Tag Archives: 12 lead

Stagnation

stag·na·tion

1 – the condition of being stagnant; cessation of flowing or circulation, as of a fluid; the state of being motionless; as, the stagnation of the blood; the stagnation of water or air; the stagnation of vapors

2 – in acupuncture: a pattern of excess that occurs when the smooth flow of Qi is stuck in an organ or meridian – the primary symptoms are pain, soreness, or distention, which characteristically change in severity and location

3 – in western medicine: the retardation or cessation of the flow of blood in the blood vessels, as in passive congestion or occlusion

“My mind rebels at stagnation. Give me problems, give me work, give me the most abstruse cryptogram, or the most intricate analysis, and I am in my own proper atmosphere. I can dispense then with artificial stimulants. But I abhor the dull routine of existence. I crave for mental exaltation.”

Sir Arthur Conan Doyle – Sherlock Holmes

Officer Leung arrives at the Chinatown police sub station early every morning. He has a personal sense of ownership in that he opened up the station sixteen years ago and he’s been walking the streets of Chinatown ever since. After checking last night’s crime reports he sets out on his morning rounds of getting out to interact with the community. He’s a familiar face to the locals and he can’t walk more than ten yards at a time without saying hello to someone. Being a native Cantonese speaker he easily communicates with the locals and they feel the ability to approach him with everything from neighborhood concerns to telling him about the birth of a son.

It’s an experiment in community policing that started decades ago and is only now beginning to take hold and show results. Many people living in ethnic enclaves of our mostly urban city seldom venture outside of their comfort zone. They may have a mistrust of police and authorities and an inability to easily communicate in English. Because of this they are many times the victims of crimes that go unreported. The community policing model is an attempt to put a familiar face on the authorities and give the people in these areas the ability to thrive in a safe environment. Officer Leung is that face in this community and he loves his job – he feels he gives back to his community every day.

Chinatown is in the midst of its morning wake-up routine: produce trucks double parked and offloading fresh goods, vendors stacking baskets of fruits and vegetables partially in the sidewalk, succulent looking roasted duck and pork hanging in windows. Quickly following the produce trucks are the professional recyclers – men in small pick-up trucks, stacked high with cardboard, providing a service to the vendors and a small income for their family.

Jin has been doing this for years and he knows all of the vendors on his street. As he methodically breaks down the cardboard boxes and stacks them in the back of his truck his shoulder continues to hurt from the strain and the cold morning. He’s thankful he wore extra layers of clothing as it’s a cold day but he seems to be working up a sweat faster than usual today. as each layer of cardboard gets added to the pile in the truck the strain on his shoulder increases. Finally he drops to one knee, holding on to the side of the truck, and grimacing in pain as he sees Officer Leung stop next to him.

I really don’t like running Code-3 through Chinatown. The public cliché about Paramedics and EMTs is that they are adrenaline junkies who love to drive fast and live for the blood and guts of a gory scene. In truth, just about every co-worker I know is really happy when a call gets downgraded to Code-2 and we get to shut down the lights and drive slower. We get far more satisfaction from a complex medical call than a bloody trauma.

But running Code-3 in Chinatown is its own special kind of hectic. Putting aside the normal stereotype about Asian drivers, the real problem is the one way streets with delivery trucks double parked on either side and the intersections where pedestrians can cross in all directions at the same time. It’s a very confusing place to drive – much less Code-3. Fortunately, my partner is handling it pretty well and I just have to help keep an eye out for the random jaywalker.

When we pull up to the scene I open the door and I’m hit with the smell of Chinatown. It’s not unpleasant yet it is unique in the city. The fresh pastries from the Chinese bakery have a sweet smell that blends well with the roasted meat from the next storefront. Layered on top of the food smells is pungent odor of Chinese medicinal herbs that waft from the herbalist’s store. All of this mixes in with the closest and least appealing smell: burning brakes from our rig.

I walk over to the officer and the man sitting on the curb. “Hi Officer Leung, what’s going on today?” Over the years I’ve seen Officer Leung walking the Chinatown beat. He’s a refreshing fixture of the Chinatown landscape.

“Not really sure. Jin collapsed while stacking his truck. He said his shoulder hurts and he saw a doctor for it yesterday but it’s worse today. He only speaks Cantonese but I can translate for you.”

“Okay, how about we move into the rig so I can check him out. Ask him to have a seat on the gurney. Thanks.” The rig has plenty of room and Officer Leung is able to sit at the foot of the gurney without getting in the way. He’s easily able to translate all of my questions pertaining to the onset of symptoms as I try to figure out what’s going on and my partner sets up the monitor to take vitals for me.

Jin has the skin signs that scream MI: pale/cool/diaphoretic, wincing in pain, holding his left shoulder, respirations coming in small gasps. My priority is to set up the 12-lead and have a really good look at the heart. Yet as I open his shirt I’m surprised to see evidence of trauma – he has bruises all over his chest. I’m a little confused as this was presenting like the perfect MI; I remove his shirt so I can fully appreciate the bruises.

As I step back to get the overview of his condition it all comes into focus. He looks as though he was just attacked by a giant squid. He has maybe a dozen circular bruises on the front and back of his left shoulder – they look like giant hickies. Turning to Officer Leung, “Can you ask him to clarify, did he see a doctor yesterday or an acupuncturist?”

After a quick exchange of Cantonese I can rule out the giant squid theory and replace it with the likelihood that he is the recent recipient of fire cupping. It’s an acupuncture technique where a piece of flash paper is lit inside of a bulbous cup which is quickly placed on the skin. The fire sucks the oxygen out of the interior of the cup which then pulls the skin into the cup as it creates suction. The result is a number of circular bruises on the skin that look like a giant squid attack. The theory is based on the principlel that stimulating areas along a meridian will release the stagnation of energy and restore normal circulation. It’s a treatment that’s been around for millennia yet as I look at the results of the 12-lead ECG printing out of the monitor I can see it’s not the treatment he needs right now: ***ACUTE MI SUSPECTED***

 

 

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.


Traffic 2/2

As I push the gurney through the sally port towards the ambulance with our police escorts, I’m able to have a few moments to myself to ponder the situation. I’ve transported many prisoners in the past and often pick up violent offenders off the streets fresh from a well deserved police “attitude adjustment” requiring a trip to the ED. But somehow this is different. This isn’t a random act of violence or even a simple premeditated crime. This man is potentially the perpetrator of organized subjugation of innocent children. The level of pure evil that spawns this behavior is unfathomable to me and I’m having a bit of a hard time with the whole situation.

I load the gurney into the ambulance and tell Kevin that I’m just going to fire off a quick 12-lead and we can start transporting. It won’t affect my transport decision as the police requested a hospital that is also a cardiac receiving center, but I need to know if this warrants alerting the cath-team if my new patient actually is having a STEMI (S-T Elevation Myocardial Infarction – heart attack). Given his skin signs and level of distress, though, I highly doubt he is.

With the 12-lead complete – normal as expected – the police cruiser pulls in behind us for an escort to the ED as we start transporting. The rote task of taking vitals and applying the monitor to a patient that I can’t talk to gives me a few more minutes to contemplate my emotional state. On the one hand I may have evil incarnate strapped to my gurney, sitting only inches from me, and that brings a flood of emotions to the surface that I’m entirely uncomfortable experiencing. On the other hand, this is a patient and I’m a Paramedic – end of story! My job is to treat the problem in front of me and be an advocate for a patient who can’t even convey his needs due to a language barrier. Conflicting emotions and logical arguments fly through my head at synaptic speed – like strobes on an ambulance – and quickly resolve in the blink of an eye.

I fall into the sequential tasks of treating my non-English speaking patient for chest pain; aspirin, oxygen, vitals, IV, nitroglycerine, vitals, nitro, etc… “Here, chew this up, don’t swallow,” I tell him as I make a chewing motion with my mouth and move my hand like a hungry sock puppet and hand him the aspirin. “Did you take any Viagra today?” Stupid question, he’s in jail, I’m a little off my game here. He shrugs in non-comprehension. I spray the nitro in his mouth. Whatever, if I crash his blood pressure out I’ll try to fix it and apologize to the docs at the ED.

The ambulance comes to a stop on the freeway as there is an accident in front of us. We heard it get dispatched as we responded to this call but I guess Kevin is a little off of his game as well since he didn’t use surface streets to bypass the congestion. I can see the police escort sitting just behind us – in the stopped traffic – through the back window of the rig.

Pulling the stethoscope from my ears after the latest check on vitals my patient turns to look me square in the eyes. In heavily accented broken English he speaks to me in a quiet voice. “I can see that you a very nice man. Is all a mistake. They not my bitches, they my sisters… I have much money. I give you. You let me go!”

  • Child trafficking is one of the fastest growing crimes in the world.
  • There are 2.5 million child sex slaves in the world today, some as young as 4 and 5.
  • More than 1,000,000 children worldwide will become victims of child trafficking this year.
  • Over 100,000 children in the U.S. are currently exploited through commercial sex, and 300,000 children in the U.S. are at risk every year for commercial sexual exploitation.
  • Investigators and researchers estimate the average predator in the U.S. can make more than $200,000 a year off one young girl.
  • The global market of child trafficking is over $12 billion a year.
  • The total market value of illicit human trafficking is estimated to be over $32 billion a year.
  • An estimated 14,500-17,500 foreign nationals are trafficked into the U.S. each year.
  • Approximately 80% of human trafficking victims are women and girls and up to 50% are minors.
  • 600,000-800,000 people are bought and sold across international borders each year; 50% are children, most are female.  The majority of these victims are forced into the sex trade.
  • There are open sex slavery cases in all 50 states.
  • U.S. citizen child victims are often runaway and homeless youth.
  • Runaways, orphans and the poor are targets for sexual predators.
  • Approximately 80% of trafficking involves sexual exploitation, and 19% involves labor exploitation.
  • There are more slaves today than ever before in human history.

Information from various sources ~ U.S. Dept. of Justice, U.S. Dept. of State, UNICEF, UN, UNODC

As long as the mind is enslaved, the body can never be free. Psychological freedom, a firm sense of self-esteem, is the most powerful weapon against the long night of physical slavery.

Martin Luther King, 1967

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.


Vicissitude

vi·cis·si·tude

1 – one of the sudden or unexpected changes or shifts often encountered in one’s life, activities, or surroundings

2 – a difficulty or hardship attendant on a way of life, a career, or a course of action and usually beyond one’s control

3 – unpredictable changes or variations that keep occurring in life, fortune, etc.; shifting circumstances; ups and downs

4 – a difficulty that is likely to occur, esp. one that is inherent in a situation

We walk up to the front door of the house. The diesel engines of the ambulance and the fire engine rumble behind us and their strobes light our way — and the rest of the quiet residential neighborhood. “This should be our last call. Let’s just bang it out fast so we can go home.” As soon as I said it I got that familiar sinking feeling in the pit of my stomach. Why the hell did I just say that?

It’s late at night in my mostly urban county and Louis and I have been working the last four days straight. To top it all off we’ve been held over every day due to the high call volume associated with the sudden heat wave. It’s not like we can just clock out when our day is done. If there are calls pending and not enough units in are available to take them then our dispatcher will hold us over. After the exhausting week that we just had we are finally seeing the light at the end of the tunnel with the idea that this could be the last call of the day.

That is of course until I said what I did. EMS personnel are some of the most superstitious people I have ever met aside from possibly baseball players. I resisted it for years until I just couldn’t ignore the trends. If I’m sitting in the front of the rig just passing the time and talking about a really bad code that I worked last year I’m practically guaranteed to get a really bad code on the very next call. When that happens once it’s coincidence. When it happens continuously for five years you start to respect the EMS gods by paying homage and doing everything possible not to piss them off. Well, I just pissed them off with a simple comment and I’m starting to get nervous as I walk through the front door.

It takes a second for my eyes to adjust as I enter. Standing in the front room of the house I know this is going to be a challenge. The multi-colored strobes from outside are casting harsh shadows in the poorly lit and cluttered living room, which is deserted. I’ve been inside the houses of ‘hoarders’ and this isn’t too far off; not the worst I’ve seen but the clutter is starting to pile up. I hear voices from the back bedroom and head that direction. Why is it always the back bedroom?

Standing in the bedroom are the LT and engineer. LT is writing down medication names on the run sheet and the engineer is just standing there. Their bags and monitor are sitting by the bed, still closed. They haven’t done anything for the patient yet. Down a tiny hallway is the fire medic standing outside of the bathroom. Finally I know where the patient is — the furthest possible location from the front door.

I can hear the fire medic doing an assessment down the hall as the LT brings me up to speed. “That’s Susie down in the bathroom there. We ran on her about four days ago for a lift assist after she fell. She refused transport last time. Today she’s been on the toilet for six hours because her legs are so weak that she can’t stand up. She was basically trapped back there until her sister came by to check in on her. So, first off, we have to figure out how to get her out of there because she’s really big. Second, we need to get social services involved because it’s obvious she can’t take care of herself anymore.”

I thank LT for the heads up and walk back to talk to the fire medic. I’ve run calls with him before and we have a casual familiarity. Turning the corner to the bathroom I see Susie sitting on the toilet. She’s maybe five and a half feet tall yet I estimate her weight to be 350 pounds.

Todd, the fire medic greets me, “Hey, how’s it going? This is Susie — she’s 81 years old. Basically, she doesn’t have any complaints — just increasing general weakness since the fall a few days ago. Her legs are too week to stand up right now and she needs a lift assist. But she said it’s okay to go to the ED to get checked out for the weakness.” Looking at her I can see that’s a great idea.

She’s pale — one might even say ashen — or it could be the harsh florescent lights in the bathroom. I’ll reserve judgement on that one. She has skin tears on her arms and legs with the discoloration of many bruises in various stages of healing. She’s breathing a little fast but otherwise seems to be in good spirits. There’s no visible distress. One of the skin tears on her leg looks fresh with the bright red sheen of an undressed wound.

I ask Louis to get the stair chair from the rig and he takes off to get it. There aren’t any stairs in this house but I can use it as a wheel chair to try to navigate the piles of clutter with Susie instead of trying to walk her out of here. I saw the walker sitting next to the bed on the way in so I know she doesn’t walk too well by herself.

The bathroom is very tiny so when she sits on the toilet the door is held open by her knees and she takes up the whole room. The firefighters haven’t really been able to access her to do an assessment because of the confined space. We’ll have to extricate her from the house as there isn’t any floor space available here, and get her to the rig before I can check her out. That’s fine by me — I work better in the comfort of my own rig. But it would be nice to have a set of vitals before we attempt to extricate her. Just as I’m thinking that Louis shows up with the stair chair.

Todd an I are able to assist Susie to transfer from the toilet to the stair chair. It must have been a comical sight as we’re doing our best to support her while reaching through the door. Once on the chair it’s up to Todd and I to do all the work and drag it out of the house — because of the clutter no one else can reach in to help us. Eventually we get her to the gurney that waits outside the front door. We now have a few more hands to help as we transfer Susie to the gurney and finally into the ambulance.

I throw some packs of disinfecting wipes to the firefighters — I know everyone feels dirty after being in that house — and then I start to assess Susie. This is the point that everything starts to go downhill as the EMS gods have their final say in the matter.

I clip a finger probe to her finger to read her oxygen saturation and heart rate but I can feel that her hands are too cold — so it probably wont give a reading. I put the stickers on her limbs to get a look at her heart and immediately see that she’s in a very fast rhythm — it’s not lethal but it’s not good either. I need to check her blood pressure as it can’t be too high with that fast of a rhythm. I can actually hear the EMS gods laughing at me — like gremlins in my stethoscope — as the needle coasts below 100 without the slightest hint of a systolic auscultation. Pulling the stethoscope off of my ears I hear the fire engine accelerate away from us. That’s just great!

In the last thirty seconds this call went from a simple lift assist and social services call to a Code-3 trip to the ED. With my assessment done I tell Louis to light it up and get moving towards the ED that’s only a mile away. Susie has a blood pressure of 92/64 with a heart rhythm of Supra Ventricular Tachycardia (SVT) at 172 beats per minute. She’s stable for the moment but she actually may have been this bad for the last six hours. I’ll need immediate attention as I get to the ED. That’s the only reason for the Code-3 return — if I do a Code-2 (without lights and siren) I stand the chance of getting stuck in triage for an hour waiting for a bed. At this point it’s more of a statement to the ED than a way to blow through traffic faster.

As we start to pull away from the house I lean down to try to reassure Susie that this is all just precautionary. Her smile and jovial attitude from before has been replaced by a frown and morose mood. I was careful not to voice any concern as i was discovering one bad vital sign after another, but she knows something is wrong. With siren blaring in the background she knows that her life has just changed. She may never be able to return to her house or to live alone again. The simple act of sitting on the toilet may be the single moment that will affect the rest of her life, and she knows it. I can tell from the look on her face that she knows life will never be the same again.

As much as I would like to talk to her right now I have work to do and only two minutes to do everything I can for her. I can attempt to convert the rhythm to a slower one if I can get IV access. A quick look at Susie’s arm tells me that’s not going to happen. She’s too fat and the veins are buried under an inch of bruised and torn skin. So I abandon the search and check my vitals again.

The finger probe still hasn’t registered her oxygen saturation. I pull out a tape-on probe and tape it to her ear lobe in the hopes of getting a reading by the time we pull into the ED. Taking my hands away from her ear I see an external jugular (EJ) vein that looks good enough to sink an IV into.

I don’t usually start EJs as most times I can get an IV started on a peripheral vein and I don’t like sticking needles into people’s necks, especially in a moving ambulance. But this looks like my only access. I tell Louis that I’m doing an EJ and not to bounce me around too much. I can hear the siren change tones as he’s navigating through intersections. I put the head of the gurney lower which allows the blood to distend the EJ making it a better target for my needle. I turn Susie’s head to the side and sink the needle in and disconnect the catheter. At this point I’m holding pressure just below the catheter in the neck so I don’t get sprayed with blood. I look over at the monitor which is right next to my head as I’m kneeling at the head of the gurney. The rhythm starts to fluctuate and drops to 60 beats per minute. What the hell! As I’m connecting the IV tubing and taping it down I see the rhythm on the monitor speed up again and resume it’s previous rate. I’ve got a little smile on my face as I realize what just happened but I don’t have time to dwell on it right now as I hear the beeping sound of the rig while we back into a parking space at the ED doors.

I reach in a cabinet and grab a preload of 6mg of Adenosine and a 10ml flush. Hitting print on the monitor I clamp off the IV tubing and fire off the Adenosine followed by the flush just as a nurse opens up the back doors of the rig.

“Did you convert her?” She’s standing at the back door with another crew that was at the ED; they are there to help us out if we need anything as they saw us come in with the lights on.

“I don’t know, we’ll find out in a second.” All eyes are on the monitor as the fast and regular rhythm starts to get uneven and finally goes to Asystole — flatline. As the last organized complexes trail off the left side of the monitor everyone holds their breath waiting for Susie’s heart to start working again. Adenosine induces a few seconds of Asystole in an attempt to restart the heart’s electrical impulses in a slower rhythm. It’s like rebooting a computer. It’s also the longest five seconds in anyone’s EMS career as you stare at the flat line and hope the EMS gods are in a good mood.

On the right side of the monitor a few organized complexes start to march across the screen, followed by a few more, and then like someone stepped on the accelerator they speed back up to the 170s. I look back to the door as four people let out a collectively held breath. “No, I guess I didn’t convert her.” I pull the cables off of Susie and the other crew helps us get her transferred into a critical room as I’m giving a report to the MD who’s waiting for us.

After filling out my paperwork I go back into the room to drop it off. They’re still working Susie up. I suspect the more they look the more they are going to find that’s wrong with her. I found out later that she finally converted after two more rounds of Adenosine.

I’m sitting in the front of the rig watching the full moon rise over the city and listening to the dispatcher dishing out calls every minute or so. We’re already an hour past our off duty (OD) time but I recognize the call signs of other units getting sent to calls who are over two hours past due to go home. I can tell this is going to be a long night.

I have a bit of a laugh at myself as I recall the drop in heart rate when I started the EJ. After spending 25 years practicing Chinese Kung Fu my fingers sometimes have a mind of their own and place them selves where they are needed. We did extensive study in acupressure both for healing and in knowing which points on the body affect different aspects of physiology. When I was holding the IV catheter down on the neck to prevent blood from spraying me I actually had my finger on a fairly reactive acupressure point called Stomach-9. It happens to be the one spot in the body where the vagus nerve is closest to the surface and vagal stimulation is actually possible from the outside. I’ve watched people get knocked unconscious as Stomach-9 was struck in a sparring match. Academically I know that vagal stimulation drops the blood pressure and heart rate through vasodilatation. Yet this is the first time I’ve ever watched this effect inadvertently stimulated while someone was on the heart monitor.

I feel a little sad for Susie as her life has just changed. I can only hope it’s for the better and she’s able to find herself in a decent place where she is taken care of. I ask the EMS gods to look out for her as I’m watching the full moon rise.

The dispatcher comes up on the radio again, “Medic-40, you’re clear for OD, have a good night and drive safe.” The EMS gods have been appeased…

 

Self Mutilation 2/2

One week later…

It’s morning at the start of my 48 hour shift as a paramedic intern. Having just checked out the rig I’m standing in the kitchen making coffee for the crew when the tones go off on the portable radios and the dispatcher comes up telling us the nature of the call and location. Taking a sad look at the stream of coffee just starting to drip into the pot I head out to the rig for the first call of the day.

Bouncing down the two lane rural highway with lights and siren I rush to put on my gloves before my palms get sweaty and make it nearly impossible.

As we take the side entrance into the mobile home park I get the feeling I’ve done this before. There’s the BRT and the neighbors in their bath robes in front of James’ mobile home.

I’m excited, this could be every intern’s dream – a call do-over. I’ll get a chance to ask the right questions in the right order, do my rule outs prior to medication administration, and not fumble while drawing up and connecting to the IV tubing. Redemption is within sight as I walk through the door.

Something is wrong. The fire crew isn’t taking vitals – they’re all just standing around the dinette. Seeing us walking in they part so I can see James. The fire captain shakes his head and picks up his clipboard. Walking out with the rest of the crew he looks at my preceptor and says, “DRT.”

I’m not sure what that means but I’m busy trying to figure out what’s going on with James. He’s sitting upright at his table, once again in boxers and flip flops, with a different bottle of wine sitting next to him with the ash tray overflowing with cigarette buts. One cigarette is still in his fingers, burned down to the filter. There is ash on the floor under his knee where his hand rests. He has new surgery scars on his chest with meticulously tied sutures.

I’d already seen a few dead bodies in my short career but never one that was my patient the week before or one that is my responsibility to pronounce. Okay, suck it up and do it by the book.

Tony has become a fly on the wall again, letting out the proverbial leash. I walk up and notice the mottled skin on his lower extremities, the ashen color of his face and torso, his glassy eyes with fixed and dilated pupils, lids still open from the fire fighter’s assessment. I grab his lower jaw as Tony had previously coached me. Rocking it up and down his torso follows the motion without the hinge of the mandible moving; rigor has already set in.

Now that I have hands on I notice how cold he is and how fresh the surgical scars are. He must have had surgery after last week’s trip to the ED. I place my fingers on his neck checking for a carotid pulse; nothing. I check for lung sounds in all fields and at the neck; no air moving. I place my stethoscope over his heart, no heat tones.

One last thing to do and I can leave.

I place the heart monitor leads on James’ torso; I need to record a six second strip of asystole (flatline) for my paperwork.

The room goes dark as I tunnel vision into the screen on the monitor. This must be what a vagal response feels like. Kneeling down to see the monitor better, or possibly because my knees just gave out, I hit print on the monitor. Where the flatline of asystole should be there is a perfectly spaced, consistent complex printing out of the machine at 72 beats per minute. What the fuck?!? That shouldn’t be there! Hell, that can’t be there!!

Now my vagal response has turned into SVT (supra ventricular tachycardia). I stand up to feel for a carotid pulse again. He’s cold and dead, there can’t be a pulse.

I move my fingers around thinking I may have the wrong placement and maybe I missed it. After ten seconds I’m positive there is no pulse.

As I pull my hand away from his neck my glove is tickled by fresh sutures on James’ left upper chest; the new surgical scar that wasn’t there last week. Underneath the skin is a small box the size of a matchbook. A pacemaker has been implanted to send out electrical impulses to the heart 72 times a minute in a futile attempt to stimulate dead cardiac tissue to contract, but it couldn’t overcome the damage that James had done with his habits and now it just served to trick the monitor into recording electrical activity in the heart.

My own SVT converts to a benign tachycardia and the lightbulb comes on: DRT means Dead Right There. I look over at Tony, who had never budged from his “fly on the wall” position. He saw the new pacemaker scars as soon as he walked in the door. I can only imagine his amusement at my momentary panic. Or maybe he’d already seen too many other interns react like I did and it was old hat.

On the slow ride back to quarters I’m going over the call in my head while sitting in the dim light of the back of the rig. I start to think about the coffee waiting for us and hope that it might actually still be drinkable. Then I look up at the radio in the front of the rig and wonder when the tones will go off again.

Self Mutilation 1/2

self

1: a person’s particular nature or personality

2: the identity, character, or essential qualities of any person or thing

3: the union of elements (as body, emotions, thoughts, and sensations) that constitute the individuality and identity of a person

 

mu·ti·la·tion

1: an injury that deprives you of a limb or other important body part

2: to physically harm as to impair use, notably by cutting off or otherwise disabling a vital part, such as a limb or vital organ.

 

 

As a paramedic intern I have three states of mind; call anticipation, call anxiety, and post call critical evaluation. During my 48 hour shifts with my preceptor I cycle between the three in a never-ending manic loop.

I’m standing in the kitchen of our quarters making coffee for the crew. It’s my routine after checking out the rig each morning.

The tones go off on the portable radios and the dispatcher comes up telling us the nature and location of our first call of the day; chest pain in the corner of the county at the far edge of our response zone. Unlike my current county which is mostly urban with a dozen hospitals, the county in which I interned was mostly rural with only three hospitals. Parts of that county were over an hour away from the closest hospital, and possibly even further from the closest most appropriate hospital. At least we’ll have coffee when we get back to quarters.

Siren wailing, strobes muted by sunlight, we speed across the two lane rural highway towards the water. I’m sitting in the back of the rig. My preceptor, Tony, is in the front holding the map book and directing his partner to the call.

Tony tells his partner to take the side entrance to the mobile home park by the water. With my call anxiety in high gear I look up through the windshield to see the BRT (big red truck) parked next to a mobile home, and neighbors in bath robes standing around the truck taking in the commotion like a Jerry Springer dinner theater. It’s a new experience for me as I can’t remember ever going into a mobile home park. Little do I realize how often this exact scene will repeat throughout my career in EMS.

 

Ambulances are drawn to mobile home parks by the same electromagnetic waves that draw ships into the Bermuda triangle. The same mysterious phenomena causes ambulances to be drawn to Walmart more so than other retailers.  I’m thinking there’s a correlation here…

Walking into the mobile home I see my patient sitting at a vintage 1960’s folding card table in the dinette; a bottle of cheap red wine sitting on the table, almost empty at 0915, and an ash tray overflowing with butts, one still giving off a slight stream of smoke.

The BLS (basic life support, meaning EMTs only, no paramedic) fire crew is finishing up a set of vitals and gives me a quick report as my preceptor becomes a fly on the wall giving me enough leash to run the call, but ready to cinch the choker if I screw up.

The patient presents with sudden onset crushing chest pain of 10 out of 10 severity, associated diaphoresis, non-provoked. Except for the cigarettes and wine.

James, my patient, is sitting at the table in boxer shorts and flip flops. His chest is scarred down the middle with an eight inch fresh surgical scar held together with staples. I will later come to recognize this as a “cabbage” (CABG – coronary artery bypass graft).

At this early stage in my experience I have to ask what it is. James tells me he had quadruple bypass surgery last week. The pain he’s feeling is exactly like the heart attack that led to the surgery.

As James is now on the heart monitor I print a strip: ST segment elevation in two of my three leads. I reposition the leads to get two additional views from S5 and McL1 as my preceptor taught me just last week. This rural county hasn’t adopted pre-hospital 12-lead ECGs so we have to do the “poor man’s 12-lead” by moving electrodes around the chest. More ST-segment elevation.

I may be brand new to the field but even I can do the math well enough to see this is a probable MI (myocardial infarction, also known as a heart attack).

We load James into the rig and start transporting. As with many other patients, we’re over twenty miles away from the closest hospital so we apply the common practice of “load and go” – start driving and treat en route to save time.

I run through my chest pain treatment protocol with staccato starts and stops. After running similar calls a few hundred times it becomes second nature, but the first few times it’s a conscious effort to remember everything. I ask about aspirin allergies before giving him an aspirin. I hold the nitroglycerine spray up to his mouth then quickly pull it back to ask if he’s taken Viagra recently. My hand fumbles while screwing the morphine vial onto the hub of the IV tubing. I have to do contortions to read the slash marks on the vial while cautiously pushing the drug into his vein. It comes loose from the hub so I have to screw it back on.

 

I also ask James how he could possibly keep smoking and drinking like he does after having heart surgery. “Don’t you know that your heavy smoking and drinking probably caused the heart attack that led to your surgery?” I asked. “Yeah, I know. But I just couldn’t stop.”

None of this goes overlooked by my preceptor. Sitting behind James in the captain’s chair I’m not really sure he’s even awake. He seems to have the uncanny ability to sleep through the siren noise, the bouncing of the rig, and the enormity of the fact that the cardiac tissue in James’ heart may be slowly dying. But of course he’s watching every move and saving his thoughts for the post call critique. Again, just enough leash and no choker yet so I must be getting it right – or at least I’m not getting it terribly wrong.

Arriving at the ED (emergency department) I stutter through a hand off to the RNs and MD that are waiting for us. They realize I’m an intern by the conspicuous lack of county patches on my uniform. The RN looks over at Tony silently confirming my report. He nods letting her know she has the full story.

Tony takes me aside after the call and runs down the entire event from start to finish. He gives praise on some aspects and well-meaning criticism on many others. Study points are identified and on the way back to quarters I practice with vials and syringes in the back of the rig to try to build the muscle memory.

Back in quarters I’m finally able to have my morning coffee. It’s two hours old and condensed to a bitter lukewarm shadow of its former self. I stare at the portable radios quietly sitting in their chargers and wonder when the tones will go off again.

 

Blunt Force Trauma

blunt

1: having an edge or point that is not sharp

3: slow in perception or understanding; obtuse

2: Slang: a cigar stuffed with marijuana.

 

force

1: cause of motion or change

2: an agency or influence that if applied to a free body results chiefly in an acceleration of the body and sometimes in elastic deformation

 

trauma

1: an injury (as a wound) to living tissue caused by an extrinsic agent

2: an agent, force, or mechanism that causes trauma

“Okay Ronald, you need to calm down and listen to me for a minute. Things are going to start happening very fast and I need you to focus. I know you can feel your heart beating way too fast and it hurts.” My cardiac monitor, sitting on the captain’s chair over Ronald’s shoulder, spits out a second 12-lead strip. Same interpretation as the first one: ***ACUTE MI SUSPECTED***
“I need you to chew up these aspirin while I explain what’s going on here. Whatever was in that blunt you smoked, maybe crack or meth, is making your heart beat too fast.”

He’s scared, staring at me with big, round, bloodshot eyes with that “doom” look that I’ve seen often with cardiac etiology. His heart is racing at 166 beats per minute, irregular, and his blood pressure is through the roof at 210 over 120. He smoked 20 minutes ago with some people he didn’t know and the weed came from an unknown source, so he has no idea what it was laced with.

When he told them he needed an ambulance they told him to “get the fuck out!” He called 911 from his cell phone a few blocks away.

Given the fact that he’s only 32 with no cardiac history it’s likely that his heart just can’t handle the fast rate and it’s causing some localized ischemia. Regardless of the etiology – whether it’s just the drugs or the unlikely occlusion of the coronary artery – I’ll activate him to the cardiac receiving center. They’ll have a cardiologist standing by when I get there to decide if he gets a trip to the cath lab or just monitoring until he calms down.

The siren starts to wail as we pull out of the parking lot where he sat waiting for us. I figure I’ve got maybe six minutes until we get there, just enough time to do what I can for him.

I hit transmit on the cardiac monitor and dial in the cardiac hospital. Bouncing down the road I place his hand on my knee and lift my heel up off the floor, making my leg an extra shock absorber so I can match the bouncing of the rig. As the needle finds a vein and gets a good blood flash I hear the monitor doing a modem handshake with the hospital to transmit my 12 lead.

Nitroglycerin and morphine are contra-indicated for his heart rate. It took a while to get used to that footnote in the protocols when I switched to working in this county because in my previous county it was part of our protocol. But so be it, I’ll play by the rules.

Fortunately we have decent sedation protocols for extreme anxiety, and I have just enough time to get two rounds of Versed on board before I get to the ED. Admittedly, I feel a bit strange treating a possible MI with a sedative but that’s what he needs right now. Ronald is really worked up, half from the unknown drug and half from the reality of the situation.

Versed is a decent drug – it’s used for procedural sedation in the hospital, like doing a reduction on a dislocated shoulder – give enough of it and you can put someone completely out, give just a little and it reduces anxiety. If you can titrate just right and walk the line between the two you can put someone in a very relaxed state yet they can still interact. It also has amnesia properties so people may not remember the pain they experience. That’s what I’m shooting for with Ronald but he’s a heavy guy so I don’t think I have enough time to get him there.

Backing into the ED another crew who heard us coming in code-3 opens the back doors and helps me unload the gurney. Walking into the critical care room the cardiologist comes in holding my transmitted 12 lead. I hand him the two follow up prints while I give a quick run down of the treatment I did and how Ronald responded.

They do a full cardiac work-up on him, and run their own 12 lead which comes out with the same interpretation. I always feel a little better when their machine and mine say the same thing.

They draw blood and send it to the lab to look for elevated troponin levels, the byproduct of distressed cardiac tissue. They’ll also run a tox screen to see what was in the blunt. Walking out, after giving a report to the staff I hear the cardiologist make an order for Ativan, another sedative. The ED has better drugs than I do but at least I got Ronald to the right place and started him in the right direction.

Off to the next call – my pager is buzzing on my belt and my dispatcher is chasing me out of the hospital for the calls that are stacking up.


Closest Most Appropriate 7/7

Now that I’m committed I pull my cell phone out and punch up the direct line to the University Emergency Department and give them a detailed description of what’s going on and what Josh’s condition is right now. The RN on the other side understands the situation and tells me that we’ll be going directly to the pediatric unit and she’ll have cardiology standing by when we get there.

The rest of the trip is somewhat uneventful as all of our tasks had been completed and it’s just a matter of monitoring Josh and reacting if anything were to change. Towards the end it’s obvious that he is starting to decompensate. He is more lethargic than before, he’s nodding off more frequently, and we have to keep him stimulated with questions and idle talk. His heart is starting to fatigue from the accelerated pace it’s been keeping for the last 45 minutes. His initial rate of 178 has now dropped to 52 and throwing consistent premature atrial contractions (PACs). Josh’s heart was bouncing from bigeminy PACs to trigeminy PACs. This means that he has normal conduction beats interspersed with abnormal beats in which the electrical conduction starts in the wrong place on the heart. This makes the contraction ineffective.

If his heart rate drops any more we’ll be turning on the external pacing pads to override his faulty electrical conduction with stronger electricity that his heart can’t ignore. It’s really an unpleasant thing to watch as someone is rhythmically shocked every second to force the heart to do its job. If I have to do it I already have the sedative ready so I can at least take the edge off of Josh’s pain, but I can’t risk sedating him too much as it will encourage the decompensation that has already started. Nothing to do now except continue the IV fluid bolus to keep his blood pressure up. We even have the pressure bag on the bag of normal saline, compressing it to push the fluids in faster.

Looking out the back window I can see we’re on University campus grounds as the large stadium and athletic fields pass through my limited field of view. The siren has stopped the constant wail and now only chirps at intersections as the cars pull to the right to let us pass. Unlike in the hood, the people here actually know what to do when the flashing lights appear in the rear view mirror.

Pulling into the ambulance bay I see the once familiar Emergency Department at University. My first ever code-3 return was to this ED. Three weeks into my new career in EMS I was working as an EMT doing inter-facility transports in this county. A skilled nursing facility (SNF) called us for a resident with a fever. Upon finding the patient in her room it’s obvious that the SNF called for a basic transport rather than calling 911 so they are not tagged by the county. The woman was septic, hypotensive, and altered. Our protocols said that if we had a transport time less than 10 minutes to the ED that we were permitted to take the patient in code-3, rather than call for an advanced life support (ALS) unit. That was the first time I called up to the driver telling him to light it up. Five years later I’m taking a crashing 8 year old for a 40 minute code-3 drive. It’s a different world yet still very much the same.

We unload Josh and wheel the gurney towards the receiving entrance. The ED charge nurse sees us coming and redirects us to the pediatric unit. There’s a team of six people waiting by the first critical room for us. As we unsnap all of our wires and transfer Josh over to the bed I’m giving a basic run down of how we found him, how he changed during transport, and an overview of his medical history. The pediatric cardiologist sees the 20 foot roll of EKG strip on the gurney and starts from the beginning, evaluating each printout and 12-lead sequentially captured during the last 40 minutes. Mom has her stack of papers and starts talking to doctor who she recognizes and is familiar with Josh.

As I’m about to leave, I look over at Josh, nurses busy connecting him to their monitoring equipment, I wave to him across the room, he gives me a thumbs up.

Closest Most Appropriate 6/7

“Don’t worry about it, just head for the bridge and I’ll get you the address.” This is not the thing that Mom needs to hear right now. We’ve got twenty minutes before we get on the bridge so I have time to make it work.

I pull out my cell phone and call our dispatch center. One of the dispatchers answers and I ask her to send out the University address to our pagers. A few seconds later my pager is vibrating on my hip. We’re on a pretty straight freeway so John is able to program the address into the GPS while driving. I hear the dry female voice of the GPS say, “In fourteen miles take exit on right.”

Moving back to Josh and the fire medic I grab my “Oh Shit Bag.” It’s the bag I clip to the net in the back of the ambulance every morning that has my seldom-used but really critical in a situation like this personal equipment. I pull out the Broslow tape and county protocol book. The Broslow tape is a measurement tool for pediatric patients – you stretch the tape out along the length of a child’s body, and it tells you approxmiately how much the child weighs based on height. Most drug dosages, as well as joule settings for defibrillation and cardioversion, are determined by weight for children, so getting a reasonable weight estimate is really important.

The Broslow tape tells us that Josh is 30kg, so his specific dose of Epinephrine is 0.3mg (as compared with 1.0mg for an adult). The fire medic and I pull out a strip of two inch cloth tape and write down Josh’s specific doses on all the medications and joule levels we could possibly use if we have run a code. In times like this it’s extremely helpful to have two medics double checking math and procedures. A misplaced decimal point can result in the patient getting ten times the dose they should get.

Glancing at the monitor and Josh every few seconds I can’t help but wonder if he is aware of what we’re doing: making a cheat sheet of medications in case his heart stops. I place the tape on the cabinet over the gurney so we can both see it. Josh looks up at the tape with its cryptic abbreviations and numbers, his eyes follow the IV tubing as it winds its way down the wall and into his little hand. “Josh, how ya doing buddy?” He holds up his tiny thumb. Wow!

One last thing to do: open the pediatric defibrillation stickers. It’s just precautionary but if I need them I don’t want to waste time attaching them, much less interrupt CPR to do it. The fire medic leans Josh forward as I place one on Josh’s back and then one on his chest, covering all of the cardiac surgery scars.

I’m keeping a mental note of our position in the county and which hospitals are closest in case Josh decompensates or codes and we have to abort the plan to go out of county. Looking out the back window I see the land fall away in the distance and our freeway turn into a bridge. Well, we’re committed now. Once on the bridge, University is now the closest receiving facility.