Tag Archives: hypertension

Scrum 1/2

scrum

1 – rugby – the method of beginning play in which the forwards of each team crouch side by side with locked arms; play starts when the ball is thrown in between them and the two sides compete for possession

2 – a confused crowd of people pressed close together and trying to get something or speak to someone

3 – a brief and disorderly struggle or fight

The limitation of riots, moral questions aside, is that they cannot win and their participants know it. Hence, rioting is not revolutionary but reactionary because it invites defeat. It involves an emotional catharsis, but it must be followed by a sense of futility.

Martin Luther King, Jr.

The high intensity LED strobes on the rig are lighting up the dark concrete canyons of empty streets in my urban workplace as I get closer to the call location. Sirens and the occasional air horn reverberate from the buildings as I creep through intersections and accelerate down the open streets. I pass City Hall and point out the tent city that was resurrected after a somewhat violent clash between the city police and members of the Occupy movement.

My EMT partner is helping to cover shifts in this county and is far from his normal surroundings of rural EMS calls. John is a part time EMT in one of the rural counties that surrounds my mostly urban county. He picked up this shift to get some overtime,  and being new in the EMS community, he wanted to come here to get some “action.” He’s about to get more than he bargained for as we get closer to the call location.

I round the corner just two blocks from my destination when I’m met with a SWAT skirmish line slowly backing towards my flashing rig. Thirty officers in full riot gear – extra padding in the uniform, full helmets with gas masks on, and plastic shields – are holding off a mob of four hundred angry people in dark clothing. The occasional bottle is lobbed from the crowd and breaks on the asphalt near their feet. The officer in charge whirls around to face me and a single motion from his baton-wielding arm is enough to convince me that I need to find another route to my destination. No arguments from me – this is the last place I want to be right now!

I pick up the mic as I point the rig up a one-way downtown street with headlights coming at me in all lanes. “Medic-40, we’re re-routing, we got blocked by protesters at Main street.” Driving the wrong way, up a one-way street, I’m giving an update to dispatch while pulling my ballistic vest from my bag and trying not to have an accident while I dodge oncoming traffic. I don’t remember this lesson being in my Emergency Vehicle Operation Course!

“You green-eyed mutha’ fucka’! I’m gon’ whoop yo ass like on Jerry Springer!” She’s screaming insults at me and balling up her fist as I escort her to the rig.

“Okay, you can whoop my ass later, let me check you out first.” Placating the psychotic patient has become something of an acquired skill in this county.

She called 911 saying that she needed an ambulance and then hung up. My dispatcher was unable to get her on repeated call backs so they sent us and a fire crew to see what’s going on. Seeing all of that in the call notes of the MDT I requested a PD back-up before we even got on scene. It’s just safer to have the guys with guns on scene when you don’t know what you’re getting into.

“Don’t you take me to no county hospital! I know my rights. You have to take me to EPS!” I’m taking a blood pressure as she yells at me. Just as I thought – way too hypertensive – she’ll need medical clearance before going to EPS (emergency psych services). She’s not going to like this because I’m now obligated to take her to the county hospital.

“Okay, here’s the thing. I need to put these restraints on you because you’re threatening me.” She struggles a little but lets me put the substantial leather wrist restraints on her – thereby greatly decreasing the chance that she can follow through with her threats to whoop my ass.

The city PD officers must be a little busy because they’re taking an eternity to get here. The fire crew simply escorted the screaming woman to the back of my rig and told me she wants to go to EPS. Before I even had her situated on the gurney the fire engine was driving away. Thanks a lot, guys!

“Why aren’t you taking your Seroquel?”

“I don’t like the way it make me feel! It make me all sleepy! Fuck you! Take me to EPS you green-eyed mutha’ fucka’!” Classic; the crazy person doesn’t like feeling normal so they stop taking their anti-psychotic medication. I’m about to make you feel VERY sleepy!

I’m drawing up a sedative in a syringe as the officers finally arrive and walk up to the back of my rig to face my not-so-pleasant patient. “I hear you want a green sheet, what’s going on?”

My patient seals the deal with her next outburst. “Fuck you! I’ll put you on a green sheet you bald-ass mutha’ fucka’. Let me up! I gon’ whoop his ass too!”

“Good enough for me. I’ll be back in a minute.” The officer walks back to his car to write up a 5150 form – a 72-hour hold for psychiatric evaluation – as his partner stands by in case we need any help.

As my patient is distracted by slinging insults at the officer I inject a sedative into her arm. With a green sheet in hand I have a pleasant drive to the county hospital and get a chance to do my paperwork while my patient snores like a chainsaw on the gurney.

 


T3 2/2

Since the drive to the ED will take a while, I strike up a conversation with Mrs. Duval to pass the time.

“They built this place maybe three years ago, how long have you lived here?”

“We moved here after the hurricane sir.” She has a polite manner and a southern twang. – apparently a transplant after hurricane Katrina. I’ve run into a lot of people who have relocated here after the hurricane. There are no definitive numbers because of the chaos at the time, but estimates are that over one million people were scattered around the country. Some have since gone back, some are still displaced.

“Do you like it here?” This area is a destination for many across the US who would love to move here, although not necessarily to the Projects – but to this general area. I’m curious about here perspective.

“It’s okay sir, but we don’t fit in so well.” I wish she wouldn’t call me sir but something tells me I couldn’t stop her.

“There’s a lot of crime in this area – are you guys doing okay?” The city PD call this area Beat-55x; it’s one of the worst in the city.

“Oh yes sir, we do fine, don’t no one bother us too much. It’s just not what we used to you know?” I’ve spent some time in the south and I know that our version of the hood is a lot different than their version. For starters no one in my hood has ever called me sir except for this charming lady.

“Do you have family here?” I’m curious to know what kind of support structure she may have.

“No sir. They all over the place after the hurricane.” Families were broken up, support structures destroyed, people displaced. Some never reconnected – it’s not like they are on Facebook and can post a status update to their wall.

“Your husband’s pretty sick. Does he always go to the emergency room or does he see a regular doctor?” I already know the answer.

“We don’t have a car sir. This the only way we can get there. I don’t understand though, he gets betta for a few day, then he has to go back. They jus can’ seem to make him betta.” It’s common – we see it all the time. It’s the other trifecta: poverty, location, and lack of education.

“You know, it’s the high blood pressure that’s the big problem right now. Is he taking his medication?” It may not be his biggest problem but you have to start somewhere.

“Yes sir. I make sure he take it every day.” She obviously loves him and she’s worried about him. But the care that they get from an emergency room will never fix this. Emergency rooms just treat them and street them. They seldom take the time to explain the overall condition, much less the causality and eventual complications. The mechanism for continuing care is non existent – there is no such thing as a house call.

“I’ve spent a lot of time in the south; that’s where my mother’s people are from. I know what y’all eat down there – lotsa fried food and salt. You know he can’t be eat’n that.” Possibly gaining a little rapport with the remnants of a southern twang that never really stuck with me.

“Oh, yes sir, I know but he like to taste his food. He always put the salt on.” No wonder his blood pressure is into gasket-blowing range.

“How bout the sweet tea, I know y’all like some sweet tea. How much sugar you put in a sweet tea?”

“Oh yes sir, he love the sweet tea. I put ‘bout a cup in a pitcha.” Yikes! A diabetic drinking that much sugar??

“You ever hear of Splenda? He’s got the diabetes, he can’t be takin’ that much sugar.” I can see the headlines now; Paramedic prescribes Splenda; man dies of cancer. Hell, but what else can I do at this point?

As I’m explaining sugar and salt substitutes I realize that Kevin has been having an almost identical conversation in the back of the rig. There’s nothing emergent to treat here – it’s their lifestyle that needs treatment and they’re not going to get it from the hospital. She tells me that she tries to help him but he won’t listen to her. She pleads with me to tell him these things because maybe he’ll hear it coming from a man.

Once at the hospital Kevin gives a report to the charge nurse and I’ve got a minute to lay it on thick for him. I cover all the points that we talked about: limiting salt, no sugar, no fried foods, eat a vegetable for God’s sake.

“Do you think this could kill me sir?” He’s a little scared with a small voice on the verge of tearing up.

“It will if you don’t fix it. Look at it like this: you didn’t have diabetes when you were a kid right?” He shakes his head. “Well, now you do and you take a pill every day to control it, but right now your blood sugar is super high. In a year you’ll have to take a shot twice a day to control it. That means sticking a needle in your belly every morning and every night. You don’t want that do you?”

“No sir, I don’t ever want to do that. Thank you sir, thank you for explaining it to me.” I didn’t give him an explanation, really, I just gave him some precautions and scared him with some possible results. It’s not enough and I know it. I even went to the EMS break room and grabbed a hand full of Splenda and gave it to the wife. They were both so appreciative and thanked me repeatedly, but still I know it’s not enough. Ultimately they escaped a hurricane and landed in the perfect storm.

After cleaning up the rig I went back in and had a conversation with the charge nurse. I learned that they have no one in the hospital for dietary consultation. Maybe, if he was admitted to the floor, they could call in a consult from their network of hospitals. I also learned that the county hospital has better dietary consults than this private hospital. Apparently they’ve cut all the “non-essential” programs. The Governator has already laid the ground work for further cuts to police, firefighters, hospitals, home health care, and education. Unbelievable!

I don’t pretend to have the answers yet I see the problems every day. This man needs a dietary consultation and someone to check on him once a week. Someone to go through the cabinets and suggest substitutes for poor eating habits. Someone to take him on a field trip to a dialysis center and see the sad people sitting in their chairs for three and four hours at a time – watching their blood get siphoned off and returned. The answer is not to spend more on health care. We need to give people the health care that they need and stop passing the responsibilities off to the next shift and by extrapolation passing the responsibilities off to the next generation.

This is the Trifecta cubed: T3

 

Hypertension –> Diabetes + Heart Disease

Location –> Lack of Education + Poverty

Poor Economy –> Unemployment + Cuts to Social Services

 

The perfect storm…the only question is which horse comes in first?

 

T3 1/2

T3

1 : trifecta; horse racing terminology – a parimutuel bet in which the bettor must predict which horses will finish first, second, and third in exact order

2 : trifecta; a situation when three elements come together at the same time and the synergistic effect is greater than the sum of the individual parts

3 : Terminator 3; a film from 2003, starring Arnold Schwartzenegger, in which humanity is brought to the brink of destruction

Ot volka bezhal, da na medvedya popal.

I ran from the wolf but ran into a bear.

Russian Proverb

I’m talking with two firefighters as we walk up the exterior stairs to a small apartment deep in the projects. One of them points to the door in front of us, “Yeah, we run on this guy at least twice a week – always the same thing: multiple complaints, all of them chronic.” We call them frequent flyers.

As we wait for the door to open I look around at the surrounding buildings from the vantage point of a second floor patio. The housing development is the size of five city blocks – 12 huge apartment buildings, 30 smaller six unit buildings, all surrounding a scraggly play field and basketball court. Built just a few years ago it’s still in good condition with strong security gates and pastel colors on the exterior walls. This is a community development project (The Projects) which differs from Section-8 housing in that local and state government pays for the project as opposed to private investors.

My medic partner, Kevin, is going to tech this call – I’ll help out if needed. A woman answers the door and only three of us walk in – the apartment is too small for all six of us and its residents.

Kevin’s new patient, Mr. Duval, has a number of chronic complaints and wants to get to the hospital so they will make him feel better. He’s a heavy guy, maybe 240 pounds, and moves very slowly – every step he takes is deliberate. Slowly he makes it down the stairs and onto the gurney. Once loaded into the ambulance I get his wife settled in the passenger seat for the ten mile drive to the ED. Four hospitals are closer than this one but we are obliged to honor his request for the hospital that he says has all of his records.

The resources that are being spent on this call are staggering: one fire engine with three fire fighters and a paramedic, one ambulance with two paramedics, a half hour ride in city traffic to a distant ED, and one hospital bed for six to eight hours minimum. The cost for all of this will undoubtedly be covered by the American tax payer through federal and state programs. It’s not even the direct cost that bothers me – it’s the extended cost to the fire departments, the EMS providers, and the hospitals. At any given time 50% of the resources in these agencies are handling calls just like this. Therefore we are 50% larger than we should be just to handle the call volume.

Being Kevin’s call I’m tuned in just enough to confirm that it’s a non-emergent call and the patient basically has chronic complaints. He has the trifecta: hypertension, diabetes, and heart disease. It’s basically a horse race to see which one kills him first. The progression up to this point is a common one that we see every day. Bad diet and no exercise lead to uncontrolled hypertension, which affects the liver, the kidneys, and heart. As a result he gets Type II diabetes and heart disease. The final outcome of this will depend on which horse wins: heart attack, stroke, or renal failure.

As Kevin calls up the vitals to me for the ring-down to the hospital, I put my money on stroke – his blood pressure is 220/140 (normal is 120/80). My guess is that renal failure will come in second given his blood sugar of 286 (normal is 80-120). Heart attack will come in third – the enlarged left ventricle of the heart is obvious on the 12-lead EKG.

Paralanguage 1/3

para·lan·guage

1 : nonverbal means of communication, such as tone of voice, laughter, and, sometimes, gestures and facial expressions, that accompany speech and convey further meaning

2 : vocal features that accompany speech and contribute to communication but are not generally considered to be part of the language system, as vocal quality, loudness, and tempo: sometimes also including facial expressions and gestures

3 : communication other than verbal

We’re responding to a home in the suburban sprawl area of my mostly urban county for “the unknown.” I used to get upset or nervous when the call wasn’t spelled out for me before I got there but now I’ve learned to embrace the unknown. At a time when the world economy is so uncertain, and the local government is cutting services, I’ve come to see the unknown as job security.

Walking into the bed room I see a man in his sixties laying on the bed with only his boxer shorts on. The fire lieutenant (LT) is using a bag to squeeze air into the mans mouth while the fire medic is checking a blood sugar. He looks up at me with just a touch of sweat on his brow. “Hey guys. So, per family, this guy is just sitting on the bed and his eyes roll back in head head and he goes unresponsive. Currently he’s: GCS-3 (completely unresponsive), irregular heart rate in the 150s, agonal respirations, oxygen saturation in the 70s, lungs sound like junk. He’s got a history of hypertension, diabetes, renal failure, pneumonia, seizures, he’s been sick for three days, and missed dialysis yesterday.” He looks down at the glucometer then back up at me. “And his blood sugar is 382.” FUCK ME!?! This guy is the quintessential train wreck!

There’s half a dozen things wrong with this guy that could cause this current state and lead to death very soon. At times like this paramedics fall back on ABCs – airway, breathing, circulation. Not having a patent airway and not breathing will kill someone faster than anything else so it’s our first priority. LT is managing the airway by holding my new patients head at a good angle and he’s breathing for him by squeezing the bag. I pull my stethoscope and listen to lung sounds; rhonchi, crackles, rice crispies, pop rocks, and an angry donkey – junk. The unknown sucks!

LT looks up at me. “We could C-PAP him.” It stands for continuos positive airway pressure. Basically a very tightly fitting mask with very high flow oxygen that helps to keep the lungs inflated and push out fluid. It’s usually used with congestive heart failure patients with fluid in the lungs.

“I can’t C-PAP an unconscious patient.” The LT is medically trained to the level of EMT-B so he may not be fully versed the the paramedic advanced life support protocols. C-PAP is contra-indicated for the unconscious patient.

“Yeah, but it might help.” He’s persistent.

“It might but I still can’t do it.” I turn to Scottie. “Can you grab the tarp from the rig? I just want to get moving with this guy.” It takes the five of us to carry him out on a big tarp with handles on the edges. We get him loaded into the ambulance and the fire medic jumps in with me as Scottie starts the drive to the ED with our strobes on and siren blaring.

My patients mentation has been improving a little over the last few minutes of getting high flow oxygen. The fire medic is starting an IV while I’m pushing a tube down the nostril so as to have a more patent airway. Suddenly big, round, and frightened eyes stair up at me and he starts ripping off electrodes and struggling with us. Guttural animalistic noises are coming out of him and it’s all we can do to save the IV. He’s combative and altered yet, strangely, I’m okay with that.

Paramedics have a saying that pertains to working with babies – a crying baby is a good baby. If a baby is crying you know he has a good airway and he’s definitely breathing. Well, the same is true for this guy. I’d rather have him agitated and altered than unresponsive; so this is actually an improvement. Looking out the back windows I see that we’re pulling into the ED parking lot.

I made sure that we transported to an ED that specializes in strokes and heart attacks so I know that anything that I was not able to check will be dealt with at the appropriate level. Sometimes in EMS there is nothing we can fix in the field; it’s just better to drive and get the patient to the ED so they can sort out what is going on.

I’m standing at the back of the rig as Scottie is cleaning up my mess. “Can you believe the LT actually wanted to put him on C-PAP?” An arm reaches past me to the box on the door that we keep full for the fire department restock. The LT pulls out a non-rebreather mask. Scottie has the “dear in the headlights look” as I turn to face to LT. “Hey, I really appreciated your help on this one, thanks fore letting me borrow your medic for a ride to the ED.” It’s my lame attempt to cover the fact that I just made an unflattering remark about the man while he was standing right behind me.

“Yeah, no problem.” And he walks off. CRAP!

Ultimately the patient had pneumonia which led to sepsis. Checking on him four days later I come to find out he’s still in ICU. He was already in an advanced stage of MODS (multiple organ dysfunction syndrome) and at the time his prognosis was not favorable for recovery.

I go out of my way to ensure I have good relationships with the Fire Department crews that I respond with. Yet this was a comment I made in the heat of the, post adrenaline, moment that was inappropriate. In EMS your partner is your sounding board and I sounded off in an unsecured place; with the doors open while parked at the ED. I should have shown better discretion and I wish it didn’t happen. But all I can do is move on to the next call.