Category Archives: Medical

Morton’s Fork 2/2

Kevin navigates the residential streets to St. Closest while I’m in the back with the sergeant tracking respirations and the fire medic helping me by taking vitals. My new patient, who was dead just a few minutes ago, is actually doing pretty well. He’s got a decent blood pressure, reactive pupils, 12-lead is clear, and he’s got some spontaneous movement in the extremities. I decide not to put him on ice (therapeutic hypothermia) based on his increasing level of consciousness and the knowledge that the ED at St. Closest wouldn’t continue with the procedure over the next 24 hours.

We move him over to the bed at the ED and I give a report to the MD and nurses who are going to continue treatment. They seem a little crestfallen as they are surprised by the level of consciousness of the patient. It’s not like anyone is sad to see a resuscitation but it’s so uncommon for someone to go from asystole to having perfect vitals and be sitting upright in a bed and staring at you that they are at little bit of a loss. Unlike in the movies, where they seem to bring people back from asystole all the time, in real life a flatline most often means game over.

I’ll check back in a few minutes but right now I have a mountain of paperwork to do in documenting all of the things we did and how the patient responded. I walk out of the ED towards the rig so I can start typing on my computer.

Two EMTs from the Inter-Facility Transport division are walking in and one of them catches my eye. “Hey, did you have Brian’s dad?”

“No, I had a code-blue with a resuscitation.” I’m just a little proud of myself for pulling off an improbable field save. They look a little bit confused but continue into the ED. I’m walking to the rig when it finally hits me. Fuck ME! The son was Brian!

I didn’t recognize him out of uniform. He’s been working as an EMT in the county forever, long before I got here. He’s a career EMT in the Inter-Facility Transport division so I seldom see him on the streets or at the ED. I’ve only talked to him a few times and I knew he looked familiar – but I just couldn’t place him.

I’m actually shaking as I tap away at the computer to document the call. I’ve never worked up the family member of someone I know, much less pulled them back from the dead. And having pulled off a minor miracle I took him to the one hospital in the county that none of my co-workers would ever want to go to – much less send their recently dead father to. I feel like I let him down, however paradoxical that feeling may be. I just can’t shake the torment in my mind.

Having finished my paperwork I drop it off in the room and see that Brian’s father is sitting up, talking to staff and family, and upon glancing at the monitors I see that every vital sign in well within normal limits. The other son and his wife thank me as I try to get out of the ED. I’m starting to feel like I need to vomit. I need to move on to the next call and shake this out.

Kevin’s waiting for me and he’s also trying to digest the news as I jump in the driver’s seat and put my hand on the key. I look up through the windshield to see Brian sitting on a bench being comforted by his girlfriend, crying tears of grief with his face buried in his hands. Try as I might, I physically can’t start the engine. I have to bring this full circle and talk to Brian even in his grief stricken state. I’m not sure if he’s going to take my head off or thank me but I have to see this to the end and do it right now. I have never felt so bad after saving someone’s life before and I can’t really come to terms with the emotional upheaval that’s ripping me apart.

Brian stands up as he sees me walking towards him and his girlfriend backs off to give us some room. I’m seriously expecting him to punch me in the throat and I know that if he does I’m just going to stand there and take it – I might actually deserve it.

“Brian, man, I’m so sorry, I had to come here, you know I did…” We’re both crying now standing just a foot apart.

“Thank you! You saved him. Thank you so much.” His huge arms envelop me in a tearful hug. Oh, thank god! I don’t need an ambulance…

“No, you saved him. You kept his heart going until we got there. It was all you!”

The emotional turmoil that I attempt to convey in this retelling may be difficult for those outside of EMS to fathom. It may seem strange but even on a successful field save we try to get out of the hospital before the family members arrive. I don’t want praise for a life saved and I definitely don’t want blame for a life lost. Speaking for myself, though I think other first responders feel the same, I must preserve my emotional detachment so I can make the right decision at critical times without hesitation. I know I did the right thing in my transport decision. But in retrospect I’m glad that I didn’t recognize Brian while on-scene. I may have hesitated longer or possibly even gone against my training. I’ll never know what I would have done but I know I’m now better prepared if the situation ever comes up again – and I have no doubt it will. 

That night Brian’s father was transferred to his hospital of choice with no deficits. After being surrounded by family members for two days he coded on the nursing floor and was pronounced dead. Our resuscitation bought him and the family some time together. Sometimes that’s enough – but in this case I wish the outcome was different.

Morton’s Fork 1/2

mor·tons fork

1 : a choice between two equally unpleasant alternatives

2 : also known as; between a rock and a hard place

3 : 1889, in ref. to John Morton  (c.1420-1500), archbishop of Canterbury, who levied forced loans under Henry VII by arguing the obviously rich could afford to pay and the obviously poor were obviously living frugally and thus had savings and could pay, too.

Each player must accept the cards life deals him or her: but once they are in hand, he or she alone must decide how to play the cards in order to win the game. 

~Voltaire

“Damn! This might be a real call…”

We pull up to the house just as the fire engine stops and three firefighters bound out – headed for our rig to grab the house bags. It’s one of those tribal customs that we all follow and no one ever knows when or how it started. If we use our bags in the house we don’t have to restock the fire department’s bags so when we arrive at the same time as fire, they always walk back to our rig and carry our bags into the house as we bring the gurney. But it’s more the haste of their movements that I’m reacting to at the moment. If this call were just the call for the altered seventy year old that my MDT told me it was, they wouldn’t be moving so fast. I’m thinking there might be a little more to this than my dispatcher led me to believe.

Kevin and I walk up to the front door with our military EMT ride-along in tow. Standing in the small foyer of the house I see the fire medic bent over and feeling for a carotid pulse of a man who is laying in the back hallway. “Yeah, it’s code-blue – bystander CPR was in progress until just a second ago.” Okay, cardiac arrest – looks like we’re working a code today. It’s my call so I ask them to move my new patient to the foyer so we have some room to work. As they carry the very large lifeless body my direction, I open up the drug box and set up the monitor. I’m going to work everything here in the foyer and see where we go from there.

Working a code is something like the altered reality of visiting the Twilight Zone for a few minutes. I have an omni-present yet tunnel visioned perception of the world where I’m acutely aware of minute detail yet still processing and interacting with my peripheral surroundings. While attaching the monitor I’m handing a BVM (bag valve mask) and NPA (nasal pharyngeal airway) to the military ride-along. For now I’ll keep him on the head to manage the airway and breathing for the patient. Later on I’ll switch him to compressions, but I want the experienced firefighter doing the first few – all too important – rounds while I figure out IV access, spin up some drugs, and evaluate the monitor for any shockable rhythms. With my mind prioritizing all of these tasks I delegate to the crew and somehow manage to listen to some random family member standing behind me, who’s telling me that he saw his father collapse and did CPR until we arrived.

Kevin thinks he has a good shot at a vein and goes for it while I have them stop CPR so I can feel for a carotid pulse and check out the monitor – no pulse and the flat line of asystole on the monitor. “Resume CPR.” I hand the OPA (oral pharyngeal airway) to the camouflaged sergeant who’s breathing for the patient right now. There was a day when I would have immediately laid down at the patient’s head and intubated while holding CPR to get that all so important tube, but the recent data seems to de-emphasize the intubation so I’ll cross that bridge in a few minutes when I figure out where this code is going. Besides, I wanted the sergeant to get the feel of inserting the nasal and oral airway adjuncts as they will be the primary ones that he uses in the future and it’s the right thing to do for the patient at this stage in a code.

Kevin looks up in frustration. “I didn’t get it, the vein collapsed on me.” After only five minutes of down-time, even with CPR, the blood volume in the vein has reduced making it deceptively hard to hit with a needle.

“No worries, I’ll drill him.” I pull out the bone drill and sterilize my target area on the lower leg where I’ll be using the electric drill to drive a metal catheter into the bone marrow and give us access to my new patient’s veinous system for drug administration.

While I drill, Kevin cuts off clothing, the rhythmic bounce of CPR rocks the lifeless body beneath me, and the army sergeant squeezes the bag every few seconds, providing life-giving oxygen. I can still hear the man’s son in my ear talking about how his father wasn’t feeling too well today and how he has a lot of medical problems – surreal Twilight Zone.

There’s too much fat on the leg and my drill never even reaches the bone. I stifle the automatic profanity that comes to mind – family members are standing over us and they don’t need to see frustration on our faces as we attempt a resuscitation. Reaching back into the drug box I pull out the bariatric bone needle and attach it to the drill. While I drill his leg a second time I explain what we’re doing to the son who’s floating over my shoulder. With the larger needle secured in the bone I attach the bag of fluids and inflate the pressure bag to force saline into the veinous system. I turn around to hand the bag to the son – I want to give him a job so he feels like he’s doing something. He did a good job by providing CPR until we arrived so I want to include him in the process. Looking up at him for the first time I’m momentarily stunned. Damn! He looks familiar but I can’t place him. I’m fairly certain I’ve never been in this house before. Whatever; work the code.

The second round of CPR is done and I do a pulse check while staring at the flat line of asystole on the monitor again. “Resume CPR, first Epi going on-board.” I inject the drug into the line and pump up the pressure bag a few times to push it into the system. I help Kevin in cutting off clothing and spin up the next drug so I’m ready to inject it at the next break in CPR. The firefighter who’s been doing compressions sits back on his haunches, after his latest two minute cycle, as I put two fingers to the patient’s neck. I’ll be damned! That’s a faint pulse. I look over at Kevin, “Confirm that pulse for me.” As I put fingers into the femoral artery and Kevin feels at the neck. A quick glance at the monitor shows a string of perfect complexes marching across the screen. Kevin and I lock eyes and simultaneously nod to each other: confirmed! The sergeant looks up at me, “He’s breathing by himself!”

Looking at the sergeant, “Track him with assisted breathing but don’t force it.” To the other two firefighters, sweat pouring off of my very competent CPR go-to guy, “Let’s get a board and some straps in case we have to resume and let’s get transporting. I’ll be going Code-3 to St. Closest.”

The voice of protesting anguish comes from behind me as the son is in tears. “Oh come on man, anywhere but there, don’t take him to that death trap!!” Okay this guy’s face is really starting to bug me, I know I’ve seen him before, but I can’t place it. And he knows our system because that ED is known for its less than stellar performance.

“Look, he’s got a pulse and I can’t risk losing it by driving too far. St. Closest is less than a mile away and I can’t bypass it by four miles – doing Code-3 – to get to Hilltop. You’ve got to believe me – it’s the only option!” I actually considered it for just a half a second but if I lost pulses during transport I will have put this patient in serious jeopardy and I’d have a lot of explaining to do to my medical director. I just can’t risk it.

The son is distraught but he’s not going to go toe to toe with me on the subject. I feel a little bad for forcing the issue against his wishes but I’ve got a dozen other things to do right now that take precedence so we carry on with the transport.


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.


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.