Closest Most Appropriate 4/7

John, my partner, is a new medic in the county so Scheduling floated him to my unit today because my normal partner is out on light duty from an injury he received while lifting a 600 pound patient. John has to be with a more experienced medic until he gets signed off by a Field Training Officer. Scheduling doesn’t seem to care that I only got signed off last week. Although we’ve never worked together, and honestly just met a few hours ago, we had a good bonding on our last call. Stat calls can bond partners in a way few things can. I imagine it’s similar to people who go to war together but I’ve never experienced that so I can only guess.

Our first call of the day was for a teenage gang banger who got shot in the ass. The large city in our county is ripe with urban violence – gangs, drugs, and everything else that eventually ends with a trip to the hospital. Consistently ranked in the top five of the country’s most dangerous cities, it tends to be a great place for a new paramedic gain experience – fast! The baby gang banger was pretty much okay – single entry wound, no exit, small caliber bullet, able to move all of his extremities. Actually a pretty basic call for the city and John and I executed the necessary tasks and got him to the trauma receiving hospital in good time.

John and I are on the same page about Josh’s treatment and I trust he’ll make the case for the Base MD well enough to allow us to do the right thing. Meanwhile I make a quick call to the supervisor and tell him what’s going on. Company protocols dictate that I alert him if I need to transport out of county. I quickly lay out the scene for him and he agrees that it’s what needs to be done. His parting words gave me a shiver, “Good luck with that.”

I see John hang up his cell phone and I give him the raised eyebrows as I’m helping to wind up the EKG wires and put them back in the monitor. “Okay, I talked to Dr. Finch and he understands the situation. He would rather us take him to Kid’s but said if the mother is insistent then we have permission to go to University by ground or air.”

I turn to Mom, “Which hospital do you want him to go to, University or Kid’s?”

“Definitely University!”

“Okay, we’ll get him there.” Mom, who has had every mother’s worst nightmare in groundhog day repeats gives me a big smile and thanks me as she starts gathering up necessary paperwork and belongings for yet another ambulance ride with her very sick child. I’ll take her with me if I have to drive him, sitting up front of course. There is a very real possibility that Josh may decompensate en route and no mother needs to watch us run a code on her kid from a ringside seat on the bench  – where you can actually hear the ribs break from CPR.

As I’m getting ready to pick Josh up and carry him to the gurney the fire captain comes up shaking his head. “They just flew a guy off the freeway, ETA for the next closest helicopter is 30 minutes.” Crap, that’s too long!

“Okay, it looks like we’ll be driving him, I’m glad that accident was the other direction on the freeway.” The captain raises his eyebrows and gives me the tight chin look that says he understands what the next 40 minutes are going to be like. He’s a paramedic also – keeps his certs current, does the occasional IV or helps out with an intubation now and then. But he’s a captain now and the fire medic that works on his crew is supposed to do all of the advanced life support interventions. He’s put in his years and deserves his position even if he would rather be pushing the Dextrose into the vein of a gorked diabetic instead of writing down the same medications on every call and asking the same tired questions of family members. Yet I can see that this is one call where he’s happy to down his engine and go back to the station to wait for us to bring back his fire medic.

Closest Most Appropriate 3/7

I join the fire medic, my partner (who happens to also be a medic), and the fire captain for a quick huddle near the kitchen.

The fire captain starts, “Okay, here’s the deal. He’s on the list at University Hospital for heart and liver transplants – his base problem is the heart but it’s cascading to other organs and is causing liver failure. Mom wants him to go to University because they know his history. He’s had six cardiac surgeries in the last three years with the cardioversion two weeks ago. But I know you guys probably have to go to Kid’s Hospital because it’s in-county.”

“Yeah, we have to go to Kid’s, but even that is 30 minutes away doing code-3 given traffic. If he starts to crash out I’ve got to take him to the nearest receiving hospital, he’s compensating right now so we have few options. Either way I could use a rider if you can spare your medic.” He nods without having to say the words, we all know how this could play out. It takes at least two people in the back of the rig to effectively run a code.

I do some quick math and take stock of what I have in front of me. Josh’s cardiac history is so complex that even Kid’s Hospital would be calling for a transfer rig as soon as I walk in the door, yet county protocol says I need to take him to Kid’s. He’s still compensating, and therefore somewhat stable for the moment. Yet kids stop compensating very suddenly and he has a very complex medical history, so it’s tough to gauge his compensatory stamina. I can get to Kid’s in maybe 30 minutes; going to University would take 45 minutes, out of county, crossing a very long bridge.

“Do you want a helicopter?” asks the captain. Hell yes I want a helicopter! Let the flight medic take this call, they have more training and  a few more cardiac drugs at their disposal. Not to mention he can get to where he needs to be faster than I can do it. But didn’t they just fly out that motorcyclist? Crap!

I decide it’s my call to make. Josh is getting to University Hospital one way or another –  they know his specific history, they have a cath lab, they have a pediatric department, and that’s where the transplant team is in case he gets bumped up on the list because of this. If Josh’s little heart is beating its last few beats right now he needs to be in the hospital that is equipped for the transplants.

“Okay Cap, can you call for an ETA for a helicopter? If it’s too long we’ll see about driving him there.” As the fire captain turns around to talk into his portable radio, I ask my partner to call our Base MD (the doctor that we call to get permission to break or exceed protocol when we need to) and make the case that we need to drive this kid out of county if we can’t get a helicopter. I ask the fire medic to start getting Josh ready to go, unhook his monitor and secure the IV.

Closest Most Appropriate 2/7

He gives me a quick run-down of the situation.

“This is Josh, he’s 8 years old and has a birth defect in the heart. He was playing with the other kids outside when he had sudden onset 10 out of 10 chest pain described as pressure and associated shortness of breath. He had a similar event two weeks ago which required cardioversion and the Cath Lab.”

“Why cardioversion?” I’m still trying to reconcile the fact that my patient is a kid and not a man in his 50s.

He moves out of the way of the cardiac monitor which has a fast series of even little bumps where the perfect electrical conduction of an 8 year old should be. He says, “It looks like atrial flutter at a rate of 178 a minute and he’s got a blood pressure of 86 over 58 off the auto BP cuff.” All BAD!

I move around the fire medic to have a look at Josh. “Hi Josh, how ya doing?” I say hoping he doesn’t see the very real concern in my face, as I kneel down to meet him eye to eye. He takes a tiny little thumb and gives me the thumbs up. Wow! Josh is a veteran of the medical community at the ripe old age of 8. He has cardiac surgical scars like a 50 year old who’s had multiple bypass surgeries and he knows he can’t talk well with the mask on, so he gives me a thumbs up instead. I give him a smile while I hold his wrist with my fingers wondering if I’ll find the weak radial pulse tacking away at 178 miles and hour. He’s pale, cool, diaphoretic. It’s a term we use a lot yet it still astonishes me when I see it. Sweaty people shouldn’t be cold to the touch and no 8 year old should ever look like this. The pulse is there and presents as I expected, fluttering along like quick rapids in a river under my fingers. We call that thready.

The fire medic kneels down with me, “Mom said that last time he was cardioverted his heart sounded like a washing machine, and that’s pretty much what it sounds like right now.”

I pull the stethoscope from around my neck and place the bell on Josh’s exposed torso next to the fresh scar tissue. Damn, if that doesn’t sound just like a washing machine. Paramedics don’t usually work with heart tones, pretty much every heart tone I’ve ever listened to sounded just like the diesel engine of my ambulance – it’s a skill and diagnostic tool better left to the cardiologist in a controlled environment. But any paramedic could tell that this kid’s heart was not doing the normal “Lump Dump” of a healthy heart. I’ve listened to heart tones of leaky valves – on the internet anyway – and I understand the concept. But this is a leaky valve on steroids. This valve simply isn’t working.

The fire medic was watching my eyes as I listened. All paramedics are similar in one respect: they are trained observers. We get lied to by most patients – people give us conflicting information, exaggerate their symptoms and distort the facts. We quickly develop very acute observation skills with a finely tuned bullshit meter. He saw me play out this scenario half a dozen different ways, most with bad endings, and the resignation that we are on this path together for better or worse. All of that was in just one look but we had an understanding: Josh was our patient and we were going to see it through together.

“Hey Josh, we’ll take really good care of you, just hold tight while I talk to these guys for a second, okay?” He gives me another thumbs up. Wow!

Closest Most Appropriate 1/7

clos·est

1 : being near in time, space, effect, or degree
2 : having a strong liking each one for the other <a close friend>
3 : very precise and attentive to details <close measurements> <a close observer>
4 : decided by a narrow margin <a close race>

uh-proh-pree-it

1 : the determination that the service provided is suited for the condition
2 : being suitable for a particular person, group, community, condition, occasion, and/or place
3 : proper

Walking up the stairs to the front door I take in the neighborhood. Children playing next door stop to stare at the fire engine – all the lights flashing – parked just in front of our ambulance, which smells of abused brake pads. It’s a nice neighborhood, not one I’m called to very often, in a quiet suburb of the county with expensive cars parked in front of well manicured lawns. I’m heading towards the door that has been left open for us and check my pager to make sure the numerics match. It’s an acquired habit from working in the hood where walking into the wrong house wearing a uniform can be a fatal mistake.

Taking the stairs one by one I’m thinking of the patient I’ll be responsible for in a few minutes and quickly brainstorming the possible treatments as compared with the equipment I have on hand. I’m a little tired and frustrated from the delayed response time and the distance my partner and I had to cover to get to this house. Nearly 16 minutes is longer than anyone should have to wait for an ambulance and 20 miles is longer than a crew should have to drive code-3 (lights and siren) to reach a call – at least in this county. But on this day I’m in a back-roads wealthy suburb of a county that is three-quarters urban sprawl. Not surprisingly, this area of golf courses and farmland doesn’t have as much freeway access as the more populous areas.

I recall during the drive that the dispatcher said something about this area being “Level Zero” – meaning no available ambulances in this part of the county – and that we were the closest unit. I’ll take her word for it as all of the ambulances in the county are tracked by GPS and calls are automatically routed to the closest crew. While driving to the call I listened to the radio traffic talking about a collision on the freeway ten miles further away  with multiple patients, one trauma activation, and another crew taking a motorcyclist to a landing zone to be air lifted to the closest trauma center.

The dispatcher was so busy with the high call volume that she didn’t send the call information to the Mobile Data Terminal which sits on the console of our unit. Usually I can get some specifics about the patient I’m responding to from there, but not on this call. So I’m going off the pager that only tells me where to go and gives a generic chief complaint of the caller. In this case it’s “Chest Pain / Shortness of Breath.” It’s a call I’ve run hundreds of times and it can manifest in any number of causes and levels of acuity. From the frequent flyer in the hood who just needs a sandwich and a place to take a nap to the identifiable coronary artery occlusion that requires a cath-lab and a code-3 trip to the nearest Cardiac Receiving Center.

Walking through the doorway to the house I see a few children and family members taking quick awkward steps to get out of my way, the way people often do when they suddenly find themselves unusually “in the way” inside their own house. I’m heading towards the kitchen/great room where I hear the squawk of the fire fighters’ radios. Walking in I see the fire captain talking to a woman in her 30s while he examines prescription bottles and writes down details. His mannerisms are business-like in the way we all turn on the A-game when it’s a real call. I’m starting to think this woman’s husband may have had a heart attack when I turn to see the small boy sitting on the sofa with a non-rebreather oxygen mask on and a fire medic kneeling at his side staring at a monitor. Another fire fighter is standing next to him holding an IV bag – the small boy already has an IV going.

Okay, now they have my attention. Sure it was a long response time but fire medics don’t usually start IVs before I get there unless it’s serious. And children don’t have chest pain! As I walk up the fire medic stands up with a relieved look in his face. Crap, this is a very real call!