent worsening and shorten recovery time. Physicians may try to remove contaminated food still in the gut by inducing vomiting or by using enemas. Wounds should be treated, usually surgically, to remove the source of the toxin-producing bacteria followed by administration of appropriate antibiotics. Good supportive care in a hospital is the mainstay of therapy for all forms of botulism.

Probability:

145/310,000,000 = probability of getting botulism once.

Multiply that number by itself = probability of getting botulism twice.

That number is 0.000000000021878%


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