Tag Archives: Geriatric

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…

 

Sexual Tension 3/3

Louis and I are taking a slow drive into the “killing fields.” That’s what we call this neighborhood since so many people die here from gunshot wounds and gang violence – cops, kids, bangers – they all die in this area. We just received the call – Code-2 – for penis pain. Now, you have to imagine that we see all kinds of stupid and tragic stuff all day long. Yet when penis pain comes over the MDT (mobile data terminal) in the rig we just have to laugh. I’m sorry but that’s the normal response. If my penis hurt I would go to my doctor or drive to the ED myself. Why the hell would I call 911?

But this is the poor neighborhood where people don’t have a primary care physician or any other avenue to the healthcare system other than by way of an ambulance to the ED. It doesn’t surprise me anymore, it just makes me sad. Code-2 also means that we are responding alone; no fire department to back us up. As we find the apartment building, not four blocks from a recent cop killing, we see bangers hanging out in the common area. We’re used to this – we always lock the doors to the rig, and have our heads on a swivel as we approach the building. Radios on our belts are on and we’re watching each other’s back as we walk up the stoop. Were I walking up here off-duty I would be missing my  wallet in less than a minute. Yet as they see we are EMS and not PD, the bangers are ready to help. They know we are only here because someone called and they look out for their own.

“Hey, you know where apartment F is?” The closest banger in his white tank top puts down his malt liquor and points up a stairway. “Thanks man.”

I’m walking up like I own the place – it’s better than letting my knees quake like they want to – and Louis has my back as we find the apartment. Knocking on the door, “Paramedics!” Louis pulls me back so I’m not standing in front of the door swing – or potential bullet trajectory…

A tall African American man in his sixties answers the door and motions for us to come inside. “Hey, what’s going on today?” I offer my typical greeting as I reach down and grab the remote to turn off the TV that is a little too loud.

“It’s my dick man, it’s hurt’n.” Before I can say anything else he unzips his pants and uses two hands to unfurl the most enormous penis I have ever seen. Sometimes I really have to take a step back and reflect on my career choice. I mean seriously, I just walked into a stranger’s house and he just exposed himself to me. Now I’m supposed to deal with whatever medical problem happens to pop up. Paramedics have an interesting mandate – whether we walk into a house with a blue baby, a dying grandparent, a choking sibling, or a wife who was beat up in a domestic violence, we MUST maintain the same expression on our face. People are relying on us to fix that which is beyond their own abilities to fix. And we do it day in and day out. Yet this is stretching my ability at the moment.

He unfurled maybe 14 inches of two inch diameter penis cradled in both of his large hands. “Okay, so what’s up, is this more swollen than it should be?” What the hell else am I going to say?

“Hell yes it’s more swollen and I can’t pee; nothing comes out!”

“So how did this happen, what were you doing?” Why the hell did I just ask that…

“See, I was have’n sex.” He lowers his voice. “And she kept saying, harder, harder, so I did and I guess I just rammed it in too hard!”

So I’ve pretty much got nothing left to figure out on this one; “So what hospital do you want to go to?”

He tells me that he goes to the County Hospital and starts walking back to the bedroom talking to someone saying he’s leaving. As soon as he turns away Louis and I look at each other – big mistake! We both double up in silent laughter and have to turn away from each other to regain composure before he returns.

I walk him out past the bangers, who ask if he’s okay, and into the rig. There’s not much I can do for this one so I give him an ice pack to stuff down his pants and just load him up with Morphine. Call it a male sympathetic response but if there’s anything wrong with a guys package then he deserves as much Morphine as my protocols allow me to push. It helps him, of course, but it also helps me get through the call without having to cringe every few seconds.

On the way to the hospital I do a quick lookup on my iPhone as I can’t remember the name of this condition. The result comes back quickly – paraphosis. It’s where the foreskin gets stuck on the proximal side of the head of the penis and constricts due to trauma. It constricts the penis and prevents urine from passing and creates a swelling of blood. It sounds painful and he’s only marginally better after the medication.

I get him through triage quickly by telling the nurse this is a matter of “life and limb” and it’s a damn big limb! I finish my paperwork and go back to his room for a signature. Sliding back the curtain I look in to see the MD injecting his penis with Lidocaine. UGH – another image I’m going to have to try to erase from my mind!

The MD tells me he’s going to numb the penis, clip on with a forcep, and pull the foreskin over the head. He’s using the Lidocaine as a local anesthetic and he’ll do a procedural sedation with Versed just before doing the deed. AHGGGHHH! Cripes, too much information.

Before leaving the ED, I decide to make a quick stop at the restroom – I learned early in my EMS career to never pass up an opportunity since I never know when I’ll get another. I have to let Louis know where I’m going, “I’m going to depress myself and hit the head,” I tell him. He replies, “Yeah, I think I’ll wait – I’m not ready for that kind of let-down just yet.” I wouldn’t even want to be as “well-hung” as my patient, but there’s still that male ego thing…

I go back to the rig to finish my lunch and hope for a nice and simple cardiac arrest call to erase the images of the last call from my head.

 

 

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!”

Home Invasion 2/2

My partner kills the siren as we enter the residential neighborhood – it’s a courtesy to people trying to sleep. No reason to wake the entire neighborhood as long as we can drive safely. He still chirps the siren as we go through intersections, but that’s much better than having it on all the time.

The strobe lights, on the other hand, continue to blaze along our drive. It’s almost midnight so we need the visibility that they provide. The strobes also reveal the realities of this neighborhood – bars on the windows, graffiti on the fences, and dogs that bark at our passing. This neighborhood may have been nice forty years ago but these days it’s deep in the hood.

We finally spot the BRT (big red truck) down the street parked in front of a house. We are responding to a “Medical Alarm: Unknown.” That’s what our dispatcher calls it when an elderly person pushes their medical alarm and the monitoring agency calls 911 for them. I still remember the commercial in the eighties with the little old lady lying on the ground saying “I’ve fallen and I can’t get up.” It became a cliché saying back then but the high frequency on calls just like that have earned it an honored place in the abbreviated shorthand of EMS communication: LOLFDGB – little old lady fall down go boom.

Pulling in behind the BRT my partner and I exit the rig and find the lieutenant (LT). I’ve seen him now and again while working this urban county so we have a cordial familiarity. I also know a few of the guys on his crew, most of whom are young as this is deep in the hood. The old timers can bid to the “vacation stations” in the more affluent neighborhoods because of their seniority. Lacking seniority the younger guys are left with the crap shifts in the bad neighborhoods. They get worked pretty hard – sometimes 20+ calls in a 24-hour shift.

It’s midnight and no one is happy about getting woken up for a call that tends to be nothing. We’ll typically get cancelled off of this kind of call – at least half the time. It usually ends up being a simple lift assist or maybe they pushed the button while at someone else’s home or at a restaurant. The elderly often don’t understand the nature of the technology. It’s not a GPS (yet) and pushing the button only sends responders to the address on record.

LT tells me that they don’t have any more information than we do. It appears that no one is home; no lights on in the house, no answer to the door. They are going around the house to see if there’s a way inside. We can’t just leave when someone activates the medical alarm. They could be having the big one and can’t get to the door. They’ll break in if they have to.

Standing in front of the house with the engine noise of two rigs and strobes flashing I’m watching the firefighters check windows for entry. If they can find me a patient I’ll be happy to jump in but breaking and entering is their specialty, not mine. A neighbor walks up to me, attracted by the commotion.

“That’s Irma’s house, is something wrong with her?”

“I don’t know, that’s what we’re trying to find out.” First responders are always circumspect about giving information to bystanders because of patient confidentiality issues. But this seems to be a concerned neighbor. She tells me that she checks on Irma a couple times a day because she lives alone and is having an increasingly difficult time taking care of herself. I ask if she has a key or if she knows of a hidden key. She answers no to both questions.

I tell the LT what I know and he assigns one of his guys to force a window open. Of course the crap job of breaking and entering goes to the rookie on his crew. You never know what’s on the other side of a window – maybe a guard dog. The rookie is able to pry the window up and climbs inside. After maybe thirty seconds he screams out the window, “She’s got a knife!” What the hell?

LT and the other two firefighters instantly spring into action. LT gets on the radio requesting city PD to respond to our location code 3 while the other two run to the BRT and slide open the exterior cabinets containing tools. They rush the front door with the Halligan (think pry-bar multi-tool) and an axe. Prying the door away from the frame one of the firefighters puts a shoulder to it and breaks the dead bolt free of the hole. The door crashes in and we all rush into the living room.

Standing in the corner of the living room is the rookie; hands in the air, eyes big and round. In front of him is a little old gray-haired lady waving a huge kitchen knife at all of us, while supporting herself on a walker. She’s terrified – almost as much as the rookie. LT is trying to reason with her, “We’re the fire department, we’re here to help, no one’s going to hurt you, put down the knife!”

The neighbor pokes her head in the doorway. “She’s deaf, she can’t understand you.” She comes inside so Irma can see her. LT has everyone back away and the neighbor calms Irma down and takes away the knife. LT is checking on his rookie and I walk Irma and the neighbor into the kitchen to see if anything is wrong with her aside from being so scared.

I spend a half hour writing notes back a forth with Irma. I find out that she must have accidently pushed he medical alarm, that hangs around her neck, while sleeping and has no medical complaints. She doesn’t want to go to the hospital – she just wants everyone to leave so she can calm down and try to go back to sleep. As I interact with Irma the fire crew tries to piece her door frame back together. They’ve done this before so they have all of the tools – wood glue, nails, etc. It’s not perfect but it will keep her secure until she can replace it, which probably won’t happen.

Irma checks out fine and signs my release of liability form so I can leave her in peace. As I’m walking back to the rig LT and the other firefighters are giving the rookie shit for getting assaulted by a granny with a knife with a walker. He’s probably going to need to change his shorts when he gets back to the station and he’ll be the brunt of jokes at dinner in the station for months to come.

As my partner flicks off the strobes and we drive out of the deep hood I realize that PD never showed up and LT didn’t cancel them. They just didn’t respond. They’ve already reduced the police force by ten percent and we’re starting to see the results on the street.

That’s more than a little disconcerting… 

Home Invasion 1/2

home

1 : A place where one lives; a residence

2 : The physical structure within which one lives, such as a house or apartment

3 : An environment offering security and happiness

 

in·va·sion

1 : an act of invading; especially : incursion of an army for conquest or plunder

2 : an action or process which affects someone’s life in an unpleasant and unwanted way

3 : an intrusion or encroachment

As Irma lay sleeping in her bed the window was slowly pushed up from the outside. A young African American man wearing a beanie hat pulled low over his ears looks in the window. He pushes the window up further to fit his torso through.
Crawling in through the now open window he stands over Irma and reaches down to grab her shoulder. Irma is a heavy sleeper and doesn’t notice. The young man is wearing a dark jacket and pants. He puts a knee on the bed and rolls Irma on her back. He puts his hand on her throat as he brings his face close to hers.

Irma is startled awake and finds herself staring at a stranger in dark clothing kneeling on her bed with his hand on her neck. She lives in a dangerous neighborhood – she’s lived here for 46 years and has watched the slow decline; more gang violence, bars appearing on windows, pit bulls behind locked gates and friends moving away after having their houses burglarized. She’s had this nightmare before but it’s different this time; nightmares stop when you wake up – this one is just starting.

The man says something to her but she’s deaf – has been for years now and the hearing aids just don’t help any more.

She’s prepared for this moment, having run the scenario a hundred times in her head. Irma swats the stranger’s hands away, to his surprise. He didn’t think a woman in her 80s could move that fast. She reaches over to the side table for her knife.

She sits up on the bed pointing the knife at the intruder. He’s scared – not of the old lady in front of him but of the 12-inch kitchen knife being waved in his face. He yells out the window to his friends.

Even more frightened now, Irma grabs her walker with her left hand and stands up. The intruder is backing away from her – the knife has him concerned. In slow shuffling steps she backs the intruder out of the bedroom and towards the living room. She’s having a hard time seeing him – he’s wearing dark clothes, the house is dark, and in the excitement she didn’t think to put on her glasses, even though they were right next to the knife on the side table.

She wants to get to the phone to dial 911. She knows she won’t be able to hear what the 911 operator says but just dialing it will ensure that someone arrives. It’s becoming increasing difficult for a woman living alone with only the occasional neighbor to check on her these days.

Irma makes it into the living room while pushing the walker with her left hand and frantically waving the knife in her right hand. She’s been able to hold off the intruder for the last minute. Suddenly the room is awash with light. The front door has been forced open and men start streaming into the room; the intruder’s friends have broken the door down!

Irma is blinded by the light in the room yet realizes that she’s surrounded by more intruders wearing dark clothing. She is unable to hear anything and she is without her glasses. The men are between her and the telephone. She was scared when she saw the stranger kneeling on her bed, now she’s terrified. This nightmare has turned into a horrible reality.

Conflict Resolution

con·flict

1 : a state of open, often prolonged fighting; a battle or war
2 : a psychic struggle; often unconscious, resulting from the opposition or simultaneous functioning of mutually exclusive impulses, desires, or tendencies

res·o·lu·tion

1 : the firm decision to do or not do something
2 : the quality of being determined or resolute
3 : the action of solving a problem or contentious matter
4 : music; the passing of a discord into a concord while changing harmony

I tell the fire crew that I’ve got this if they want to cut out. They are always in a hurry in this city and when it’s a stat call that’s a great thing, but when it’s a geriatric patient who’s looking for his reading glasses on a non-emergent call, they tend to get impatient and that’s not so good. I’d rather let my patient take his time and feel comfortable than hurry him out the door. He finally spots his reading glasses on the music stand surrounded by three trumpets he’d been practicing a short time earlier.

We were called here because his wife noticed that he got dizzy when he stood up from the couch and was slow to answer questions after sitting back down. I do my assessment and find him negative for stroke signs, STEMI (S-T elevation myocardial infarction, meaning heart attack), diabetic problems, and everything else I could think to ask about that may cause a near syncopal (fainting) episode.

It’s likely that the beta blockers he takes for hypertension kept his heart rate low enough that his blood pressure couldn’t keep up with the sudden demand of standing up and he got a little light headed. His wife cares about him and wants him to get checked out anyway. Both he and I can see that arguing with her is a losing proposition so he’s going to humor her and go to the ED with me. That’s okay with me, honestly I would rather take a man in his mid-eighties to the ED than spend an hour documenting why I didn’t take him.

I complete my entire assessment in his living room and he’s symptom-free so I’ve got very little to do as we drive to other side of the city to his preferred hospital. Being a non-emergent call (some might call it a BS call), I don’t have to rush him to the closest facility or take him to a specialty hospital — he can choose where to go. If it makes him feel better to go across town that’s fine with me.

As I’m sitting on the bench in the back of the ambulance, filling in his demographics on the laptop for my paperwork, I do a quick lookup on him to see if we’ve transported him before. We have, so his information comes up. His insurance information indicates VA (Veterans Administration) coverage.

His name is of Japanese decent and he’s in his mid-eighties. I always like to thank the older Vets for their service and sometimes hear some stories when I get a chance, so I ask if he fought in the war. Men in their eighties only recognize one war; everything since was just a conflict.

“Oh yeah, I fought in the war, got drafted in ’44 as soon as they let me out of the internment camp.” He has a slow meticulous cadence almost as if he is planning where to stop and take a breath and adjusts his words to facilitate regular breathing.

“Are you serious, you were locked up and then you went to fight for the country that did that to you?”

“Yeah, my mother told me to. She said, ‘You were born here, this is your country. If they want you to fight for it then it’s your duty.’ So I did.”

I remember hearing about the 442nd Combat Infantry Group that fought in Europe. It was comprised almost exclusively of Japanese-Americans. They became the most highly decorated regiment in the history of the US Armed Forces with 21 Medal of Honor recipients. Yeah, okay I’m a geek, I’ve been known to put off cleaning the kitchen because there’s something compelling on the history channel, much to me wife’s chagrin.

“Well, I was sixteen when they put me in the camp. When I turned eighteen they said I had to sign up for the draft and as soon as I did they drafted me. I was supposed to go to the 442nd and was in the States training for it because they were losing those guys all the time — almost half of them died. But part way in they changed their mind.

“See, I was bilingual with no accent so they wanted me to help out in the Pacific. They sent me to language school for seven months, it was supposed to be nine months but they were in a hurry. Once I was done I got attached to the War Crimes Investigators and did translation for the interrogation of prisoners as we took back Manila.”

I think of the integrity and maturity that was displayed by this eighteen year old boy. After being imprisoned in a camp for two years at such a formative time in his life, he’s able to come to terms with some of the most difficult issues faced by humanity; prejudice, loyalty, inequality, duty.

“So you’re eighteen and doing the translation as they interrogate people?”

“Yeah, they were worried about me being so young at first too. They asked me, ‘Are you sure you can do this?’ I said, ‘I don’t know, let’s give it a try!’ So I guess my language skills were pretty good because it was easy for me. They were really impressed and kept me busy for the rest of my tour as we moved across the Pacific and into Japan. Being bilingual probably saved my life – as a translator I wasn’t really in danger of being killed.

“When my tour was over I got a job as a contractor in McArthur’s Tokyo doing intelligence work translating military documents. It was a good job, I did that for another five years.”

I imagine what it must have been like for him as a young man of Japanese descent – working within the American military machine after the national outrage following the bombing of Pearl Harbor. Then to go to the country of his parents’ birth immediately after atomic bombs were dropped on civilian targets. The conflicted emotions must have been overwhelming.

“So what did you do when you finally came back to the States?”

“Oh, I worked as a CPA for twenty something years. I mean, I still do some work for them in tax season but mostly I’m too busy to work any more.”

“Too busy? So you’ve got a lot to do these days?”

“Oh yeah, I’m real busy. I play the trumpet in two bands, seems like I got a gig a couple times a week and I’m practicing all the time. I even go to a brass workshop for two weeks every year. I love to play the trumpet, it keeps me young.”

His face lights up, he sits up a little straighter, and gestures with his hands while talking about music. This obviously means a lot to him – it seems it’s a big part of his life.

“When did you start playing?”

“Oh, when I was a kid in high school, then when we were in the camp it was pretty much the only entertainment we had. A few of us in the camp could play an instrument. We’d get together and play concerts to keep people’s spirits up. Then when I went into the Army I played the bugle to wake people up in the morning.

“When I got out and started working I didn’t have a lot of time, but twenty years ago I retired, well mostly retired, so I had a lot more time to play again. Been doing it ever since!”

As we’re backing into the ED I realize I haven’t done any paperwork. I’ve been listening to this fascinating man throughout the trip. He’s a man of honor and duty who led an amazing life and is now enjoying his golden years as a musician. The whole time I’ve been talking to him he was smiling with an alert sparkle in his eyes as if recalling fond memories. He has made peace with the past and expresses his strength of character and love of humanity through his music. I am a better person for having met him.

 

 

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.