Tag Archives: ipad

Ignis Fatuus

ig·nis fat·u·us

1 : a phosphorescent light that hovers or flits over swampy ground at night, possibly caused by spontaneous combustion of gasses

2 : something that misleads or deludes; an illusion

“Some say his sweat can be used to clean precious metals and he appears on high-value stamps in Sweden. All we know is – he’s called The Stig.” A man in a white racing outfit and tinted visor accelerates an impossibly expensive sports car away from the starting line as he speeds around an air strip turned race track somewhere in England.

The crackle of the radio interrupts our moment of down time. “Medic-40, copy Code-3 for an unknown.”

Lifting the iPad off of the MDT I see the call information appear as Scottie acknowledges the dispatcher that we’re en route. Pressing pause on the video of our latest down time obsession, Top Gear (BBC version), I switch to the mapping application and plug in the new address. Scottie isn’t wearing a white racing outfit but he’s doing a good approximation of The Stig as we race our ambulance through the hood. I pull up the street view on the iPad to see the street level photographs of our destination.

“Hey, we’re going to the post office.” All I know is that we’re heading to the post office for an unknown emergency. The call information in the MDT is useless – it doesn’t say what’s going on or why we’re going there.

The fire engine beat us to the call, as they usually do in this area, so we walk right into the post office to see what’s going on. The firefighters are standing in the lobby with a short man in his forties. He’s dirty with black smudges on a shirt that used to be white and he tracks me with his eyes as I walk up.

The fire medic looks up as we approach. “Hey guys, we just got here a minute ago and we’re still trying to figure out what’s going on. Basically this guy has been wandering around the lobby for the last ten minutes and wouldn’t leave when the manager told him to. He’s not talking to us and he seems altered.”

“Great, let’s go to the hospital!” Unlike our friends across the pond in England I don’t have any alternative transport decisions. I’m quite envious of their ability to transport to an urgent care facility, or even schedule a home visit by nurse for later in the day. They can even refuse to transport someone based on no medical merit. I only have three possibilities on each call; transport to the ED, transport to emergency psychiatric services, or have the person sign an AMA (against medical advice) form. Since an altered person can’t sign out it’s obvious that I’m going to the ED and I can do all of my assessment en route.

My new patient, Jose, walks with me to the ambulance. Although he’s not talking to me I  can assess quite a bit just from a little walk. He’s moving all extremities without difficulty, he’s obeying commands as he walks, he’s looking at me when I talk to him, and his skin signs are normal. I’m not getting any smell of alcohol and that’s high on my list of rule-outs given his appearance and the neighborhood.

Scottie passes the computer back to me and starts driving to the ED. All of my assessments are coming back perfectly normal, even his blood sugar and 12-lead EKG. I attempt to check for nystagmus in the pupils but Jose doesn’t get the concept of following my pen and not turning his head. I hold his head straight and move my face to his peripheral extreme and tell him to look over at me. He’s finally able to do it and I see the characteristic pupils bouncing off the side of the eye that is usually indicative of a high blood alcohol level. I feel that I’ve got the best-rule out I’m going to get so I start an IV, put some oxygen on Jose, and start typing in my computer as Scottie gets closer to the ED.

About a mile from the ED Jose looks over at me, “Wh-where are we going?”

“Hey, Jose, we were a little worried about you so we’re taking you to the hospital. What’s your last name?”

He answers yet it’s slow. There’s no slur to the speech but he has a delay almost like he needs to think about the right answer before he tells me. I run him through some stroke tests and he passes without any noticeable deficits.

“H-how did I get here?”

“You were at the post office and they called us. Do you remember seeing me at the post office.”

“Y-yes.” He’s still delayed and has a round-eyed thousand yard stare.

“Why didn’t you talk to me earlier?”

He thinks for a second. “I-I don’t know.”

“How did you get to the post office?”

“I th-think I walked.”

“What were you doing before I saw you?”

“I’m n-not sure.” It must be strange for someone to be missing parts of their memory.

Just as Scottie puts the rig in park at the ED Jose has a revelation. “I th-think I know where I was. I was in the garage working on my son’s go-cart.”

Now I’m the one having a revelation. “Was the garage door closed?”

“Y-yes.”

Jose did in fact have elevated carbon monoxide levels in his blood. The CO bonded to the hemoglobin, pushing out the oxygen, and tricking my machine to read a 100% oxygen saturation. He was actually having a hypoxic event and the oxygen that I gave him helped him enough to start talking again. Although nystagmus is usually a sign of an elevated blood alcohol level, CO poisoning can create the same effect. Jose didn’t present with the typical flushed/rosy skin tone. Yet even if he did I would have seen that as a further sign of alcohol use. The black smudges on his shirt were not indicative of a homeless man yet they are a byproduct of being a mechanic. Sometimes a drunk is just a drunk but sometimes it’s a real emergency. It’s nice every once in a while to be reminded of that.  

We were able to confirm that no one else was in the garage when we called his family. I certainly didn’t want my next call to be for his son. He was discharged a few hours later with strict instructions not to enter the garage.


Tough Love

tough

1 : strong or firm in texture but flexible and not brittle

2 : difficult to perform or understand; a tough assignment

3 : capable of great endurance; sturdy, hardy

love

1 : a feeling of intense desire and attraction toward a person with whom one is disposed to make a pair; the emotion of sex and romance

tough-love

1 : when people intentionally do not show too much kindness to a person who has a problem so that the person will start to solve their own problem

My flashlight illuminates the graffiti covered walls of the parking garage as Scottie and I walk in to look for my patient. “Hello, Paramedics. Did anyone call 911?” Scottie has his light out and we’re doing our best CSI impression as we search the dark parking garage for any signs that something is wrong or someone is in need of help. But all we find are parked cars, dumpsters, graffiti and trash – typical for the hood.

We were sent here Code-2 – no lights, no siren, and no firefighters. The notes in the MDT (mobile data terminal) were sparse and just told me we were responding to a man who isn’t acting right and is in the parking garage. Most people in my mostly urban county don’t act right so this call could be anything or nothing at all. The founding fathers of the 911 system must roll over in their graves each time we bear witness to the daily abuse of the system that we encounter. People will call for an ambulance for just about anything. They consider it the same as calling a taxi – only better because it’s free to them. Either their insurance covers it or if they’re uninsured, the state covers it (or my company doesn’t get paid). In any case, it’s not money out of their pocket like a cab or bus would be.

As we walk up the stairs to the main courtyard of the crappy apartment building, we run into a woman. “Hey, I called you guys for Tyrell.” She’s in her mid thirties, a little out of breath, and just a bit worked up.

“So what’s going on with Tyrell?”

“Okay, so, well, I’m the building manager. I saw Tyrell walking around all agitated, well, just not acting right.” So far this woman is about as helpful as my MDT. “So I took his blood pressure. I’m a dialysis tech, and his pressure was 132/84. But he’s just acting strange and I think his potassium might be elevated.” Really… I’ve watched dialysis techs do some really appalling things over the years so she’s not scoring high marks on my informed witness scale.

“So, why would you think his potassium is high – is he a dialysis patient?” I really hope I’m masking my cynicism.

“Well, no, but people do strange things when their potassium is off, and his blood pressure is 132/84.” Okay, I’m done. Telling me his blood pressure twice doesn’t change the fact that IT’S PERFECT!

“Where is Tyrell?” I’m not going to get anything useful from this woman so I might as well go to the source.

“He’s in 301.”

As we walk up the next two flights of stairs I’m talking over my shoulder to Scottie. “Have you ever noticed that when a man carries a hammer everything looks like a nail?”  Scottie’s still laughing as I rap loudly on the door. “Paramedics, do you need an ambulance?”

The door opens and a cloud of marijuana smoke wafts out of the apartment, quickly followed by a young man in a dark hoodie; presumably this is Tyrell. He’s got the baggy pants that are the uniform of the hood and one hand is always in the process of preventing a wardrobe malfunction. He quickly walks right past me towards the stairs with the stiff leg walk I see in the hood all the time.

I’m talking to the back of his hoodie as he walks away from me. “Hey where you going?”

“The hospital!” Muffled by the hoodie I can barely hear him as he takes the stairs towards the street.

“Okay, so what’s wrong with you?” I’m actually having a hard time keeping up with this guy.

“I jus gots to go!”

At this point Scottie’s patience runs out, and I’m not far behind him. “Well, if you keep walking that direction you’ll be there in five minutes.” He just walks to the back of the rig and stands there waiting for me to let him in. Whatever…

I get Tyrell situated on the gurney and start my regular assessment questions as Scottie retrieves the laptop from the front of the rig. “Okay, Tyrell, tell me why I’m taking you to the hospital today.”

“Cuz I been stiff all day.”

“What do you mean by stiff?”

“Like hard, like down there.” He’s pointing to his baggy pants that are tented at the groin.

“You mean you’ve had an erection all day?” Seriously, that’s where this is going?

“Yeah, for like five hour!” He’s agitated and squirming on the gurney. I’ve been getting him hooked up to the monitor while talking to him and notice his heart is racing at 140 beats per minute.

“What did you take?” I know he has marijuana on board but it’s obvious he’s got other stuff working on his system right now.

“Libigrow.” Never heard of it. I look it up on my iPad and see that it’s one of these male enhancement over the counter drugs that you see advertised on late night TV. Basically it’s just asian herbs, B vitamins, and stimulants – the stupid man’s Viagra.

We’re driving to the hospital and Scottie is taking side streets that are riddled with pot holes and speed bumps. I’m getting bounced all over the back of the rig and I decide to give Tyrell some Benadryl in an IM injection. Our county has a protocol for “mild sedation” which allows us to administer this for anxiety. I’d say this counts.

Tyrell gets extremely nervous when I pull out the large needle for the injection. His eyes are big and round while I’m drawing up the drug into the syringe. He’s obviously terrified of needles. I decide to have some fun with him so I’m playing up the bumps in the back of the rig.

I’m looking at his tented pants and holding the syringe. “Okay Tyrell, I have to give you a shot.”

“Hell no! Not down there man. You not gonna stick me down there?”

“No man, it’s just a little shot in the arm.” Tyrell actual tries to climb into the cabinets on the other side of the gurney as I roll up his sleeve to expose his deltoid. He whimpers like a baby as I stab him in the shoulder.

When we arrive at the hospital I explain Tyrell’s situation to the triage nurse. “Hey, Tyrell, you said you’ve been hard since eleven o’clock this morning?”

“Yeah, but I ain’t hard no more.”

“When did that happen?”

“Before we got here.”

“About the same time you saw that needle?”

“Yeah.”

The triage nurse starts laughing. “Great! You fixed him! Now take him out to the lobby.”

 

Lachrymatory 1/3

lach·ry·ma·to·ry

1 : of, pertaining to, or causing the shedding of tears

2 : a small, narrow-necked vase found in ancient Roman tombs, formerly thought to have been used to catch and keep the tears of bereaved friends

We’ve been sitting here in the rig, parked deep in the hood, for the last 25 minutes. Scottie is playing a word game on his iPhone and I’m checking e-mail and reading EMS blogs on my iPad. There’s an assault going on six blocks from us but there are no police officers on scene yet so we have to stage here until they tell us it’s safe to enter. It’s been raining all day and the wipers are on delay; going off every few seconds to wipe the rain from the windshield.

“Anything new in the notes?” Scottie doesn’t even look up from the game.

Glancing over at the mobile data terminal (MDT) in the center console I see that nothing has changed. “No, still no PD on scene.” It’s unbelievable to me that an assault can continue for a half hour and the police are stretched so thin that they don’t have the manpower to respond. I wish the city council members who voted to lay off the officers six months ago could spend the day with us and see what their decision is costing the public.

At the 30 minute mark the MDT finally shows that two officers have arrived on scene and five minutes later we are cleared to enter. We pull up at the same time as the fire engine who was staging on the other side of the incident. We ran a call with this crew earlier in the day and they were a good group. Walking up to the corner I smell the fresh scent of rain. It’s refreshing how it washes down the hood and makes it a little more pleasant but even the rain can’t change the fact that it’s a dangerous neighborhood.

The officer walks up to me and points to a young woman in tears standing by his car. “Just one vic – looks like a domestic, assaulted with closed fists.”

She’s crying and breathing fast but otherwise she looks okay at first glance; no blood and she’s able to walk and move all extremities. I look over at the LT on the engine and tell him I can handle it so they can clear and go on to the next call. As the engine is pulling away I walk my patient to the ambulance and she climbs in to sit on the gurney.

As I’m doing my regular checks of vitals and cataloging wounds the officer pops his head in the back door. “Hey, can you guys hang out here for a few? My crime scene tech is in a really bad mood and doesn’t want to go to the hospital for photos”

I slam the ice pack into my knee to activate it and hand it to my new patient to apply to her facial swelling, along with a few tissues to wipe away the tears. “Yeah, no problem, I’ve still got a little to do here and she’s pretty much stable.”

As I continue my assessment the officer is standing in the back door of the rig and questioning my patient, Anika. I listen in and start to get the story of what happened. She’s a foster kid who ran away from home with her adult boyfriend. She’s been living with him for the last few months. Today he was angry and and he took it out on her by hitting her in the head, stomach, back, and kicking her when she fell to the floor. She’s more emotionally distraught than physically hurt – all of the injuries are pretty minor. As she’s telling the story the other officer walks up with a gun. That is exactly why we were staging until the scene was secure…

“When he was beating you down did you ever see this gun?” With a cracking voice and uncontrolled tears she tells him no. The officer is looking for anything that would increase the charges on the assailant. Possession of a firearm during the commission of a crime would increase the time he spends behind bars.

Anika asks the officer, “How long is he going away for?” She’s scared yet also conflicted.

“We’ve got him on an outstanding warrant and firearm possession but you need to press charges for the assault to stick.” Anika is holding the ice pack to her quickly swelling face and eye while shaking her head. She doesn’t want to press charges. “Look, I’ve seen this before, it just gets worse; the next time he’s really going to hurt you. You didn’t do anything wrong and you don’t deserve this. It’s not okay to treat a woman this way. You need to help put this guy away so he doesn’t hurt you or anyone else. I’m telling you; it’s going to get ugly next time.”

I’m tracking her respirations on the monitor so I can see a wave form for each breath she takes. The wave form is getting smaller and the duration between breaths is getting shorter – she’s starting to hyperventilate. The officer is pushing her a little hard but it’s for her own good. We all know where this kind of thing will lead. We’ve all seen the final outcome and it really is as ugly as the officer said it would be.


Distraction 2/2

Walking into the entertainment center I see the jumpy house with it’s bright yellow entrance which matches the yellow of my gurney. Sitting on a bench is a woman holding  a small girl who’s bleeding from the foot. The firefighters walked in maybe 30 seconds before we did. I’m in the more affluent neighborhood of my mostly urban county. The fire crews are more pleasant here as they don’t get run as hard as the inner-city crews. They are quick to break out the bandages and stop the bleeding.

Fortunately I’m able to get a look at the wound before it’s completely covered. It’s a one inch evulsion (skin torn away from underlying tissue) to the top of the small girl’s right foot; muscle and adipose tissue are visible where the skin should be. It looks as though someone just carved away the skin with a knife. The girl, whom I come to find out is named Kimberly, is crying. It’s more of a sad constant cry than a hysterical outburst. She must be quite a mature little lady not to be flipping out right now. Her mother, on the other hand is very distraught; brow furled, talking quietly in her daughter’s ear, she’s holding on by a thread. While inspecting the foot I notice that Kimberly’s pants have a thick quilted lining sewed into them; obviously a modification. I start to ask the mother questions; I want to take her mind off of her daughter as much as I need to understand what happened here.

“I really don’t know, I mean I only turned my head for a second.” Her brow is furled, voice cracking under stress, trying very hard to hold back the tears; very emotional. “One of the other children must have landed on her. She has Ehlers-Danlos Syndrome so she’s susceptible to skin tears.”

There are so many syndromes out there, I may run into the same one every few years or never see one in an entire career. I have to be honest with her. “I’m not familiar with that syndrome. How does it effect the skin?”

“It’s genetic, I have it also and passed it down to her. We’re missing the gene that creates collagen in the skin so the skin and connective tissue have no elasticity; even a simple bump can create a tear.”

Now that she’s focusing on me and not the compounded levels of guilt about her daughter I see that she’s a well spoken, educated woman. She has lived with this syndrome for all of her thirty something years and is fully versed in all of it’s intricacies.

I’m not going to be able to do much for Kimberly other than understand the nature of the syndrome a little better then treat the symptoms. Genetic repair hasn’t made it to the pre-hospital bag of tricks yet. “Are there any bleeding, coagulation, or clotting issues associated with the disorder?”

“No, it’s strictly collagen, it doesn’t effect the blood at all. That’s why I made the padded cloths and protect her as much as I can but they said she had to be bear foot in the jumpy house. I knew I shouldn’t have let her go in but it’s a special day.” She’s doing her best not to loose it in front of her daughter. The firefighters have finished wrapping the foot and Kimberly has stopped crying; just sporadic whimpers as she’s held in her mother’s arms.

Their both on the edge of cracking, I need to keep them focused on me to avoid a negative emotional feedback loop. “Okay, so Kimberly’s foot is protected now that it’s wrapped, how about you let me take you to the hospital? Their going to need to close the wound, either with sutures, or possibly a glue, to protect against infection.”

“No, I’ll drive her myself, God knows, I’ve done it before.”

“So, here’s the thing. She’s perfectly stable right now and I have no problem letting you drive her. But you’re very emotional right now. It would be much better if you had someone else drive so you can take care of her on the way. The last thing I want is to get called to a traffic accident and find the two of you there. Is your husband around or can you call him?”

“No, he’s out of the picture, I’m here alone.” Her non-emotional response tells the whole story. Paramedic opens mouth and inserts foot; news at eleven…

“Then it’s definitely a good idea to let me take you, it will keep the both of you safer and I can give Kimberly some medicine to help with the pain a little.” She agrees with a bit of a relieved look on her face. With all of the issues that she’s dealing with right now at least this is one less thing to worry about and she can focus on her daughter.

Once in the rig I tell my partner that we can start moving; all of the necessary treatment was done on scene by the firefighters. Kimberly is laying on the gurney in the back of the rig with mom sitting next to me on the bench seat. Kimberley is still letting out a soft stream of whimpers.

While I’m explaining to mom that I can give Kimberly some morphine for the pain I reach up to the front of the rig and grab my iPad. I don’t like to dope kids when their parents are present without a good explanation. I’m planning on using the iPad to keep Kimberly busy while I draw up the morphine and explain the effects to mom. I launch an app and hand it to Kimberly, after surreptitiously checking for blood on the hands.

“Kimberly, this is Talking Carl, say hello to him.” She looks at the screen to see an animated character waving at her. He looks like a short fat sibling of Gumby.

In a tentative voice, “Hi Carl.” Two seconds later in a slightly higher pitched voice Carl’s mouth moves and he mimics Kimberly, “Hi Carl.” bobbing back and fourth he waves at Kimberly. She starts giggling, “Mommy, he talked to me!” two seconds later Carl starts giggling and moving his mouth and in his exaggerated high pitch voice, “Mommy, he talked to me!

This goes on for ten minutes of giggles and laughter as we drive to the hospital. I show her how to tickle Carl on the screen and Carl starts laughing then she laughs and Carl mimics it and it starts all over again. It looks like we just created a positive emotional feedback loop. As Kimberly is now busy and mom is actually starting to smile for the first time since I met them I have a minute to look up the syndrome on my iPhone. It’s exactly what mom described.

With Kimberly fully engrossed in playing with Carl I see a relieved look on mom’s face and we have a few minutes to talk. Quietly so as not to distract her daughter mom confides in me. “I didn’t want to take off her shoes but they said she had to be bear foot in the jumpy house. I just wish I could wrap her in bubble wrap for the next ten years..” She’s conflicted with emotion; she wants to protect her daughter but at the same time she wants to let her explore, have fun, and be a normal child. She remembers her own childhood all too well and wants to do good by her daughter.

I’m pulling out my iPhone again, “Have you ever seen the shoes that martial artists wear to protect their feet when they spar? It covers the top of the foot with a half inch of foam dipped in a rubber coating. It’s bare foot on the bottom so it might be okay for the jumpy house.” I pull up a picture on my phone and mom sees how it may be applicable to her little girl. It’s not bubble wrap but it’s a good idea. We spend a few minutes browsing the site and looking at the different protective padding options that may be applicable.

As we arrive at the ED they are both a little more relaxed. Walking into the room, pushing the gurney, to get Kimberly settled in the bed I realize that I actually had two patients on this call; Kimberly with her foot and her mother with her anxiety. I didn’t lay healing hands on either of them nor did I open up the drug cabinet or perform any paramedic skills. Rather I treated with compassion, conversation, laughter, and a little distraction.

Distraction 1/2

dis·trac·tion

1 : a thing that prevents someone from concentrating on something else

2 : the act of distraction or the condition of being distracted

3 : something, especially an amusement, that distracts

4 : extreme mental or emotional disturbance; obsession

Kimberley always new she was different, ever since she was young. Now that she’s older she’s starting to understand it better. Mommy says that she can get hurt easier than the other kids so she has to be extra careful. But this is a special occasion; today Kimberly turns six years old.

Kimberly has her padded pants, her thick long sleeve shirt, the squishy headband around her head, and a big smile on her face as she enters the jumpy house. All of her friends from school are here; brightly lit faces and laughter as the primary colors of the inflatable castle illuminate everyone in a surreal light. The smell of kettle corn and pizza speak to the treats that await them when play time is over.

Outside the jumpy house Kimberly’s mother nervously talks to the other parents as the inflatable castle deforms from the constant jumping of the kids inside. She had reservations about bringing Kimberly to this place today but she wants to let her beloved and sheltered little girl have a special day. She paces outside the jumpy house, holding her breath at every fall.

She carries the weight of the world on her shoulders. Being a single mother of a fragile little girl she is on constant vigilance for Kimberly’s safety. She carries the guilt for her contribution to Kimberly’s condition and the roll that it may have played in her father taking himself out of her life.

One of the other parents brings her a soda as they all know she wants to stay close to the jumpy house. As she turns to accept it the smile of gratitude turns to alarm as she hears the sound of Kimberly cry out in pain. It’s a primal instinct that all mothers are programed to respond to; the sound of their child in distress. Spilling the drink on her shirt as she rushes to the clear observation panel of the jumpy house she knows what what to expect from her own experiences.

Laying in the corner of the jumpy house is Kimberly. Blood smears the bright yellow inflatable fabric, children scatter away from her daughter as they don’t understand what’s happening. How can such a happy experience go bad so fast? Kimberly’s mother knows exactly how it can happen; from personal experience and from the lengthy explanations from the geneticist.