T3 2/2

Since the drive to the ED will take a while, I strike up a conversation with Mrs. Duval to pass the time.

“They built this place maybe three years ago, how long have you lived here?”

“We moved here after the hurricane sir.” She has a polite manner and a southern twang. – apparently a transplant after hurricane Katrina. I’ve run into a lot of people who have relocated here after the hurricane. There are no definitive numbers because of the chaos at the time, but estimates are that over one million people were scattered around the country. Some have since gone back, some are still displaced.

“Do you like it here?” This area is a destination for many across the US who would love to move here, although not necessarily to the Projects – but to this general area. I’m curious about here perspective.

“It’s okay sir, but we don’t fit in so well.” I wish she wouldn’t call me sir but something tells me I couldn’t stop her.

“There’s a lot of crime in this area – are you guys doing okay?” The city PD call this area Beat-55x; it’s one of the worst in the city.

“Oh yes sir, we do fine, don’t no one bother us too much. It’s just not what we used to you know?” I’ve spent some time in the south and I know that our version of the hood is a lot different than their version. For starters no one in my hood has ever called me sir except for this charming lady.

“Do you have family here?” I’m curious to know what kind of support structure she may have.

“No sir. They all over the place after the hurricane.” Families were broken up, support structures destroyed, people displaced. Some never reconnected – it’s not like they are on Facebook and can post a status update to their wall.

“Your husband’s pretty sick. Does he always go to the emergency room or does he see a regular doctor?” I already know the answer.

“We don’t have a car sir. This the only way we can get there. I don’t understand though, he gets betta for a few day, then he has to go back. They jus can’ seem to make him betta.” It’s common – we see it all the time. It’s the other trifecta: poverty, location, and lack of education.

“You know, it’s the high blood pressure that’s the big problem right now. Is he taking his medication?” It may not be his biggest problem but you have to start somewhere.

“Yes sir. I make sure he take it every day.” She obviously loves him and she’s worried about him. But the care that they get from an emergency room will never fix this. Emergency rooms just treat them and street them. They seldom take the time to explain the overall condition, much less the causality and eventual complications. The mechanism for continuing care is non existent – there is no such thing as a house call.

“I’ve spent a lot of time in the south; that’s where my mother’s people are from. I know what y’all eat down there – lotsa fried food and salt. You know he can’t be eat’n that.” Possibly gaining a little rapport with the remnants of a southern twang that never really stuck with me.

“Oh, yes sir, I know but he like to taste his food. He always put the salt on.” No wonder his blood pressure is into gasket-blowing range.

“How bout the sweet tea, I know y’all like some sweet tea. How much sugar you put in a sweet tea?”

“Oh yes sir, he love the sweet tea. I put ‘bout a cup in a pitcha.” Yikes! A diabetic drinking that much sugar??

“You ever hear of Splenda? He’s got the diabetes, he can’t be takin’ that much sugar.” I can see the headlines now; Paramedic prescribes Splenda; man dies of cancer. Hell, but what else can I do at this point?

As I’m explaining sugar and salt substitutes I realize that Kevin has been having an almost identical conversation in the back of the rig. There’s nothing emergent to treat here – it’s their lifestyle that needs treatment and they’re not going to get it from the hospital. She tells me that she tries to help him but he won’t listen to her. She pleads with me to tell him these things because maybe he’ll hear it coming from a man.

Once at the hospital Kevin gives a report to the charge nurse and I’ve got a minute to lay it on thick for him. I cover all the points that we talked about: limiting salt, no sugar, no fried foods, eat a vegetable for God’s sake.

“Do you think this could kill me sir?” He’s a little scared with a small voice on the verge of tearing up.

“It will if you don’t fix it. Look at it like this: you didn’t have diabetes when you were a kid right?” He shakes his head. “Well, now you do and you take a pill every day to control it, but right now your blood sugar is super high. In a year you’ll have to take a shot twice a day to control it. That means sticking a needle in your belly every morning and every night. You don’t want that do you?”

“No sir, I don’t ever want to do that. Thank you sir, thank you for explaining it to me.” I didn’t give him an explanation, really, I just gave him some precautions and scared him with some possible results. It’s not enough and I know it. I even went to the EMS break room and grabbed a hand full of Splenda and gave it to the wife. They were both so appreciative and thanked me repeatedly, but still I know it’s not enough. Ultimately they escaped a hurricane and landed in the perfect storm.

After cleaning up the rig I went back in and had a conversation with the charge nurse. I learned that they have no one in the hospital for dietary consultation. Maybe, if he was admitted to the floor, they could call in a consult from their network of hospitals. I also learned that the county hospital has better dietary consults than this private hospital. Apparently they’ve cut all the “non-essential” programs. The Governator has already laid the ground work for further cuts to police, firefighters, hospitals, home health care, and education. Unbelievable!

I don’t pretend to have the answers yet I see the problems every day. This man needs a dietary consultation and someone to check on him once a week. Someone to go through the cabinets and suggest substitutes for poor eating habits. Someone to take him on a field trip to a dialysis center and see the sad people sitting in their chairs for three and four hours at a time – watching their blood get siphoned off and returned. The answer is not to spend more on health care. We need to give people the health care that they need and stop passing the responsibilities off to the next shift and by extrapolation passing the responsibilities off to the next generation.

This is the Trifecta cubed: T3

 

Hypertension –> Diabetes + Heart Disease

Location –> Lack of Education + Poverty

Poor Economy –> Unemployment + Cuts to Social Services

 

The perfect storm…the only question is which horse comes in first?

 

T3 1/2

T3

1 : trifecta; horse racing terminology – a parimutuel bet in which the bettor must predict which horses will finish first, second, and third in exact order

2 : trifecta; a situation when three elements come together at the same time and the synergistic effect is greater than the sum of the individual parts

3 : Terminator 3; a film from 2003, starring Arnold Schwartzenegger, in which humanity is brought to the brink of destruction

Ot volka bezhal, da na medvedya popal.

I ran from the wolf but ran into a bear.

Russian Proverb

I’m talking with two firefighters as we walk up the exterior stairs to a small apartment deep in the projects. One of them points to the door in front of us, “Yeah, we run on this guy at least twice a week – always the same thing: multiple complaints, all of them chronic.” We call them frequent flyers.

As we wait for the door to open I look around at the surrounding buildings from the vantage point of a second floor patio. The housing development is the size of five city blocks – 12 huge apartment buildings, 30 smaller six unit buildings, all surrounding a scraggly play field and basketball court. Built just a few years ago it’s still in good condition with strong security gates and pastel colors on the exterior walls. This is a community development project (The Projects) which differs from Section-8 housing in that local and state government pays for the project as opposed to private investors.

My medic partner, Kevin, is going to tech this call – I’ll help out if needed. A woman answers the door and only three of us walk in – the apartment is too small for all six of us and its residents.

Kevin’s new patient, Mr. Duval, has a number of chronic complaints and wants to get to the hospital so they will make him feel better. He’s a heavy guy, maybe 240 pounds, and moves very slowly – every step he takes is deliberate. Slowly he makes it down the stairs and onto the gurney. Once loaded into the ambulance I get his wife settled in the passenger seat for the ten mile drive to the ED. Four hospitals are closer than this one but we are obliged to honor his request for the hospital that he says has all of his records.

The resources that are being spent on this call are staggering: one fire engine with three fire fighters and a paramedic, one ambulance with two paramedics, a half hour ride in city traffic to a distant ED, and one hospital bed for six to eight hours minimum. The cost for all of this will undoubtedly be covered by the American tax payer through federal and state programs. It’s not even the direct cost that bothers me – it’s the extended cost to the fire departments, the EMS providers, and the hospitals. At any given time 50% of the resources in these agencies are handling calls just like this. Therefore we are 50% larger than we should be just to handle the call volume.

Being Kevin’s call I’m tuned in just enough to confirm that it’s a non-emergent call and the patient basically has chronic complaints. He has the trifecta: hypertension, diabetes, and heart disease. It’s basically a horse race to see which one kills him first. The progression up to this point is a common one that we see every day. Bad diet and no exercise lead to uncontrolled hypertension, which affects the liver, the kidneys, and heart. As a result he gets Type II diabetes and heart disease. The final outcome of this will depend on which horse wins: heart attack, stroke, or renal failure.

As Kevin calls up the vitals to me for the ring-down to the hospital, I put my money on stroke – his blood pressure is 220/140 (normal is 120/80). My guess is that renal failure will come in second given his blood sugar of 286 (normal is 80-120). Heart attack will come in third – the enlarged left ventricle of the heart is obvious on the 12-lead EKG.

Paralanguage 3/3

Six hours later.

“Medic-40, respond code-3 for the unknown, you’ll need to stage out for this.”

“Medic-40 copies we’re en-route and we’ll stage.”

Scottie had the last tech so this is my call. Scottie is driving us through the suburban neighborhood as I navigate using my iPad. Looking down at the map; “Hey, this is the same section-8 complex we went to three weeks ago for the 18 year old who was hyperventilating. Remember – it was your tech and we found her collapsed in the stairway?” Scottie had that call so fortunately I just drove that day. It was a ridiculous situation for a girl that had nothing wrong with her yet felt she needed to take an ambulance to the ED. It’s unfortunate but that’s what we deal with some days and we just strike it up to an easy call as we escort the patient to the lobby of the receiving ED. I really wish there was more I could do to help alleviate the system from abusive calls.

Scottie pulls over maybe three blocks shy of the complex as I’m pulling up the satellite view on google maps to refresh my memory on the apartment complex layout. Trying to get my bearings I’m looking in the direction of the complex. Three police cars pass us on the main arterial with their lights on and running fast. Then, with the windows cracked, I hear multiple fire engines and trucks approaching the same block. We can see the apartment complex roof from our staging post and I can see flames coming off the roof. A few seconds later I pick up the mic; “Medic-40, it looks like this is a structure fire, PD and FD are on scene; we’re going in.” The dispatcher acknowledges and tells us to advise on conditions.

As we pull up to the complex we have to park on the street as the fire engines/trucks/police cruisers are taking up the whole parking lot. We walk up to see what’s going on and to check in with the BC to tell him where we are and help out if there are injuries. I can see the building where the fire fighters are attempting to put out a third story apartment that seems fully engulfed in flames. There’s a woman standing on a balcony right next to the fire engulfed corner apartment. A fire crew is tilting up a very tall ladder to attempt a rescue.

Just then a woman runs out of the building next to us and literally throws her three year old son into Scottie’s arms. “He was is the fire, it started in the living room, please help him!” Then she runs back inside the building. The only problem is that it’s not the same building that’s on fire. This is a confusing fire scene with all of the people standing around, presumably evacuated from the burning building. The police are holding a perimeter to limit access to the area and and fire crews are clearing apartments, fighting a fire, and attempting to do a rescue. I’ve got to get to the BC; he’s the one calling the shots here and he needs to know where we are.

I turn to Scottie, “Take him back to the rig and check him out, I’ll check in with the BC.” As Scottie is carrying the kid back to the rig I keep going to look for the white hat that signifies the BC.

I finally find the BC and his two helpers on this scene; three white hats standing at the epicenter of all of the commotion. As I’m approaching them I see that one is a captain and two are lieutenants – one of which is LT from earlier in the day. So this is a three alarm fire and they brought out the more experienced captain to run the fire scene.

I acknowledge the two lieutenants and address the captain. “Captain, I’ve got one unit doing stand by on…” He cuts me off by holding up his hand as he heard something on his radio.

Speaking into his microphone. “Truck 5, cut a vent above unit 306, and one above the hallway. Engine 12, clear the first floor starting from the west. Engine 18 clear the second floor starting from the west.” Looking back at me. “I’m sorry, you were saying?”

He’s a busy man, I need to keep it short. “I’ve got Medic-40 doing a stand by on Halcyon with two medics on board. So far we have one possible patient but he came out of an adjacent building; not sure what’s going on with that, my parter is checking him out.” Looking over at the ladder against the building I see that they are half way down with the victim. “I’ll take her back to the rig and check her out. If we have any transports I’ll handle calling in other units. I’ll be on-scene until you tell me different.”

“Perfect, thank you.” He’s a man of few words. Then back to his mic, “Engine 8, lay supply lines from Halcyon to the number two exposure. Truck 3 – you’re clear to cut power.” As I’m walking closer to the ladder a fire fighter is escorting the rescued woman towards me. I’m thinking about the job that the captain is doing; coordinating six teams involved in – fighting the fire, rescuing people, searching for victims, overhauling burned out buildings. It’s overwhelming to me – I’ll stick with medicine.

The firefighter hands off the woman to me and goes back to the fire. As I’m walking her towards the rig I’m having a hard time communicating with her; she has a thick Indian accent and shakes her head when I ask some questions. She seems to have very limited understanding of English. Another woman from the crowd runs up to us as I get closer to the ambulance and starts talking with her in Hindi.

“Hey, do you know her?” I ask the young woman.

“Yes, she’s my neighbor, I was just asking if she’s ok.”

“Can you walk with us and translate for a little while?” She agrees and I hand the old lady off to Scottie in the rig along with a translator.

Looking up at Scottie, “Hey, where’s the kid?”

“His family came by and took him. He was totally fine, no soot in the nares or mouth, no burns. He wasn’t any where near the fire. Either his mother was just flipping out or she was setting up a law suite. Whatever…”

“Weird. So, this lady was just taken off of the balcony adjacent to the fire. Maybe 15 minutes of smoke exposure. She doesn’t speak English but I brought you a translator. If you can check her out I’ll see if there are any more victims.”

I walk back through the police perimeter to check in with the BC. Looking up at the building I see there are no more flames and just a few apartments seem to be burned with black soot ringing the windows like mascara. The rolling black smoke from before has turned to lighter wispy smoke coming from smoldering burnt wood that’s saturated with water.

Standing near the three BCs I quietly take in the sights; firefighters walking around with tanks on their back and carrying tools, ladders being taken down, hoses being drained and stowed on trucks. The captain is still coordinating things on his radio. “Truck 5 your clear to begin overhaul in unit 306. Engine 8 and Truck 3 are clear for station.” It’s looking like they’re just about finished.

The Captain turns to me. “We just had the one rescue from the balcony; no other vics. What do you have?”

“The kid wasn’t involved and checked out fine. His family took him. My partner is working up the woman from the balcony; minor smoke inhalation. We’ll get her transported but it’s just precautionary; she looks good. I can continue to stand by during overhaul if want us here.”

“No, that’s ok; you’re clear to transport.” He comes up to shake my hand. “I just want to say that I appreciate you’re professionalism, you guys did a good job, and that helped us do our job. Thank you.”

“Thank you sir, that means a lot to me.” I’m at a loss for any more words. That was high praise from a very competent man.

He turns to LT. “Can you go out to the rig and get information on the woman?” LT nods and we start walking back to the rig. They need patient info for their paperwork.

We talk about the fire and the crowd and the fire that we both went to this morning. It’s a good conversation and it seems that we’re past the point of having any bad feelings between us. I’m sure the high praise from his Captain reminded him that even good people make mistakes and our world is too small to let bad feelings continue. We’re two colleagues having a water-cooler conversation in the aftermath of a fire – quietly walking through the crowds of people, police officers, firefighters in smoky turn out gear, and the ever present street vendor selling popsicles and churros.


Paralanguage 2/3

Six weeks later.

“Dispatch, Medic-40, do you have anything working on Halcyon and Winston? We just got passed by two engines and a truck running code-3?”

Sitting at the red light the fire department just flew past us and I figure it’s possible they could use some EMS on scene wherever they are headed. Besides, dispatch was about to move us up to the Big City and anything to keep us here in the quiet suburbs is a good thing. So I’m basically fishing for a call.

“Medic-40, stand by, I’m checking.” Fifteen seconds later. “Medic-40, yeah, respond code-3 to the fire stand by at 104 Garden St.”

“Medic-40 copies, we’re en-rout.”

Fire stand by calls are some of my favorite calls. Basically we sit in the ambulance and watch the firefighters put out a fire and if anyone gets hurt we take care of them. Most times no one gets hurt so it’s basically dinner theater EMS style as we get a chance to eat lunch and watch something interesting.

I’m driving as this is Scottie’s tech. We’re both Paramedics so when one person is in the back taking care of a patient they are said to be “teching” the call. We switch up on every call so I’m the driver/helper on this call. I catch up to the fire truck and pull in behind them at the apartment building. I didn’t see any significant smoke as we pulled up so I suspect it’s not that big of a blaze.

The EMS personnel in this county are usually well outside of the fire department command structure, yet when we enter into a situation like this we become the medical branch connected to the battalion commander (BC); the BC calls the shots on a fire scene. Scottie and I walk up to make contact with the BC and let him know we are here and where to direct patients if any should turn up.

It’s LT from six weeks ago working as acting BC. Crap!  Scottie and I have run into him maybe five times in the last six weeks since my indiscretion and every time he’s been cold to us; me in particular. It’s not like we have a few minutes at the water-cooler to work things out between us; every time we see each other we have a job to do and we’re in public scrutiny and the patient takes priority. It makes it hard to work out things like this.

Scottie tells him where we are and that we’ll stand by if he needs anything. LT ignores me and tells Scottie that it’s probably nothing but wants us to hang out until he can confirm the extent of the damage. Looks like it was a small kitchen fire to an apartment on the top floor; minimal damage to adjacent units.

The parking lot is full of families that were told to leave the building until things are under control. There are street vendors selling popsicles and churrros in the parking lot as LT comes back to tell us we are clear from the scene. No injuries and no need for EMS. I happily drive off to the next call.


Paralanguage 1/3

para·lan·guage

1 : nonverbal means of communication, such as tone of voice, laughter, and, sometimes, gestures and facial expressions, that accompany speech and convey further meaning

2 : vocal features that accompany speech and contribute to communication but are not generally considered to be part of the language system, as vocal quality, loudness, and tempo: sometimes also including facial expressions and gestures

3 : communication other than verbal

We’re responding to a home in the suburban sprawl area of my mostly urban county for “the unknown.” I used to get upset or nervous when the call wasn’t spelled out for me before I got there but now I’ve learned to embrace the unknown. At a time when the world economy is so uncertain, and the local government is cutting services, I’ve come to see the unknown as job security.

Walking into the bed room I see a man in his sixties laying on the bed with only his boxer shorts on. The fire lieutenant (LT) is using a bag to squeeze air into the mans mouth while the fire medic is checking a blood sugar. He looks up at me with just a touch of sweat on his brow. “Hey guys. So, per family, this guy is just sitting on the bed and his eyes roll back in head head and he goes unresponsive. Currently he’s: GCS-3 (completely unresponsive), irregular heart rate in the 150s, agonal respirations, oxygen saturation in the 70s, lungs sound like junk. He’s got a history of hypertension, diabetes, renal failure, pneumonia, seizures, he’s been sick for three days, and missed dialysis yesterday.” He looks down at the glucometer then back up at me. “And his blood sugar is 382.” FUCK ME!?! This guy is the quintessential train wreck!

There’s half a dozen things wrong with this guy that could cause this current state and lead to death very soon. At times like this paramedics fall back on ABCs – airway, breathing, circulation. Not having a patent airway and not breathing will kill someone faster than anything else so it’s our first priority. LT is managing the airway by holding my new patients head at a good angle and he’s breathing for him by squeezing the bag. I pull my stethoscope and listen to lung sounds; rhonchi, crackles, rice crispies, pop rocks, and an angry donkey – junk. The unknown sucks!

LT looks up at me. “We could C-PAP him.” It stands for continuos positive airway pressure. Basically a very tightly fitting mask with very high flow oxygen that helps to keep the lungs inflated and push out fluid. It’s usually used with congestive heart failure patients with fluid in the lungs.

“I can’t C-PAP an unconscious patient.” The LT is medically trained to the level of EMT-B so he may not be fully versed the the paramedic advanced life support protocols. C-PAP is contra-indicated for the unconscious patient.

“Yeah, but it might help.” He’s persistent.

“It might but I still can’t do it.” I turn to Scottie. “Can you grab the tarp from the rig? I just want to get moving with this guy.” It takes the five of us to carry him out on a big tarp with handles on the edges. We get him loaded into the ambulance and the fire medic jumps in with me as Scottie starts the drive to the ED with our strobes on and siren blaring.

My patients mentation has been improving a little over the last few minutes of getting high flow oxygen. The fire medic is starting an IV while I’m pushing a tube down the nostril so as to have a more patent airway. Suddenly big, round, and frightened eyes stair up at me and he starts ripping off electrodes and struggling with us. Guttural animalistic noises are coming out of him and it’s all we can do to save the IV. He’s combative and altered yet, strangely, I’m okay with that.

Paramedics have a saying that pertains to working with babies – a crying baby is a good baby. If a baby is crying you know he has a good airway and he’s definitely breathing. Well, the same is true for this guy. I’d rather have him agitated and altered than unresponsive; so this is actually an improvement. Looking out the back windows I see that we’re pulling into the ED parking lot.

I made sure that we transported to an ED that specializes in strokes and heart attacks so I know that anything that I was not able to check will be dealt with at the appropriate level. Sometimes in EMS there is nothing we can fix in the field; it’s just better to drive and get the patient to the ED so they can sort out what is going on.

I’m standing at the back of the rig as Scottie is cleaning up my mess. “Can you believe the LT actually wanted to put him on C-PAP?” An arm reaches past me to the box on the door that we keep full for the fire department restock. The LT pulls out a non-rebreather mask. Scottie has the “dear in the headlights look” as I turn to face to LT. “Hey, I really appreciated your help on this one, thanks fore letting me borrow your medic for a ride to the ED.” It’s my lame attempt to cover the fact that I just made an unflattering remark about the man while he was standing right behind me.

“Yeah, no problem.” And he walks off. CRAP!

Ultimately the patient had pneumonia which led to sepsis. Checking on him four days later I come to find out he’s still in ICU. He was already in an advanced stage of MODS (multiple organ dysfunction syndrome) and at the time his prognosis was not favorable for recovery.

I go out of my way to ensure I have good relationships with the Fire Department crews that I respond with. Yet this was a comment I made in the heat of the, post adrenaline, moment that was inappropriate. In EMS your partner is your sounding board and I sounded off in an unsecured place; with the doors open while parked at the ED. I should have shown better discretion and I wish it didn’t happen. But all I can do is move on to the next call.

Peaceful Warrior 3/3

Walking into the small bedroom with the fire medic we can actually feel the heat radiating off of the little old man laying on the bed. He’s frail and skinny, dressed in traditional Punjab garb and a matching turban on his head with a long white beard. Sitting on a side table by the bed I see the Kirpan. It’s a curved knife, one of the five external articles of faith, that symbolizes the safety of all and the carrier’s personal duty and responsibility as a Sikh to protect the innocent in the message of peace.

The family called us because he’s “not acting right.” It’s a common call in this mostly urban county and pretty much just means I have to rule out everything with a full work up. My new patient tracks me with his eyes as I kneel beside the bed to put my hand on his chest; attempting to get a quick read of core body temperature. Even through his light clothing he’s really hot and I notice he’s not sweating – bad sign.

“Does he speak English?” I’m addressing the grandson who followed us into the bedroom. In families that are recent immigrants I find that the children make the best translators as they learn English through the schools.

“I speak little English,” replies the boy in a thick accent and not directly addressing my question. I don’t think I’m going to get much translation on this call.

I try going back a forth a few times to get an assessment of my patient’s mentation, his normal baseline, medical history, allergies, medications etc. I’m batting about 50% on getting straight answers and quickly decide to stop waisting time and get moving to the hospital.

I take the time to explain to the family that I’m going to have to remove my patient’s turban. He’s burning up and I need to start the cooling process. They’re not happy about taking off his turban but eventually we have an understanding that it’s the best thing for him. As I’m taking off the turban and shirt I notice he’s wearing adult diapers and there’s a plastic sheet on the bed. Checking his pulse I see that he’s in the 130s. It’s pretty obvious where this is going.

As I slip the turban from his head I notice the long, uncut hair neatly wound around the top of his head and secured with the Kanga, a wooden comb. The uncut hair and comb are two more of the five external articles of faith which symbolize cleanliness and tidiness. Sikhs believe that the hair, like everything else, is a gift from god and therefore remains uncut.

He’s light enough that I can just cradle him and move him to the gurney myself. While carrying him to the gurney his arm dangles in front of me with the Kara – iron bracelet – resting against his outstretched hand. Heading towards the ambulance I have a working differential diagnosis and I’m mentally running through treatment options.

The elderly who wear diapers and have incontinence issues often get urinary tract infections. This often leads to fever and sepsis if it’s not treated quickly. Laying on the plastic sheet with all of his clothes on he was radiating heat and increasing the fever. Eventually he stops sweating as he gets dehydrated. The elevated heart rate is the body’s compensation mode – attempting to circulate an ever-decreasing fluid level and fight off the infection.

I tell Scottie we can start transporting right away. I’m on the fence about lighting up the rig and driving fast but decide against it as I can’t confirm his level of consciousness because of the language barrier. If anything changes I’ll light it up but for now we’re driving Code-2. I check his vitals, run a 12-lead, and use the temporal thermometer. Wow!

I poke my head through the pass through to give Scottie the ring down information. “78 year old male, possible ALOC (altered level of consciousness), language barrier, fever by two days, temp of 106.2, sinus tach at 138. Go ahead and call it a sepsis alert also. Code-2 for now.”

Our county recently initiated the use of sepsis alerts. Sepsis has finally blipped on the collective radar of the hospitals in the county and they’re asking us to give them an early heads up when it’s a strong possibility. Basically people were sitting in the waiting room or stuck in triage and were getting overlooked in the critical first stages of sepsis where aggressive treatment of fluids and antibiotics can reverse the downhill spiral of MODS (multiple organ dysfunction syndrome).

I start a very large IV and turn the fluid on letting it go wide open. With this size needle I should be able to get a liter on board during the ten minute drive to the ED. I break out some ice packs and place them on his neck, in the armpits, and tuck them into his diapers at the femoral artery. Reaching over to the control panel I flick the air conditioning on high. The best thing I can do for my patient is an aggressive fluid challenge and try to get the fever down.

As I’m pulling the gurney out at the hospital I look up to make eye contact with a patient I can’t communicate with other than giving him a reassuring look. He has a peaceful look on his face as he looks down at the IV in his arm. His gaze continues down his arm to the iron bracelet and he seems just a little more relaxed for the reminder of his faith. I envy him.

After running a lot of calls in a part of the county that has a high Sikh population I became curious about their culture. I started reading and researching to learn more about them. I feel it’s important for a Paramedic to understand the people who live in the community so as to better serve their needs. It was fascinating to learn of their rich history and devout faith with a focus on: honesty, equality, fidelity, militarism, meditating on God, and never bowing to tyranny. I find them honorable, caring, hard working people. But most of all I see that they are just like everyone else – they have the same illnesses, the same vices, and the same ideals; they are human just like everyone else. 

 

Peaceful Warrior 2/3

“The hymns in Guru Granth are an expression of man’s loneliness, his aspirations, his longings, his cry to God and his hunger for communication with that being. It speaks to me of life and death; of time and eternity; of temporal human body and its needs; of the mystic human soul and its longing to be fulfilled; of God and the indissoluble bond between them.”

Pearl S. Buck Noble Laureate, ‘Good Earth’

Walking towards the exam room in the doctor’s office I’m almost knocked down by a short woman in a white coat who is leaving the room in a hurry. There are three firefighters standing in the hallway and I hear continuous coughing coming from the exam room where the fire medic is attempting to talk to the patient.

I’m in the suburban part of the county where there are many clinics and urgent care extensions of the regular hospitals. Fortunately, people in this part of the county actually use these resources and it alleviates a lot of traffic to the ED. That’s usually a good thing but as today is Friday and people seem to want to get checked out prior to the weekend, it seems to be the only call I’m running today. This is the third time in as many hours that I’ve walked into a clinic to pick up a patient and take them to the ED. It tends to be a boring call as there is usually already a diagnosis and all of the initial work up has been done prior to my arrival.

As I poke my head in the exam room I see the fire medic walking towards me. “So that white coat that just tore out of here was the doctor. She says he’s been sick for six months and isn’t responding to the antibiotics. He needs a chest x-ray and blood work done at the ED. That’s about all I’ve got, this guy is coughing so much he really can’t answer any questions. Are you guys good?”

“Yeah, I got it, thanks guys.” The firefighters grab their bags and head out of the clinic. This seems like an easy call; basically he’s sick. It’s just a little more than the clinic can handle so they are off-loading him to the ED. I’m sure that the fact that it’s 1730 on a Friday has nothing to do with it.

I grab the stack of papers, check to make sure my new patient is wearing a mask, and push the gurney through the empty waiting room to the rig. It’s a rainy day with a bit of wind. The winter has finally started in this part of the country and, as we live in a temperate climate zone, this is about as bad as it gets. Although mild by comparison to other parts of the country it’s enough to set off the noticeable increase in calls for “flu-like symptoms.”

Once in the rig I go straight to my cabinet that holds the masks. I put on a very solid mask and eye protection and switch out the flimsy clinic mask for one that offers more protection on my patient along with a nasal cannula for oxygen that also reads end tidal CO2. He’s been coughing every few seconds and actually seems to be in a bit of distress. His skin signs are pretty crappy: diaphoretic and pale, but hot to the touch.

Scottie comes around the back of the rig with the computer and I tell him I’m good, we can just drive to the ED that is less than a mile from here. As the rig starts moving I’m trying to take vital signs on my new patient yet he’s constantly coughing, grabbing tissues, lifting his mask, and unable to talk to me because of the coughing. I’d really like to give him an IV, a 12-lead, and listen to lung sounds. But his constant agitation and coughing prevent even the basic assessment. Just about the only thing I can get him to hold still for is a tape on pulse oximetry which comes back at 84% and a heart rate of 122 beats per minute.

I decide to just bring him in with the minimal assessment and apologize to the receiving RN later. So I focus on the paperwork that I grabbed at the clinic, but find it to be absolutely useless! It’s a six month old blood work up – basically no help to me at the moment.

My patient, Habib, is blowing snot everywhere and has a productive yellow cough that is quite disturbing. After every cough he apologizes to me. Sometimes he has to take the mask off to clean his face. “Habib, put the mask back on!”

“Sorry, sorry.”

I’m a little stern with him but it’s warranted; I’m in an enclosed space with someone who may have a communicable illness and I certainly don’t want to catch it from him.

I’m looking at the minimal paperwork and notice his last name is a classic Sikh name and he has the identifiable iron ring on his wrist. He has short hair and a clean shave; both signs that he is not following Sikhism to the absolute letter. Sikhism is no different than other religions – it’s up to the individual to define their level of devotion. He is well mannered yet clearly having a bad day.

It’s a short ride to the ED and I’m happy to open the back doors and roll him into the receiving bay. I park the gurney right next to the administrative desk. There’s no better way to get a bed faster than to sit in front of the desk with a patient who’s hacking up a lung.

It’s a short wait and I get him transferred over to a bed. I go to the EMS desk and start typing up my report after a quick hand off to a nurse where I apologize for having almost no information and having done practically nothing for him other than a taxi service. Of course I stopped by the restroom to do a scrub down of all my exposed skin and a wipe down of my uniform with some toxic smelling wipes.

Ten minutes later the nurse walks up. “I hope you used universal precautions because he’s HIV positive.”

“Yeah, I’m good, eye protection and everything. Thanks for the heads up.”

I later come to find out he has streptococcus pneumonia; a particularly bad strain of bacterial pneumonia that is common in HIV patients with compromised immune systems and low white blood cell count. It presents with: fever, hypotension, productive cough, and remarkably low oxygen saturation. It’s a drug resistant strain that often leads to bacterial meningitis as the bacterium transfers from the lungs into the blood stream. Habib was transferred to the ICU a few hours later.


Peaceful Warrior 1/3

peace·ful

1 : undisturbed by strife, turmoil, or disagreement; tranquil

2 : of or characteristic of a condition of peace

 

war·ri·or

1 : one who is engaged aggressively or energetically in an activity, cause or conflict

2 : a man engaged or experienced in war, or in the military life; a soldier; a champion

In thy childhood you were ignorant and blind. And in your youth, you were lured away by sin. In the third stage, you gather riches and when you get old, regretfully you leave them all off.

Ramkali – Sikh Guru

“Sikh temple, seriously?” I didn’t even know we had a Sikh temple in the county and I’ve been working the streets for years. This is one of the things that I love about working here; the cultural diversity is never ending and continuously developing. This call is pretty far from our current post so I have time to check the notes on the call. The notes in the mobile data terminal (MDT) tell us that we’re responding to a man who burned his hand in a kitchen deep fryer.

I’ve been called to a few deep fryer mishaps and it’s never pretty. In this case I’m hopping it’s the left hand because Sikhs wear a steel or iron bracelet on their right wrist. Given that we have a long response time I expect the fire department would clip it off with the bolt cutters before we arrive. The secondary burn from the steel and constriction while the hand swells could be problematic.

Strobes are illuminating the darkness and Scottie is navigating us deftly as we speed through the suburban sprawl. I decide to see how big this temple actually is and pull up the google street view on my iPad.

“Uh, Scottie, this is a huge temple and the notes say there’s a festival going on right now. We might have some crowd control issues. If we can I’ll want to move him to the rig quick so I can work him up without an emotional crowd scene.”

I’ve run a number of calls in the Sikh homes in this part of the county and I feel they are largely misunderstood by most Americans. In the post 9/11 outrage many Sikhs were mistakenly thought of as being Muslim – one man was even killed in an ignorant act of violence. In fact, quite the opposite is true. Sikhism is an offshoot of Hinduism that came about in the 16th century. In only 500 years it has grown to the worlds fifth largest religion – and this from a religion that does not actively recruit. With its roots in the Punjab region of India, which borders on Pakistan in the northwest part of the country, the Sikhs found themselves on the front lines of conflict and protecting India from Muslim expansion. Many people in this country fail to see past the beard and turban to fully appreciate their rich history and culture.

As we round the corner to the temple I can see that my crowd concerns were well founded. Pulling into the circular driveway I see at least five hundred people in the courtyard of the temple. Parked cars have been lining the residential streets for the last several blocks and their large parking lot is full. A bearded man wearing a turban and traditional garb – covered by a reflective vest – is waving us past using a flashlight with an illuminated orange cone. Its a paradox of old world and new that somehow reminds me of a Jedi master. We pull up behind the big red truck to the side of the temple.

Half a dozen young men in turbans and traditional dress encircle us as we exit the rig with the gurney. They usher us towards the side entrance to the kitchen while providing a crowd break. They are yelling excitedly at the crowd in Punjabi; presumably telling them to get out of the way. They’re doing a great job of clearing a path as the crowd parts allowing us to pass.

There are men, women, and children of all ages. The strobes from our rigs illuminate the intricate metal lace interwoven in the women’s head scarves and the traditional curved knives worn at the men’s waists. Many people have plates of food in their hands and the delicious smell only serves to remind me that we never got a lunch break today – a feeling which is juxtaposed with the fact that the man who may have prepared some of this food is now in excruciating pain.

Finally we turn the corner to the kitchen to find my new patient. He’s a man in his forties wearing a white traditional shirt and matching turban. His right hand and forearm are wrapped in a trauma dressing. His face is silently contorted in pain yet he doesn’t make a sound. Damn! It is the right hand.

As the fire medic unwraps the dressing so I can have a look I catch a minty smell. The arm appears to have circumferential partial thickness burns to approximately four percent of overall body surface. Yet it’s difficult to visualize the surface because of a white ointment that appears to be slathered over the arm.

I know the firefighters wouldn’t have put anything on it so it doesn’t really make sense to me. “What’s all the white stuff?”

The fire medic looks up at me with a totally straight face and deadpan delivery, “Toothpaste.” Seriously? Toothpaste?? what the hell?!?

Okay, I’ve seen people put some strange stuff on burns but this is a first. In the last few years I’ve seen: mayonnaise, butter, and yellow mustard. It seems people are always treating burns like a hot dog, although I’m still waiting for sweet relish. But toothpaste is a new one.

I listen to the description of how it happened as I cut his shirt off and move him to the gurney. I’ll leave the turban on for heat retention as he’ll get cold and start shivering here in a few minutes; covering the head helps to hold in heat. I see the bracelet that was cut off of his wrist sitting on the counter, pick it up, and put it in my patient’s good hand. He’s still stoic yet seems to appreciate having it back. He inspects the perfect circle that is now broken and frowns as he puts it in his pocket.

The bracelet is called a kara and is worn by both male and female initiated Sikhs. It is one of the five external articles of faith that identify a Sikh as dedicated to their religious order. The Sikhs wear the kara as a reminder to have a calm spirit and life – it’s an expression of eternity. In India, warrior Sikhs are still seen wearing several karas of large sizes, designed to be used as a weapon in hand to hand combat. It’s an integral item in the martial training that was developed by the warrior Sikhs. I wonder if he assigns significance to the fact that bolt cutters have severed the perfect circle and thereby thrown mind, body, and spirit into a state that is less than harmonious.

Once he’s on the gurney I stick to my original plan and start moving quickly to the rig to treat him further. As I head out of the kitchen my six escorts jump into action and make a path through the crowd. I wish I could take these guys to every call with me as they are doing a great job of expediting my egress from the temple.

After loading into the rig I tell Scottie we can start driving. All of my treatment can be done en route to the hospital because hot oil burns have a way of getting worse with time. I’ve watched blisters form in front of my eyes while transporting similar hot oil burns. Treatment at this point is fairly straightforward: irrigate with sterile water to minimize the heat of the oil and get rid of the toothpaste, get rid of the trauma dressing and apply a sterile burn sheet, load him up with as much morphine as I can, and treat for any signs of hypothermia.

The body’s reaction to a moderate burn is to shift fluids to the tissues to replace fluid loss from the burn. It’s called third spacing as the fluids are taken out of the circulatory system and shunted to the peripheral tissues.This can reduce the blood pressure and cool the core, thereby inducing hypothermia and dropping the blood pressure.

It’s a long ride to the burn center – I have to go out of county as he meets burn patient criteria. Having a circumferential burn to the fingers and wrist could result in swelling, yet the skin is no longer elastic so it could restrict circulation or burst like a grape. A burn center is better equipped to deal with this than a basic ED.

My treatment is basic at this point and he has been stoic throughout. I can still administer a few more rounds of morphine yet as I go to administer he holds up his good hand and refuses additional pain meds.

Laying on my gurney In the back of the ambulance, arm elevated to reduce swelling and so he can feel the cool air if the air conditioning, this brave man refuses pain medication. His face softens from its original squinty-eyed grimace and he relaxes his back to lie more comfortably. With turban in place and a peaceful look to his face I see a tear trickle from the corner of his eye and travel down his face to get absorbed in his beard.

Acceptance is the bridge. Accept the pain, accept the wounds, accept yourself as you are. Don’t try to pretend to be somebody else, don’t try to show that you are not this. Don’t be egoistic, and don’t go on pre-tending and laughing while your heart is crying. Don’t smile if your eyes are full of tears. Don’t be inauthentic, because by being inauthentic you are simply protecting your wounds from being healed. Your whole being will become rotten.

Osho; ABC Of Enlightenment