Tag Archives: Cardiac

Dia de los Muertos 1/3

Dí·a de los Muer·tos

1 : the day of the dead

2 : a holiday, particularly celebrated in Mexico, which focuses on gatherings of family and friends to pray for and remember friends and family members who have died

The fabric roof recedes behind my head in silent automation and reveals the stars in the heavens in all their glory. A moment of solitude and infamy which is quickly interrupted by the speeding commuter train on its elevated track, with its onslaught of light and noise, rushing off to unknown destinations. At the end of my shift I sit behind the wheel of my personal vehicle and take a deep breath – finally it’s over – and listen to the engine cycle into a familiar purr to tell me that it’s ready for the drive home.

I recline the driver’s seat to stare straight up at the infinite expanse of the universe and wonder where the three dead souls have gone this night. It wasn’t my fault, I mean seriously, how am I supposed to reverse multiple years of abuse in the fifteen minutes I’m with a patient? Well, the last one was probably my fault, I pushed him a little too hard, but even still – it was his time to die. 

Any why does it always come in threes?

Precision German engineering growls back at me as I depress my foot and accelerate away from the deployment center. Cold wind rushes past my face and street lights streak overhead as the flappy paddles on the steering wheel cycle the gears up in a desperate attempt to distance myself from the memories of a day from hell. Three hundred and thirty-three horses are unbridled at the on ramp to the freeway, with a rapid acceleration, as the increased g-force pushes me into the seat. The cold wind bites at my short sleeves and exposed skin – it’s a little too cold for a convertible ride so late at night – but I did it on purpose knowing full well what to expect. I wonder if that’s what a cutter says as she drags the razor blade in ever increasing depth across her forearm? Does pain and discomfort somehow remind you that your alive and in that revelation then become a celebration of life? Or is it time to check myself into Emergency Psych Services on a 5150 – should I start to worry when the madness actually starts to make sense?

“Medic-40 copy code three for the OD on the transit bus. PD is on scene, Code-4, you’re clear to enter.”

We’re only a few blocks away and Kevin puts us behind the bus and fire engine in just a few minutes. As we walk up to the bus I see a man in his early thirties surrounded by county sheriff officers and firefighters. He’s looking at me in this kind of thousand yard stare as the fire medic shows me the empty bottle of vodka they pulled out of his pocket. It’s the classic “drunk on the bus” and I’ll have to take him to the ED because he can’t even walk by himself. It takes four of us to pick him up and plop him on the gurney and the firefighters take off without even taking vitals or offering to help out.

As I strap the seat belts on my new patient I notice a little bit of plastic between his lips. I reach up and pull out a baggie that’s been chewed down so all that’s left is just a few white grains of powder – obviously an attempt to hide a drug possession from the officers. I hand the baggie to the officer and feel for a pulse; strong in the sixties – good for now. “Kevin, I’m good to go as soon as we load up, this could go downhill fast…”

My new patient isn’t answering questions or even acknowledging that I’m here so my only assessment is what I see on him and the monitor. The most obvious options for the white powder are crack cocaine, crystal meth, or heroin. Crack and meth speed you up; heroin slows you down – I really hope it’s the heroin because that’s the only one I can turn off.

We’re a half mile from the hospital when the vomit and head spinning scene from the Exorcist starts up right there in the back of my ambulance. First thing I notice is the heart rate climbing from 66 beats a minute to an incredible 236 in the course of twenty seconds. As I tell Kevin to upgrade to Code-3 the vomiting starts. Now I’ve got bio-hazard all over the back of the rig (not to mention the stench), and all of my focus is on keeping his airway open to prevent him from aspirating vomit into his lungs. I’d love to throw a line in and hit him with a sedative but I can’t do it at the expense of his airway. Well, I guess it wasn’t heroin.

Two minutes later we have him in the ED. Two minutes after that they are throwing the drug box at him to slow down his heart and attempting a gastric lavage to clean out his stomach. Fifteen minutes after that they are doing CPR – his heart had stopped beating when it gave out from fatigue. Twenty minutes after that the maintenance crew is mopping up the vomit from the floor and trying not to disturb the dead body on the table with the sheet pulled over its head.


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

Dissolution

dis·so·lu·tion

1: annulment or termination of a formal or legal bond, tie, or contract

2: decomposition into fragments or parts; disintegration

3: formal dismissal of an assembly or legislature

4: extinction of life; death

It’s a Code-2 response – no lights and no siren – and I’m in a morose mood as I make my way to the middle of the county. I’m responding solo and driving myself for once. The passenger seat next to me is empty. Scottie is responding from the other side of the county and I’ll meet him there. As I start to get closer I see others on their way to the same place. Uniforms in cars and ambulances, driving slowly in the same direction. I pass a fire engine with its cab full of new hires who are in the academy. I ponder the lesson that the brass is teaching them by having them take the day off from the hard work of the academy and attending a funeral: death is real.

As I make the turn into the cemetery I see the ambulance parked across the street. The cemetery happens to be at a normal posting location. Ambulances are sent to this intersection as it has easy access to a few different cities, as well as the necessities of a mobile crew: a bathroom, some shade, and nearby food options. Many of the cars parked along the wide streets running past the headstones bear county EMS stickers in their back windows.

Walking up to the small chapel I pass ten ambulances, four fire engines, and even a ladder truck. Our brothers and sisters from the fire service have made a good showing – every city in our county is represented, and we all appreciate their presence.

Walking over the small grassy hill to the chapel I see the sea of uniforms – I’ve never seen so many of us in one place before, and it’s overwhelming. Paramedics, EMTs, dispatchers, firefighters, police officers, and of course the honor guard with class-A uniforms complete with swords. There’s even a mounted EMT from the equestrian unit – I never even knew we had an equestrian unit.

All are here to pay their last respects.

At any given time at least a third of us are working the streets and responding to calls in the county. But the 24×7 nature of our work and the size of our county makes it difficult to get so many of us together at one time and in one place. Today is the exception – they put out the call to neighboring counties for mutual aid. Other counties’ EMTs and medics came into our county, checked out our rigs, and opened up the map books to respond to our calls, allowing us to gather for this final goodbye.

There have to be over 300 uniforms standing around the chapel, yet Scottie is able to pick me out of the crowd and he makes his way through it to stand next to me. We have a comfortable silence between us. We’ve only been partners for about a month but spending twelve hours together on a daily basis can bring people together fast. I notice that many other partners have found each other and taken comfort from being together during this emotional time. There is one person who is unable to stand with their partner and that stands out that much more for his solitude.

I find myself in a line which is slowly making its way into the chapel; the honor guard stands at attention as we enter the doors. As I enter the chapel I realize that all the seats are taken and this is actually a line to view the casket – it’s an open casket funeral. I wasn’t quite prepared for this and that’s a strange thing to say. Unlike most people in the world, we get up in the morning and put on a uniform knowing that we have the possibility of seeing a dead body or even watching someone die. Somehow I forgot about that this morning and I wasn’t prepared to see a friend in a casket. I place the rose petals on his chest and file out the back of the chapel before I lose it.

Eulogies are given and a life that ended too soon is remembered. I look over at the crew that worked him in his last minutes and feel an unbelievable sadness. They were camping and hiking that day and too far away from any urban areas when they saw the skin signs. We all know the skin signs – pale, cool, diaphoretic – and the cardiac etiology that they speak to. They did CPR on a friend without their paramedic equipment and waited the 45 minutes for the ambulance to respond.

I can imagine the time feeling like hours as everyone does the sad math in their head. Only about 15% of cardiac arrest patients actually survive. Once in cardiac arrest the chance of survival diminishes by 10% for every minute of down time. I can imagine the absolute anguish of seeing the ambulance finally arrive only to find out it’s an EMT ambulance with no advanced life support equipment on board. The county where they were hiking isn’t as well funded as our county. The three medics and two EMTs that were with him could only use the most basic of skills in an attempt to save his life. The EMS gods were in a very bad mood that day.

The color guard snaps to attention and the bugler begins the sad song of Taps. The flag is ceremoniously removed from the casket and meticulously folded to be handed to the family. The casket is slowly taken from the small chapel to its final resting place. The procession slowly walks past a double flank of hundreds of uniforms standing at attention with salute in place. One of our own has been taken.

The color guard does a sharp left face and marches off. A final salute is given and the assembled uniforms are dismissed.

One week later Scottie is driving us to the post across the street from the cemetery. He angles the rig so we don’t have to look at the rows of headstones with flowers laid beside them.

“I don’t like this post any more.”

“Yeah, neither do I…”

 


Sexual Tension 2/3

As we’re pulling up behind the BRT, Louis and I recognize the SRO from last week. This time we were called for chest pain – one of the EMS bread and butter calls. Standing in front of the lobby is a man in his late sixties wearing a camouflage jacket with a heavy-set woman standing next to him. A few firefighters are standing with him while the engineer sits in the cab. He’s old-school – he doesn’t go on medical calls.

Walking up I catch the eye of the fire medic. He tells me it’s a chest pain call and asks our unit number for his paperwork. Seconds after giving him my number their engine is pulling away. The patient and I are still standing on the sidewalk. That’s the way it is sometimes in the Big City – fire crews are tired of medical calls and take off as soon as they can.

I look at the fire sheet that the LT handed me before they bugged out to get the patient’s name. “Hey Jessie, so what’s going on today?”

“It’s my chest man, it just don’t feel right.” Louis is getting the gurney because if this is an actual chest pain call I don’t want to walk the patient and put more strain on the heart.

“Okay, so how bad is the pain?”

“No pain, man, it just feels like it’s thump’n too fast.”

I reach down and feel his radial pulse. Just a quick look but it’s upwards of 150 beats per minute. Would’ve been nice if the fire department had actually taken some vitals.

I’m getting Jessie settled on the gurney, “So what were you doing when this all started?”

“I was having sex man!” He’s got a big smile on his face; he’s proud of this proclamation. His wife, standing next to him holding his medications in a bag, hits him on the shoulder. “Hey cut it out!” he chides her, then back to me, “It’s the first time in a year.”

Despite the fact that this is an “emergency” he’s in a good mood and joking around with us and his wife. He knows something is wrong but he’s a playful man and won’t let it get him down. “Well, I’m sorry you didn’t get to finish you’re business.”

“Oh, I finished my business, don’t worry about that. I called y’all after I was done.” We all have a laugh as we’re wheeling him towards the ambulance.

I look over at the wife as we’re about to load the gurney in the ambulance. “Can’t you see this is a fragile old man, don’t you know you have to do all the work?” I’ve got a mock-accusation tone to my voice – I’m having fun with them as I sense they’re okay with it.

In the way that only a heavy set African American woman can pull off with credibility, she puts her hands on her hips, leans towards me, and with head bobbing for emphasis, “I WAS doing all the WORK, just ASK him!” Jessie just smiles…Louis and I are attempting to maintain our composure, but we’re only half effective.

I put Jessie on the heart monitor and run a 12-lead EKG. He comes back with Atrial Fibrillation with Rapid Ventricular Response at 162 beats per minute – no chest pain and no heart attack that my monitor can see. So basically, he’s got a fast and irregular heart beat – the electrical impulse reaches the ventricles of the heart and starts over sooner than it should. It’s not really a lethal rhythm that would require shocking him right now as his blood pressure is fine for the moment. It’s a rhythm that will either subside on its own or persist until he fatigues and becomes unstable. I can help it start subsiding by administering a sedative to help him relax. Some counties have beta blockers and anti-disrhythmics for use in this situation but unfortunately we don’t have that in our protocols. If he becomes unstable I can shock his heart back into a decent rhythm, otherwise it’s just best to help him relax and hope that it’ll resolve on its own.

As we’re driving to the hospital I start an IV and give him four milligrams of Versed to help sedate him and relax the heart. Because of his age and potentially unstable condition, he gets immediate attention at the ED, and a room close to the front where the nurses can keep an eye on him. The 12-lead that the ED runs comes back the same as my monitor’s interpretation and they pretty much just keep an eye on him until he calms down.

After a few more calls I take a patient back to the same hospital and get a chance to check on Jessie. He’s smiling and putting on his camouflage jacket as he’s getting ready to go home. “You doing a’right Jessie, ready to head out?”

“Oh yeah, I’m all good. I got me a fine woman to go home to!”

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.

Closest Most Appropriate 5/7

I carry Josh down the front stairs of the house to my gurney waiting by the gate, get him settled in, switch over the oxygen to my tank and get him loaded into the rig. The fire medic jumps in behind me and starts reassessing a blood pressure while I hook Josh up on my EKG monitor. Meanwhile, John is getting the mother settled in the front passenger seat.

I don’t usually run a 12 lead on an 8 year old but this is cardiac etiology and I really want to see his electrical conduction from the additional points of view just to make sure I’m not missing anything that might change my transport decision. To get a clean tracing I need take the 12 lead before we start moving to avoid any interference from a moving ambulance.

As soon as I start to get a rhythm on the monitor I get my first piece of good news on this call. The fire medic’s monitor is only able to see one heart lead at a time, my monitor is preset to see two leads and one of those leads is showing me an organized complex of electrical conduction, not the even lumps of atrial flutter. I’m staring at an irregular rate from 150-180 but at least it’s organized.

It appears that all of the heart surgeries and the original defect have altered Josh’s electrical axis – his electrical conduction starts in a slightly different place on the heart and takes slightly different paths as it stimulates the contraction of cardiac muscle. As a result, in the default view of Lead 2 it looks just like atrial flutter but in Lead 1 and Lead 3 it looks much better. I’m starting to feel a little better about the drive ahead.

Everything else can be done en route, so with the EKG done, it’s time to go. I look up and see John and Mom looking back at me. “The 12-lead is good, let’s go.” As we start to exit the neighborhood with lights flashing and the siren making its familiar noise I’m almost starting to feel a little confident that this call will have a good outcome.

John says something from the front and I didn’t quite hear it so I move closer to the pass-through. We’re on the freeway in the far left lane. John flicks off the siren as the traffic is clear in front of us. In a slightly concerned voice he leans back so I can hear him. “I’ve never been to University, I don’t know how to get there.” Crap!

My GPS is sitting on the front dash. I can get to most places in the county without it and definitely to every hospital in the county. It’s occasionally good when we are off in the hills or if I have an inexperienced partner. But I didn’t program in the out of county hospitals.