Ignis Fatuus

ig·nis fat·u·us

1 : a phosphorescent light that hovers or flits over swampy ground at night, possibly caused by spontaneous combustion of gasses

2 : something that misleads or deludes; an illusion

“Some say his sweat can be used to clean precious metals and he appears on high-value stamps in Sweden. All we know is – he’s called The Stig.” A man in a white racing outfit and tinted visor accelerates an impossibly expensive sports car away from the starting line as he speeds around an air strip turned race track somewhere in England.

The crackle of the radio interrupts our moment of down time. “Medic-40, copy Code-3 for an unknown.”

Lifting the iPad off of the MDT I see the call information appear as Scottie acknowledges the dispatcher that we’re en route. Pressing pause on the video of our latest down time obsession, Top Gear (BBC version), I switch to the mapping application and plug in the new address. Scottie isn’t wearing a white racing outfit but he’s doing a good approximation of The Stig as we race our ambulance through the hood. I pull up the street view on the iPad to see the street level photographs of our destination.

“Hey, we’re going to the post office.” All I know is that we’re heading to the post office for an unknown emergency. The call information in the MDT is useless – it doesn’t say what’s going on or why we’re going there.

The fire engine beat us to the call, as they usually do in this area, so we walk right into the post office to see what’s going on. The firefighters are standing in the lobby with a short man in his forties. He’s dirty with black smudges on a shirt that used to be white and he tracks me with his eyes as I walk up.

The fire medic looks up as we approach. “Hey guys, we just got here a minute ago and we’re still trying to figure out what’s going on. Basically this guy has been wandering around the lobby for the last ten minutes and wouldn’t leave when the manager told him to. He’s not talking to us and he seems altered.”

“Great, let’s go to the hospital!” Unlike our friends across the pond in England I don’t have any alternative transport decisions. I’m quite envious of their ability to transport to an urgent care facility, or even schedule a home visit by nurse for later in the day. They can even refuse to transport someone based on no medical merit. I only have three possibilities on each call; transport to the ED, transport to emergency psychiatric services, or have the person sign an AMA (against medical advice) form. Since an altered person can’t sign out it’s obvious that I’m going to the ED and I can do all of my assessment en route.

My new patient, Jose, walks with me to the ambulance. Although he’s not talking to me I  can assess quite a bit just from a little walk. He’s moving all extremities without difficulty, he’s obeying commands as he walks, he’s looking at me when I talk to him, and his skin signs are normal. I’m not getting any smell of alcohol and that’s high on my list of rule-outs given his appearance and the neighborhood.

Scottie passes the computer back to me and starts driving to the ED. All of my assessments are coming back perfectly normal, even his blood sugar and 12-lead EKG. I attempt to check for nystagmus in the pupils but Jose doesn’t get the concept of following my pen and not turning his head. I hold his head straight and move my face to his peripheral extreme and tell him to look over at me. He’s finally able to do it and I see the characteristic pupils bouncing off the side of the eye that is usually indicative of a high blood alcohol level. I feel that I’ve got the best-rule out I’m going to get so I start an IV, put some oxygen on Jose, and start typing in my computer as Scottie gets closer to the ED.

About a mile from the ED Jose looks over at me, “Wh-where are we going?”

“Hey, Jose, we were a little worried about you so we’re taking you to the hospital. What’s your last name?”

He answers yet it’s slow. There’s no slur to the speech but he has a delay almost like he needs to think about the right answer before he tells me. I run him through some stroke tests and he passes without any noticeable deficits.

“H-how did I get here?”

“You were at the post office and they called us. Do you remember seeing me at the post office.”

“Y-yes.” He’s still delayed and has a round-eyed thousand yard stare.

“Why didn’t you talk to me earlier?”

He thinks for a second. “I-I don’t know.”

“How did you get to the post office?”

“I th-think I walked.”

“What were you doing before I saw you?”

“I’m n-not sure.” It must be strange for someone to be missing parts of their memory.

Just as Scottie puts the rig in park at the ED Jose has a revelation. “I th-think I know where I was. I was in the garage working on my son’s go-cart.”

Now I’m the one having a revelation. “Was the garage door closed?”

“Y-yes.”

Jose did in fact have elevated carbon monoxide levels in his blood. The CO bonded to the hemoglobin, pushing out the oxygen, and tricking my machine to read a 100% oxygen saturation. He was actually having a hypoxic event and the oxygen that I gave him helped him enough to start talking again. Although nystagmus is usually a sign of an elevated blood alcohol level, CO poisoning can create the same effect. Jose didn’t present with the typical flushed/rosy skin tone. Yet even if he did I would have seen that as a further sign of alcohol use. The black smudges on his shirt were not indicative of a homeless man yet they are a byproduct of being a mechanic. Sometimes a drunk is just a drunk but sometimes it’s a real emergency. It’s nice every once in a while to be reminded of that.  

We were able to confirm that no one else was in the garage when we called his family. I certainly didn’t want my next call to be for his son. He was discharged a few hours later with strict instructions not to enter the garage.


Tough Love

tough

1 : strong or firm in texture but flexible and not brittle

2 : difficult to perform or understand; a tough assignment

3 : capable of great endurance; sturdy, hardy

love

1 : a feeling of intense desire and attraction toward a person with whom one is disposed to make a pair; the emotion of sex and romance

tough-love

1 : when people intentionally do not show too much kindness to a person who has a problem so that the person will start to solve their own problem

My flashlight illuminates the graffiti covered walls of the parking garage as Scottie and I walk in to look for my patient. “Hello, Paramedics. Did anyone call 911?” Scottie has his light out and we’re doing our best CSI impression as we search the dark parking garage for any signs that something is wrong or someone is in need of help. But all we find are parked cars, dumpsters, graffiti and trash – typical for the hood.

We were sent here Code-2 – no lights, no siren, and no firefighters. The notes in the MDT (mobile data terminal) were sparse and just told me we were responding to a man who isn’t acting right and is in the parking garage. Most people in my mostly urban county don’t act right so this call could be anything or nothing at all. The founding fathers of the 911 system must roll over in their graves each time we bear witness to the daily abuse of the system that we encounter. People will call for an ambulance for just about anything. They consider it the same as calling a taxi – only better because it’s free to them. Either their insurance covers it or if they’re uninsured, the state covers it (or my company doesn’t get paid). In any case, it’s not money out of their pocket like a cab or bus would be.

As we walk up the stairs to the main courtyard of the crappy apartment building, we run into a woman. “Hey, I called you guys for Tyrell.” She’s in her mid thirties, a little out of breath, and just a bit worked up.

“So what’s going on with Tyrell?”

“Okay, so, well, I’m the building manager. I saw Tyrell walking around all agitated, well, just not acting right.” So far this woman is about as helpful as my MDT. “So I took his blood pressure. I’m a dialysis tech, and his pressure was 132/84. But he’s just acting strange and I think his potassium might be elevated.” Really… I’ve watched dialysis techs do some really appalling things over the years so she’s not scoring high marks on my informed witness scale.

“So, why would you think his potassium is high – is he a dialysis patient?” I really hope I’m masking my cynicism.

“Well, no, but people do strange things when their potassium is off, and his blood pressure is 132/84.” Okay, I’m done. Telling me his blood pressure twice doesn’t change the fact that IT’S PERFECT!

“Where is Tyrell?” I’m not going to get anything useful from this woman so I might as well go to the source.

“He’s in 301.”

As we walk up the next two flights of stairs I’m talking over my shoulder to Scottie. “Have you ever noticed that when a man carries a hammer everything looks like a nail?”  Scottie’s still laughing as I rap loudly on the door. “Paramedics, do you need an ambulance?”

The door opens and a cloud of marijuana smoke wafts out of the apartment, quickly followed by a young man in a dark hoodie; presumably this is Tyrell. He’s got the baggy pants that are the uniform of the hood and one hand is always in the process of preventing a wardrobe malfunction. He quickly walks right past me towards the stairs with the stiff leg walk I see in the hood all the time.

I’m talking to the back of his hoodie as he walks away from me. “Hey where you going?”

“The hospital!” Muffled by the hoodie I can barely hear him as he takes the stairs towards the street.

“Okay, so what’s wrong with you?” I’m actually having a hard time keeping up with this guy.

“I jus gots to go!”

At this point Scottie’s patience runs out, and I’m not far behind him. “Well, if you keep walking that direction you’ll be there in five minutes.” He just walks to the back of the rig and stands there waiting for me to let him in. Whatever…

I get Tyrell situated on the gurney and start my regular assessment questions as Scottie retrieves the laptop from the front of the rig. “Okay, Tyrell, tell me why I’m taking you to the hospital today.”

“Cuz I been stiff all day.”

“What do you mean by stiff?”

“Like hard, like down there.” He’s pointing to his baggy pants that are tented at the groin.

“You mean you’ve had an erection all day?” Seriously, that’s where this is going?

“Yeah, for like five hour!” He’s agitated and squirming on the gurney. I’ve been getting him hooked up to the monitor while talking to him and notice his heart is racing at 140 beats per minute.

“What did you take?” I know he has marijuana on board but it’s obvious he’s got other stuff working on his system right now.

“Libigrow.” Never heard of it. I look it up on my iPad and see that it’s one of these male enhancement over the counter drugs that you see advertised on late night TV. Basically it’s just asian herbs, B vitamins, and stimulants – the stupid man’s Viagra.

We’re driving to the hospital and Scottie is taking side streets that are riddled with pot holes and speed bumps. I’m getting bounced all over the back of the rig and I decide to give Tyrell some Benadryl in an IM injection. Our county has a protocol for “mild sedation” which allows us to administer this for anxiety. I’d say this counts.

Tyrell gets extremely nervous when I pull out the large needle for the injection. His eyes are big and round while I’m drawing up the drug into the syringe. He’s obviously terrified of needles. I decide to have some fun with him so I’m playing up the bumps in the back of the rig.

I’m looking at his tented pants and holding the syringe. “Okay Tyrell, I have to give you a shot.”

“Hell no! Not down there man. You not gonna stick me down there?”

“No man, it’s just a little shot in the arm.” Tyrell actual tries to climb into the cabinets on the other side of the gurney as I roll up his sleeve to expose his deltoid. He whimpers like a baby as I stab him in the shoulder.

When we arrive at the hospital I explain Tyrell’s situation to the triage nurse. “Hey, Tyrell, you said you’ve been hard since eleven o’clock this morning?”

“Yeah, but I ain’t hard no more.”

“When did that happen?”

“Before we got here.”

“About the same time you saw that needle?”

“Yeah.”

The triage nurse starts laughing. “Great! You fixed him! Now take him out to the lobby.”

 

Suicidal Ideation 3/3

“Medic-40 copy code three.” The dispatcher’s abrupt call snaps me out of my otherwise boring day surfing the web on my iPad. It’s been quiet today – not too many calls have been getting sent out. Crews across the county have been sitting idle for the last few hours. Scottie is off today so I got assigned one of the float EMTs – we call that “mystery meat.” This is the first time I’ve worked with him and I got tired of listening to his diatribe six hours ago – so I’m happy to have a call.

“Medic-40 go.”

“Medic-40, code three for you. 1055 Vincent St. for the 22 year old male with a noose around his neck. You’ll need to stage for this please. PD is en route.”

“Medic-40, ten-eight” (we’re en route). Plugging the address into my iPad I see that we’re only ten blocks away from the call. We’ll be there in just a minute.

Almost immediately the radio crackles again. “Medic-22, we’d like to jump that call for 40.” Finally something interesting to relieve the boredom of the day and everyone else wants a piece of it. I’m not sure where 22 is but we’re close enough to make it in stellar time and I really want something to break the monotony of the day. Not today guys.

“Medic-40, we’re pretty much on top of it, we’ll take the call. Thanks Medic-22.”

As we pull out of the parking lot where we have been sitting for the last few hours a fire engine screams past us headed towards the call – we pull in behind them with our lights and siren singing a duet. I like going to calls with the fire engine clearing traffic for us. People tend to clear out of the way a lot faster for the BRT than they do for a little ambulance. It’s like having a big brother who’s a linebacker clearing the hallway between classes in high school – we just follow along in the wake.

Two police cars pass us as we turn into the residential neighborhood and the BRT follows them straight to the house. So much for staging and waiting for police to secure the scene. I’m usually happy to stage and wait for police to call us into the scene – it’s safer. But in this case there are only a few possible outcomes; the person is dead and has been for a while, he just hung himself and cutting him down now could save his life, or it’s complete BS.

As we get out of the rig the firefighters are headed into the house with their bags. We decide to just walk up and see what’s going on before pulling the gurney and equipment out. Walking to the front door a woman exits the house with her hands covering her face, crying. I step through the front door and into the living room to an officer coming down the stairs with a young man in handcuffs.

The officer comes over to us. “He wasn’t hanging; just lying on the bed with a noose around his neck. He said he wanted to hang himself but couldn’t find anything to tie the other end of the rope to. We’ll have a green sheet for you in a few.”

According to the American Foundation for Suicide Prevention:

  • Over 34,000 people in the United States die by suicide every year.
  • In 2007 (latest available data), there were 34,598 reported suicide deaths.
  • Suicide is the fourth leading cause of death for adults between the ages of 18 and 65 years in the United States (28,628 suicides).
  • Currently, suicide is the 11th leading cause of death in the United States.
  • A person dies by suicide about every 15 minutes in the United States.
  • Every day, approximately 90 Americans take their own life.
  • Ninety percent of all people who die by suicide have a diagnosable psychiatric disorder at the time of their death.
  • There are four male suicides for every female suicide, but three times as many females as males attempt suicide.
  • There are an estimated 8-25 attempted suicides for every suicide death.

Suicidal Ideation 2/3

An officer meets us as we walk up to the apartment building. “She’s in that apartment. Watch your step as you go in, there’s blood all over the place. Looks like she bit her tongue. We’ll have a green sheet for you in a few.”

We were called here for a 5150 but it’s looking like there’s more going on than someone who voiced suicidal thoughts. Once an officer hears a person say they want to kill themself, they have to write up a Form 5150 – it’s on green paper so we just call it a green sheet. Basically the 5150 is a tool used by law enforcement to hold an unstable person for 72 hours during which time they are psychologically evaluated. More often than not they are not “suicidal” – they just said the wrong thing at the wrong time or PD has nothing else to hold them on so they get the person off the street using the 5150 because it’s less paperwork for them.

Walking into the apartment I see two more officers standing in front of a slim woman in her forties. She’s sitting on a chair in front of a closet with blood dripping down her chin –  enough to saturate her shirt. She has ligature marks around her neck which are consistent with the belt that is sitting next to her. Looking in the closet I see the closet rod is broken in the middle.

The officer lets me take it in before he gives me the update. “Hey guys, this is Sandy. She’s been going through some pretty rough times and she tried to kill herself today. She drank a bottle of wine and put a belt around her neck and tied it to the closet rod. She hung there for maybe ten seconds before the rod broke. When she hit the ground she bit her tongue pretty bad. The blood freaked her out so she called 911.”

As I kneel down to examine Sandy I see the bottle of wine on the side table – it’s a Mondavi Pino Noir; not the usual crappy two-buck-chuck that they sell in the local liquor stores. Sitting next to the bottle is a Riedel Vinum wine glass. Riedel is known for being shaped so that the wine lands on your palate just so, and you pay for the privilege – a single glass can cost $25 or more. Well, she gets points for taste even if she can’t calculate load bearing stability very well.

“Hi Sandy, I’m going to be taking you to the hospital to get you checked out. Can you open your mouth so I can see what’s going on?” Sandy nods her head and opens her mouth. Pulling out my flashlight I see that she’s nearly severed the end of her tongue – it’s being held on by less than a half inch, yet the bleeding has slowed to a small trickle. I pull out a sterile piece of gauze and tell Sandy to pinch her tongue with her fingers as we walk out to the ambulance.

Once in the rig I can assess Sandy a little better. She checks out fine aside from the tongue and a minor abrasion to the chin. My only real concern is if the attempted hanging caused any damage to the throat that could cause airway obstruction issues or if her tongue were to swell to the point that it blocked her airway. Admittedly these are big concerns, yet I don’t find anything that would make me light up the rig and drive fast.

Sandy’s not much for conversation – partially because she’s holding her tongue (literally) and the reality that if not for the closet rod breaking she would be dead right now. We start driving towards the trauma center – I don’t plan to trauma activate her but I want her in the trauma center where they are prepared – in case the swelling causes any issues over the next hour or so.

I dim the lights in the back and tap away on my laptop as we take a quiet drive to the ED. I’ve watched partners in the past who will talk to people on a 5150 to try and figure out where they went wrong and offer advice. I have mixed feelings about that as it’s not necessarily our function in the medical community. Although I’ve probably taken more psych classes than my peers I feel it’s my job to treat the physical condition and understand the mechanism that led to the injury – so as to give as much information to the nurses and doctors that will continue to care for the patient. I feel it’s inappropriate to play Paramedic Psychoanalyst.

I’ve transported more people on 5150s for voicing suicidal ideation than I can even count – one man was even placed on a hold for texting it. But this is a different presentation. Sandy wanted to end her life so desperately that she put together a plan and acted on it. The carpenter that installed the closet will never know that had he put a third closet rod support in the middle, as he should have, a woman would be dead right now.

Suicidal Ideation 1/3

sui·cid·al

1  :  intending or wishing to commit suicide

2  :  likely to lead to death, destruction, ruin, or very much against somebody’s best interest.

 

ide·a·tion

1  : The faculty or capacity of the mind for forming ideas; the exercise of this capacity; the act of the mind by which objects of sense are apprehended and retained as objects of thought.

Sick of trying – what’s the point

Sick of talking – no one listens

Sick of listening – it’s all lies

Sick of thinking – just end up confused

Sick of moving – never get nowhere

Sick of myself – don’t wanna live

Sick and tired – and no one cares

Sick of life – it sucks

Suicide is an alternative

 

Suicidal Tendencies – “Suicide is an Alternative

(80’s punk rock/crossover band)

We’ve been standing in front of the house for maybe ten minutes and police cars keep arriving: plainclothes detectives, gang unit, even the brass – I’ve never seen this level of response to an active case. All of the officers on scene are quite emotional and that’s not normal for this group – they rarely get broken up on scene and they see some of the worst things humanity can dish out. Something is definitely wrong but no one is talking to us.

It’s nearing dusk and the fog has started to build in the city next to the water. All members of the light bar fraternity (Police, Fire, EMS) are represented here with their strobe lights cutting rays into the fog as the city gets colder from the encroaching marine layer.

Every type of call in EMS has a vibe and all of the responders seem to pick up on the collective unconscious signals. Some are humorous to the responders – like when a gang banger shoots himself in the groin while stuffing his Glock-19 into his pants. Some are all business – like when a child is having a severe asthma exacerbation. Some are just sad – like when an elderly person dies in their sleep. Yet this is a vibe I’ve never felt before – I just can’t quite put my finger on what’s going on and the officers aren’t talking to us or letting us into the house. They just talk quietly on radios and phones as more police cruisers keep arriving.

Another five minutes and an officer comes out of the house – I can’t even count how many stripes he has on his sleeve but it’s obvious this is his crime scene. He’s emotional but he’s stuffed it down into the closed recesses of his mind so that his professional side can run the show. He’s all business as he fills us in.

“Thanks for standing by so long. We had to do a thorough search of the residence before letting anyone inside. We’ve got a fifty-two year old male in the garage; apparent suicide, GSW to the head. It’s obvious he’s dead but I need you to pronounce so we can get on with the investigation. When you go inside don’t touch anything – just get in, pronounce, and get out. It looks like he fell on the gun and we can’t get to it so don’t move the body at all; he may still have a finger on the trigger. And guys, one more thing – he’s one of us.”

My heart just dropped into my stomach and I’m having a hard time breathing. Now the collective vibe of the scene is hitting me full force – an officer just committed suicide.

I follow the officer with all the stripes on his sleeve through the back door of the garage, carrying just the ECG monitor and my stethoscope. The officer stands aside so I can do my assessment.

Crumpled face forward in the middle of the garage is a body in dark clothing. There’s a small pool of blood near his head and blood splatter on the ceiling of the garage. I’m being careful not to step on anything as I kneel behind him and see a forty caliber shell casing on the floor to the right. I smell the metallic scent of fresh blood from the pool that is slowly coagulating as I put my fingers to his neck to feel a warm body without a pulse. A single slice with my trauma sheers up the back of his thin shirt exposes his back to me. As I’m listening on the back for any breath or heart tones I see the exit wound the bullet made as it went through the back of his head. Without moving the body I place my electrodes on his back in the same configuration I usually use on a person’s chest. I don’t want to roll him over since I don’t know where that gun is pointing right now. The monitor shows the flat line of asystole that I expected to see. I print out six seconds of flat line and rip the strip off the monitor and put it in my pocket. I disconnect the monitor and retrace my steps out of the garage without disturbing anything.

The officer with the stripes was watching me the whole time from the doorway. I tell him what he already knows. “Yeah, he’s gone.” Looking down at my watch, “We’ll call it confirmed at 1855.” He nods his head and writes a note in his little book.

I walk back to the rig to start my paperwork. Sitting in the passenger seat with the laptop open on my knees, I’m typing as my partner comes back from talking with the fire crew that’s packing up to head back to the station.

He gets in the driver’s side. “So, I was just talking to fire and I got the story. He was a detective on the force for fifteen years but he’s been on administrative leave for the last couple of months. He’s got some alcoholism issues and his unit commander was on his way here today to drive him to get checked in for detox. The commander is the one with all the stripes. He got here an hour late because of a case and found the guy in the garage…”