1 – one of several parts or pieces that fit with others to constitute a whole.
2 – a type of Federal assistance provided by the United States Department of Housing and Urban Development (HUD) dedicated to sponsoring subsidized housing for low-income families and individuals.
3 – category of discharge from the United States military for reason of being mentally unfit for service. The meaning of Section 8 became known in households worldwide as it was used often in the 1970s TV series M*A*S*H, in which the character Corporal Klinger was constantly seeking one.
As we’re responding to an address in the hood, lights and siren running in the background, my partner Brent and I are playing the prognostication game. It’s a way to alleviate the monotony of the day a little by trying to guess the actual nature of a call from the minimal information on the MDT (mobile data terminal), which is often inaccurate.
The prognostication game is a way of staying sharp. We take into account the time of day, socio-economic make-up of the neighborhood, whether it’s a house, apartment, or “corner of” call, and if the call was initiated by cell phone or land line. In our busy county each crew runs around 1000 calls a year so we start to see trends pretty fast.
The prognostication game is also a means for bragging rights between partners – we keep track over a period of time (a shift, or a week) and the loser buys the winner coffee. The only downfall to the game is you have to be willing to drop the pre-conceived assessment immediately when you get there and your actual assessment points in a different direction.
The dispatch notes on the MDT only tell us we’re responding to a 47 year-old female with shortness of breath. I nailed the last one with the 35 year old male having abdominal pain with a pre-arrival diagnosis of pancreatitis aggravated by alcohol consumption. This time, I’m going with the easy odds of an asthma exacerbation. Brent has about the same odds with the guess of a panic/anxiety attack.
We arrive on scene to see the BRT parked in the parking lot of a high density federally subsidized housing project. We call it Section-8 housing in reference to the portion of the U.S. Housing and Community Development Act of 1974 which provides a subsidy for low income families and individuals. The neighborhood is largely African American and the frequency of asthma in urban areas like this is quite high; that’s why I went with the easy odds this time.
As we walk into the ground-level apartment we see the patient sitting on the sofa with fire fighters doing an assessment. In unison my partner and I stop, mid-stride, and our jaws drop.
We stand there, dumbfounded, staring at the decor. One whole wall of the apartment is covered with NASCAR matchbox cars, still in their packages and perfectly aligned – tacked to the wall with edges touching. There must be 300 cars on the wall.
On the adjacent wall is an altar with a picture of Jesus flanked by pictures of Dale Earnhardt and Dale Earnhardt Jr. The holy trinity, really? All pictures are of equal size and displayed with equal prominence. Sitting on the altar are shoebox sized models of the number 8 car and the number 88 car aligned with their respective drivers. What, no car for Jesus?
In the kitchen are two cats, one sitting on the counter the other sitting on the ground. Both cats are fixated on a cage on the kitchen floor with four birds that nervously jump from perch to perch.
There’s an angry looking, heavy-set white woman, probably not related to the Hispanic looking patient, standing near a day bed that’s covered in cash. A four foot square tapestry hanging on the wall over the bed with a picture of a white tiger has the caption, “The Eye of the Tiger” under the image.
I’m starting to think my asthma guess is out because of the chaotic nature of the furnishings. There are some interesting contradictions in the décor which could speak to the mental stability of the occupant. I mean seriously, who puts a bird cage on the floor when you have cats? Which animal is being tormented more by the close proximity? And being a NASCAR fan is great, although I’ve never seen one in this neighborhood, but deifying the drivers??
Someone with a psych history is more likely to have an anxiety induced hyperventilation. Brent was probably right on this one…
The thing is, Paramedics are trained observers that profile. Maybe that’s not a politically correct thing to say these days but I believe it’s true. The city police won’t use the “P-word,” but the FBI likes it so much they made a division of people who specialize in it. Paramedics often get only half the story on any given situation, we are often lied to by our patients, and many times the patients have no idea what’s going on. So we have to fill in the blanks. That’s why we play the prognostication game – to exercise our mental abilities to fill in the blanks.
If I’m going to a call in the hood and someone is passed out then I’m looking for signs of drug/alcohol use. If I’m going to a call in the affluent neighborhood and someone is passed out I’m looking in medicine cabinets to check for an overdose on prescription medication. It’s just a matter of prioritizing the rule-outs based on observations and high probability odds. Everything will get checked by the time I get to the hospital but I modify the order of rule-outs based on what I see and how the patient is presenting.
The fire medic has been waiting for me to take it all in; I suspect they had the same reaction that we did. Finally I have a look at my patient. She’s breathing very fast with shallow breaths. I see the cardiac monitor; she has a heart rate of 136 with a regular rhythm.
The fire medic tells me she thought she was having an asthma attack and used her inhaler, but she is still short of breath. I look at the O2 saturation on the monitor and it reads 100%. She’s getting plenty of oxygen to the blood so she should be fine. The fire medic watches as my gaze shifts, gives me a shrug and tells me her lung sounds are clear. I’ll recheck the lung sounds when I get her in the rig but right now I want to cut the fire crew loose as I’m not going to need any help on this call. They get run pretty hard in this neighborhood so I try to take over the call fast when it’s possible so they can try to get some down time before the next call goes out.
I introduce myself to Rita, my new patient, and tell her that I’ll be taking her to the hospital. As she’s getting her purse the LT asks her about the money. He’s going to lock up for her but wants to know what to do about the money laying on the day bed. Rita says to give it to the angry looking white woman telling us it belongs to her.
Once I get Rita into the rig I start over with the questioning and examination. I ask if there was any kind of emotional event that precipitated the asthma attack; she says no. I check her lung sounds and they are perfect – no bronchial constriction or wheezing. I have her on my End Tidal CO2 (ETCO2) detector so I can measure the CO2 in exhaled breaths and have a real time wave form on the monitor to see how she is breathing. It also gives me an accurate count of respirations per minute.
Rita is breathing at 44 times a minute with an ETCO2 of 16. Normal readings would be a respiratory rate of 16-20 and an ETCO2 of 35-45 so there is definitely something wrong here. When I ask she again denies any emotional stressors or history of anxiety or panic attacks or any drug use. Looking down at Rita’s hands I can see the carpopedal spasm beginning to cramp her fingers – basically, breathing too fast changes the metabolic balance in the body resulting in cramping fingers and feet.
I tell Brent we can start driving as I’ve done my rule-outs and decided what my treatments are going to be. I start an IV and inject Benadryl into the tubing to sedate her a bit. Benadryl is a drug that’s typically used for mild allergic reactions or seasonal allergies, but our medical director added it to our protocols for mild sedation, which is an off-label usage (i.e., drowsiness is a side-effect of Benadryl). It’s not going to put anyone completely out but it does help to calm people down. I think part of it is a placebo effect in that people see me draw up a medicine and inject it while I’m telling them it’s going to make them feel better.
I turn the lights down in the rig and sit at the edge of the bench quietly doing my paperwork on the laptop. In some cases my treatment for a panic attack patient is to ignore them. Maybe that sounds cold but I have my reasons and often it works. Many times a panic attack is to get attention or to get out of a situation. Well, Rita doesn’t seem to want any attention. She’s staring at the cabinet and not looking at or interacting with me. I’m thinking she wanted out of a situation. Having accomplished that I’m going to leave her to her thoughts while we take the fifteen minute drive to her favorite hospital.
As we’re pulling into the hospital I take a look at the monitor. Rita’s respiratory rate has dropped to 22 and the ETCO2 level has risen to 20. Both numbers are moving in the right direction and Rita has had her eyes closed for the whole trip. After getting her into a room and giving the report I sit down to finish my paperwork at one of the nurse’s desks.
A few minutes later, Rita’s nurse comes out and I catch her eye – I thought of something else. “You know, there’s one other thing.” I tell her, “There were $400 dollars all spread out on a day bed and an angry looking woman who may have been the building manager. I’m thinking it’s the middle of the month so if she was paying rent now it’s pretty late. And even Section-8 housing is more than $400. I bet that’s what caused the attack in the first place.”
The nurse’s eyebrows lift up and she goes back in to ask about the money. Three minutes later she comes out shaking her head up and down. “That was it.”
It looks like I’m buying coffee tomorrow morning as Brent is winning the prognostication game today…