Tag Archives: Heart Attack

Stagnation

stag·na·tion

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

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

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

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

Sir Arthur Conan Doyle – Sherlock Holmes

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

Dead Space

dead

1 – having lost life, no longer alive

2 – having the physical appearance of death; a dead pallor

3 – not circulating or running; stagnant: dead water; dead air

 

space

1 – the infinite extension of the three-dimensional region in which all matter exists

2 – an empty area which is available to be used

dead space – a calculated expression of the anatomical dead space plus whatever degree of overventilation or underperfusion is present; it is alleged to reflect the relationship of ventilation to pulmonary capillary perfusion

Walking back into the ED room to get a signature from the nurse I’m momentarily surprised at the level of commotion surrounding the man that was my patient just a few minutes ago. I look up to the overhead monitor that displays his vitals and see the obvious cause for excitement – asystole, the most stable heart rhythm in the world, is marching across the screen and slowly erasing the beautiful complexes of normal heart beats as it fills the screen with the flat line of death. The Paramedic Intern pulls a short step stool out from the corner just as the attending MD makes the call for him to begin CPR. Well, I guess my differential diagnosis was correct, small comfort considering he’s dead now.

There’s a question in paramedicine that is useful to the Paramedic in deciding a course of action on any given call – is this person big sick or little sick? The speed at which we can determine the acuity level of any given patient helps us in determining how fast we move through the call. On occasion the first look at a patient can tell you everything you need to know in terms of acuity. As I walked into the bedroom I could see that this is one of those times. My new patient looked up at me from the bed and it’s obvious that this is big sick and I’ll be moving fast today.

The firefighters arrived just a few seconds before us so they’re still attaching the monitor  leads and trying to get a blood pressure. I know what they’ll find based on the patient’s skin signs alone. The term – pale/cool/diaphoretic – gets overused in our business but it still surprises me when I see these skin signs manifest on a patient. A man of his ethnic background would be hard pressed to look pale so the fact that he looks ashen tells me all I need to know. My first thoughts on a call like this are about extrication. I want to get this guy out of here, into my ambulance, and start driving. Everything else can be figured out on the way to the hospital but the main priority is getting him from the bedroom to the ambulance. The problem is that he’s over two hundred pounds and there are three flights of stairs between me and my ambulance.

I send my partner back to the rig for a stair chair as I start to take in the vital signs and patient history to see if I can paint a picture of the last few hours that led to this big sick presentation. It seems that he and his wife were out running some errands and he started feeling sick about an hour ago. He vomited once and now he’s presenting with an altered mental status, very low blood pressure (72/48), fast heart rate (118 bpm), clear lung sounds, and skin signs that are screaming “heart attack” at me. Of course that was until I ran the 12-lead for the second and third time. The results keep showing nothing even remotely concerning in the cardiac department. In his altered state the only intelligible uttering I can make out from him is, “I…can’t…breathe…”

I put a non-rebreather oxygen mask on him and start the trek of three flights of stairs to the ground floor and the relative comfort of my ambulance where I can start to figure this thing out. The new stair chairs with the revolving treads make quick work of the stairs while preserving our backs in the process. It seems we’re on the ground floor in just a minute or two and headed towards the ambulance.

Finally inside the ambulance, I have decent light and all of my tools at hand so I can try to analyze his condition while driving to the closest hospital. I’ve already ruled out the possibility of a STEMI (S-T elevation myocardial infarction – a.k.a. heart attack), which would require a cath-lab, so I am free to head to the nearest hospital. As I check his 12-lead a fourth time – on the right side this time, still looking for the elusive STEMI – the firefighters decide it’s a good opportunity to leave. Figures. Looks like I’m on my own on this one.

With lights flashing and the siren singing a duet with the air horn I bounce down the road while starting two IVs in my quickly fading patient. Once that’s done I set up two bags of warm saline flowing wide open to drop as much fluid on him as possible and try to keep that blood pressure out of the double digits.

I slip the non-rebreather off of his face and put on a nasal cannula that has a receptacle for reading the exhaled breath and measuring the end tidal carbon dioxide (EtCO2). I actually do a double take as the reading comes back as 8 when the normal reading should be between 35 and 45. Hell, I’ve stopped CPR and pronounced people dead with higher EtCO2 readings!

A number this low just doesn’t make sense. I listen to lung sounds again and they are still coming up clear. I check his blood sugar to rule out a DKA (diabetic ketoacidosis)  presentation and it comes up perfect. Sepsis could possibly take the reading this low and explain the presentation but not with an onset of just one hour. There’s only one other differential diagnosis that is making sense to me right now and when that flashes into my head I’m more relieved than I can admit to see the bright lights of the ED out of the back window as my partner backs us into a spot by the double doors and I prepare to give my findings to  the doctors on the other side.

In these days when science is clearly in the saddle and when our knowledge of disease is advancing at a breathless pace, we are apt to forget that not all can ride and that he also serves who waits and who applies what the horseman discovers. 

Dr. Harvey Cushing

 

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

Traffic 1/2

traf·fic

1 : the passage of people or vehicles along routes of transportation; traffic congestion

2 : dealings, business, or intercourse

3 : social or verbal exchange; communication

4 : buying and selling; barter; trade, sometimes of a wrong or illegal kind

5 : to carry on trade or business, especially of an illicit kind; human trafficking

The lock on the heavy jail cell door releases and the door slides open with mechanical precision, making a loud clunk which reverberates off of the austere concrete walls of the sally port (a double-door safety system that they have in prisons. From the outside, you go through one door, and when it closes and locks, the second door opens to let you into the interior). Standing in front of me is the fire captain who’s taking information from the jail’s processing officer – he looks up long enough to point us down a hall. We continue walking down the hallway of holding cells and I see freshly processed prisoners, still wearing their street clothes, sitting on benches in their cells watching the procession of uniforms glide past their limited view through the bars. In the open cell at the end of the hall I finally see my patient – a man in handcuffs, leg shackles, and an orange jump-suit – sitting on the bench with firefighters taking vitals and four very large officers keeping an eye on things.

Finally, I see a friendly face – the fire medic stands up to give me a quick report. “Hey KC, so it’s your basic incarceritis. Forty-eight year old male, chest pain by three hours, vitals normal, no primary symptoms. That’s about all we have unless you speak Mandarin.”

“Sweet! No problem.” I step around the medic and address the prisoner. “Ni hao ma?” In perfect intonation I ask him how he’s doing in a typical Mandarin greeting. Fortunately I grew up in the Chinese community of my home city and know enough Chinese to order dinner, get my face slapped, and yell like a drill sergeant at a class full of kung-fu students. Unfortunately, it’s all in Cantonese and I just exhausted my Mandarin repertoire.

The prisoner stands up with a hopeful look on his face and fires off an excited string of Mandarin. “好. 这些人不相信我. 我有胸部疼痛.”

In unison the firefighters and officers look at me to see if I can tell them what’s going on. “Sorry man, that’s all I got, let’s go to the hospital.” I motion to the gurney as he does the shackled penguin waddle out of the holding cell. Kevin and I put on the leather hand restraints as the officer takes off the handcuffs. I’ll need access to his arms to treat him, yet he’s still in custody.

As we’re walking past the rows of holding cells I’m asking one of the officers what’s going on. “Yeah, we used the translation service on the phone, he said he has chest pain and knows that no one will believe him so we called you guys.”

“What’s he in for?” I always ask as I want to get an idea of how dangerous someone is – it doesn’t affect my treatment but it’s nice to get a heads up if I’m going to be sitting in close proximity to a violent criminal.

“We picked him up yesterday on a sting-op. Busted about a dozen brothels in a couple different counties. These guys were trafficking young girls from Asia on container ships and forcing them into prostitution. This guy was pimping out girls as young as thirteen! I tell ya’, right now, I hope he is having a heart attack – he deserves it!” Damn!

 



 

Heart Attack 2/2

There’s a saying in paramedicine: trauma is trauma. Basically that just means that it is what it is. Unlike a complex medical emergency with co-morbid factors on a patient with chronic conditions who takes ten medications, treatment for trauma is actually pretty simple. If it bleeds, plug it. If it’s floppy, splint it. Then go find a trauma surgeon quickly. Yet the real nuance to effective trauma care is staying ahead of injuries by anticipating problems before they happen and caring for the injuries that you can’t see.

All of Maria’s vitals are recovering nicely and she’s answering my questions well enough, although she’s understandably in a lot of distress and on the verge of freaking out on me. I made sure to apply the occlusive Asherman dressing to the chest wound. In a perfect world that will reduce the risk of a collapsed lung. In the imperfect world that I live in I’m not certain I could do a needle decompression to re-inflate a lung on Maria because she’s just too fat. But for now she’s breathing effectively in all lung fields.

I call my vitals up to Kevin as all of my assessments and treatments are pretty much done. I just need to start a couple IVs before we get to the ED. I take the oxygen mask off of Maria, as her saturation is at 100%, and put on a nasal cannula that tracks her expelled CO2 and gives me a visual waveform of each breath. I’ll be able to see a change in respiratory effort if she develops any complications.

She’s still a little scared and crying now and then. I cover her up with a blanket and tuck it around her shoulders. On one hand I want to stay ahead of the impending shock symptoms by keeping her warm yet on the other hand the simple act of tucking a blanket around someone tends to calm them. Despite the constant bouncing of the rig and melodic whine of the siren Maria seems a little more relaxed.

“Maria, you’re doing really well. I’m just going to start a couple IVs in your arm. You can help me out by talking to this nice officer over here. She has a few questions for you.”

The officer has been waiting patiently for me to finish my initial assessment and treatment. Hearing my prompt she stands up so Maria can see her and begins the question process.

“Maria, who stabbed you?”

With tears rolling down her cheeks she answers. “My boyfriend…”

I’m in my own little world as I preform the rote task of starting IVs and reassessing vitals. It’s strangely calming to have a single task in front of me as I’m a fly on the wall listening to the back and forth between the officer and Maria, as she tearfully describes the melodrama of an argument that escalated to attempted murder.

As Kevin and I push the gurney into the brightly lit trauma room we’re met by a room full of hospital staff. Fresh baby docs are pacing nervously wondering who gets to do the chest tube today, seasoned nurses are leaning against the wall, thinking about the twenty other things they should be doing while they are interrupted by this trauma, and the stoic teaching docs are standing in the background to observe everything and be ready to jump in the second before someone makes a mistake.

“Good morning, this is Maria…”

The officer was able to get suspect information before we even reached the ED. His name, vehicle description, address, and associates were relayed to police dispatch during the trip. By the time we rolled into the ED police were already on the man hunt. I heard the police dispatch tell them that he has prior warrants for violent crime and to consider him armed and dangerous. I stood in the corner of the trauma room with the officer who rode with me and explained what the doctors were finding as they did their assessment.

A quick sonogram showed that Maria had plural effusion – excessive fluid pouring into the lungs. And then a second pass showed that the knife tore open the pericardium – the sac that surrounds the heart. The fact that Maria was a large girl actually saved her life. Had she been any smaller the knife would have punctured the heart. She was up in the operating room before I even finished my paperwork. By the end of my shift she was recovering in the ICU and the (now ex) boyfriend was in custody. Had the officer not come with me the suspect information would have been delayed until after the anesthesia wore off and that would have given him a 6 hour head start.

 

 

Heart Attack 1/2

heart

1 : a hollow muscular organ that pumps the blood through the circulatory system by rhythmic contraction and dilation

2 : regarded as the center of a person’s thoughts and emotions, especially love or passion

at·tack

1 : to set upon with violent force

2 : the act or an instance of attacking; an assault

Passion is the enemy of precision. Forget the misnomer ‘crime of passion’. All crime is passionate. It’s passion that moves the criminal to act, to disrupt the static inertia of morality.

Daryl Zero; The Zero Effect 1998

Kevin angles the rig behind the BRT in the parking lot of the apartment complex and puts it in park with the strobes still flashing. I can see the firefighters grouped around some shrubs and by their actions I can see it’s a serious call. All scenes that we go to have a vibe and once you get used to reading body language you can usually tell how serious a call is before even getting to the patient. Bags are open, oxygen is about to be administered, clothes are being cut away, officers are asking questions of bystanders, the police dog is barking from the back seat of the K9 unit… this is a serious call.

Kevin looks over at me, “Just go, I’ll grab everything.” It’s my tech and Kevin knows I want to get to the patient and start my assessment and treatment quickly.

As I walk up to the shrubs I see an officer holding her hand on the patient’s chest. Judging by the amount of blood covering my new patient’s clothing it appears that the officer is holding direct pressure on a wound.

The fire medic is applying the oxygen mask as he looks up at me. “We just got here a second ago. Looks like a penetrating wound to the chest; maybe a stab wound. Unknown downtime; she was found a few minutes ago by a bystander.”

The bloody shirt is finally removed and I ask the officer to lift her hand briefly so I can visualize the wound. She lifts up her bloody glove and I clear off some of the blood with a dressing. I see a three centimeter horizontal stab wound just to the left of the sternum. Pushing my fingers into the chest for landmarks I find that the wound is directly over the 5th intercostal space and it’s likely the knife slipped between the ribs. Judging by the length of the wound the knife likely traveled pretty deep. Crap! That’s a bad place to miss the ribs!

I look over to the rig just as Kevin rolls the gurney next to the shrubs. “I need an Asherman and C-spine.” Kevin nods and rushes to get the supplies, returning in just a few seconds. Kevin and I tend to truncate our communication to the bare minimum on stat calls. More often than not we’re thinking the same thing and we really don’t need to verbalize most things during treatment. It makes things flow so much better when partners are on the same page and have worked together for a while.

As we cut off the rest of my patient’s bloody clothing and look for any additional wounds, I try to get a baseline on her mentation. She’s not tracking with eyes or answering questions yet she has spontaneous, erratic movement of all extremities. Actually a little too much movement – she’s slowing down our attempts to strap her to a board. I look forward to the day that we adopt a protocol that allows us to forego spinal immobilization when a patient presents with no neurological deficits. But for now we have to do it based on an abundance of precaution.

With my patient strapped down and the occlusive Asherman dressing applied, we’re ready to start transporting. It takes four of us to lift the gurney as my new patient is a bit on the obese side. I’m at the head as I push her towards the ambulance. She yells out as we lift the gurney and her big round eyes look up at me with a terrified gaze as she locks onto my eyes.

I smile down at her. “Hi, I’m KC, what’s your name?”

“Maria.”

“Maria, we’re going to the hospital because you got stabbed. I’ll ask you some more questions in a minute.” We load the gurney into the rig and I turn to Kevin before jumping in. “Code-3 trauma to Big City Trauma Center, I’ll get you vitals on the way.” Kevin nods and goes up front to drive.

I turn to the officer that was holding pressure on the wound. “She started talking just a second ago. Do you want to come with us?”

The officer gives me a big smile as she pulls off bloody gloves and tells her sergeant that she’s going to ride with us to the ED. There are usually only two reasons to take an officer with me: to get suspect information, or to witness a dying declaration. As we pull away from the apartment complex I’m hoping it’s the former. I’d really rather Maria didn’t die on me.


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…”

 


Necromancy

nec·ro·man·cy

1 : the practice of communicating with and learning from the dead to predict the future

2 : see also necromancer; one who practices divination by conjuring up the dead

The elevator is cramped with all of equipment and people squeezing close together. My partner, Scottie, stands next to me with all of our equipment stacked on the gurney and the strange addition of two SWAT officers with body armor, helmets, and assault weapons. I can smell the cordite from the recently fired weapons. We passed the shooter on the way to the elevator still warm with spent shell casings laying in the hallway; at least a dozen hits to center mass – no need for medical attention. We’re not here for him; we’re here for the unknown amount of victims that he shot before SWAT took him out.

The silence is broken when one of the SWAT officers keys his mic to alert the rest of his team that he’s coming up in the elevator with paramedics. Adrenaline is pushing through everyone’s veins and has been for the last twenty minutes. Sympathetic nervous systems are stimulated; pupils dilate, pulse and respirations increase, we have to fight not to tunnel vision on what we are about to see.

The doors slide open to reveal two more SWAT officers securing elevator access to this floor of the building. I hear the cries for help as we exit the elevator and see the blood splatter on the wall. Following the blood streaks to the ground I see a wounded officer and tunnel vision gets the best of me. I put a hand over the arterial spray coming out of his thigh as I’m applying the tourniquet with the other hand. Scott pulls the quick release on the officers body armor to check for additional wounds. As the bleeding has stopped I stand up and see the elevator doors open again; it’s my second EMS team with their SWAT escorts.

“Okay, he’s got a GSW to the thigh, arterial spray, tourniquet in place; he’s first out. I’m going to walk the floor and get the criticals ready for extraction.”

Turning from the injured officer to the rest of the room I take in the sites and sounds. It’s a typical legal office with cubicles in the center surrounded by offices. Cries for help are coming from all over the office space. SWAT officers are holding perimeter positions where they can secure the whole room so we can extricate the victims. It’s called force protection; once they eliminate the threat they then secure the scene so we can treat and transport the victims while under protection.

I had a plan before the elevator doors opened but I’ve already deviated from it by front loading the wounded officer for extraction. It’s a natural reaction to take care of the uniforms first; they are here to protect me and I want to protect them first in my treatment; it builds trust between agencies. But the reality is that there are probably other victims that are hurt worse. I need to get a handle on this before the scene gets away from me. I need to get back to my plan.

Standing by the reception desk at the front of the office I yell across the room as loud as I can. “If you can hear my voice and can walk I need you to start walking towards the stairs. Start walking now if you can!” Bloody office workers start to emerge from the cubicles; some limping, starring at blood on hands in disbelief as the SWAT officers herd them to the stairs.

Looking down at the receptionist I see what looks like a shotgun wound to the head. Checking a pulse and finding nothing I move on. A hysterical mother is cradling her twelve year old son who had a GSW to the neck; he can talk but can’t move any appendages, traumatic paralysis.

“Scottie, c-spine this kid, he’s next out.” I see Scottie headed in my direction and the third EMS crew is coming out of the elevator with their SWAT escorts. I need to pick up the pace and sort this chaos out quickly.

I’m making my way around the office with my SWAT shadow. A man in the office clutching his chest, no injuries, probable heart attack; he can wait, I move on. A woman with bilateral GSWs to the knees, arterial spray; two tourniquets and I move on. Another woman with a through and through GSW to the chest; two occlusive dressings to stop the sucking chest wound and I move on. A DOA; I move on. A woman with venus bleeding from a GSW to the leg; pack the wound with gauze imbedded with clotting agents, tell her to hold pressure on it and I move on. An old lady hiding under the desk who was too afraid to move when I called out but has no injuries; I pull her out and have a SWAT officer walk her towards the stairs as I move on. Finally I’ve made it around the room of offices and cubicles and back to the DOA receptionist.

I send another EMS team towards the sucking chest wound lady as the kid with the neck wound is getting pushed towards the elevator on a gurney. Then the two women with leg injuries are pushed out on gurneys. And finally the man with a probable heart attack is wheeled past me while sitting in his office chair. The SWAT officers protected the EMS crews throughout the whole process; they held the perimeter and escorted us too and from the scene.

I’m making a final lap around the office space to make sure I didn’t miss anyone when a man in a reflective yellow jacket steps out from a cubicle wall. “END EX, END EX!”

The SWAT officers repeat the order to End Exercise over their radios. The DOA receptionist gives me a big smile as she stands up and stretches; sore from not moving for the last ten minutes. Her hollywood quality head wound is still glistening with fake blood.

The basic premise of this scenario is that there is an active shooter situation with multiple victims who have been shot and are in various states of severity. The on scene Unified Command-ers propose using a SWAT team to eliminate the threat and once that is accomplished, to escort the EMS team into the scene and be given close quarter force protection while providing the needed medical care (triage, emergent treatment) and then egress the area under cover and protection.

This was obviously a very elaborate exercise in which 29 SWAT teams from various local and international agencies participated. Currently we do not go into the “warm zone” so fast on the heals of SWAT and under force protection protocols. Yet that concept is being challenged on many levels as the necessity of early medical intervention has growing acceptance.

After the exercise I had an interesting conversation with the head of the Israeli EMS training division. He related a situation where a suicide bomber created an MCI with 150 injured people in which EVERYONE was treated and transported within 29 minutes. We are no where near that proficient yet. But with the new reality of global terrorism and increasing frequency of natural disasters we must continue to train for the worst case scenario.

After running the scenario as the EMS team lead I ran it again as EMS support with a different SWAT team and then observed from the sidelines as another group ran through. It was an extremely enlightening experience. Not only in my own shortcomings  but in the tactics and priorities of other agencies. We can’t predict the future or know what we will face but we can train and push our skills in the hopes that we are prepared. EMS does not conjure the dead yet we do quarry the dead; we learn form them so that we can help others in the future.



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 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.