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.

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