Tag Archives: Pediatric

System Status

sys·tem

1 – a condition of harmonious, orderly interaction

2 – a group of interacting, interrelated, or interdependent elements forming a complex whole

3 – a set of principles or procedures according to which something is done; an organized scheme or method

 

stat·us

1 – a social or professional position, condition, or standing to which varying degrees of responsibility, privilege, and esteem are attached

2 – a state of affairs or a change in social standing

Beep, beep, beep. “Medic-20 copy Code-3. Respond Code-3 to 123 Main Street for the three year old unconscious.” The dispatcher’s voice comes across the radio interrupting me as I am filling out my status report. I glance at the computer to see where the address is in comparison to where Medic-20 is posting. Medic-20 is about a mile from the call location and I’m another mile further than they are from the call. I put the SUV in drive and start heading that direction. There is a certain advantage to having the entire system status on my computer in the supervisor’s rig.

There’s a sixth sense to interpreting the description that the dispatcher gives to a call and actually knowing what is going on before arriving on scene. The wording in this call and the location put the little hairs on the back of my neck on end and I feel it’s something that I should get involved in today. For one thing, a three year old doesn’t know how to fake going unresponsive. We see it every day with adults who just plain decide to shut down and let EMS pick up the pieces. But a three year old isn’t quite that devious. Besides that, the address is an indoor swimming pool and water park and there is nothing good about a kid who’s unconscious near water.

I’m catching too many red lights as I head in the direction of the call so I remedy the situation. “Dispatch, S-4, can you attach me to Medic-20’s call and show me en-route?” The dispatcher comes back at me in a monotone response, “S-4 copy, showing you en-route.” The computer on my console starts making tones and a green line is routing me to the location where I’ve already started driving. Now that I have clearance to run hot to the call I can turn on the lights and siren and make better time. I take my little SUV through the red lights without a partner to help clear intersections. It’s still a bit unnerving to drive Code-3 without someone to help navigate, but it’s necessary. The traffic backs up in front of me and I switch tones in the siren to activate the rumbler; a low harmonic pulse that literally rattles the inside of the vehicles in front of me until they pull to the right. Unbelievably traffic clears, allowing me to make good time to the call. As I’m pulling into the parking lot I see my crew walking through the doors at the main entrance with a gurney and the fire engine is already sitting in front of their rig. I park my little SUV behind all of the big boy toys and casually stroll into the building without any equipment and not wearing my gloves.

It’s a strange experience to enter the scene of an emergency without equipment or protection, but the fact is that I’m not here to work on a patient or bring tools to the scene. There are two Paramedics ahead of me and the entire complement of advanced life support equipment has been carried in by others. My job is to support the team and ensure that patient care is seamless in regards to agencies and environment.

I walk solo through the water park and just keep the others in sight as I follow in silence. Screaming kids and teens are playing in the water and on the slides, lifeguards are watching from elevated chairs, chlorinated water splashes my boots. Finally I catch up to the crew in the lifeguard office where the child is sitting in a chair.

I know the paramedic from my service who is Medic-20 today. She was a new Level-1 Paramedic that was assigned to mentor under one of my old partners last year. My old partner was assigned to mentor under me a number of years ago so it seems the cycle continues. My teachings have passed to my partner who passed them to this wide eyed young Paramedic standing in front of me who is now on her own and making her own calls. She takes the report from the fire medic as I listen over her shoulder.

“So, apparently the little girl was pulled out of the water without a pulse and not breathing. They did CPR on her and then someone brought her here when she started breathing and they called us. She’s doesn’t speak English, her parent’s aren’t here, and all we have is a neighbor who is basically no help at all. Right now she’s just lethargic but she’s alert, at least, as much as I can tell she’s alert, but she’s really not talking much at all.”

I’ve been looking at the little girl while listening to the report. It seems to fit her presentation. With all of the strangers poking her and taking vitals right now I would expect her to be a little more agitated. Yet she’s looking like she just woke up from a nap. I slip an ungloved finger up to her eye and touch her dark skin while pulling her lower eyelid down a bit; bright white. Okay, good enough for me, she had a hypoxic event and she’s recovering. The mucus membranes of the eye shouldn’t be that white yet if they are the person is either very dehydrated or recently had a hypoxic event; that seems to fit the story. As the EMT from Medic-20 and the firefighters are transferring the patient to the gurney I catch the eye of the Paramedic. She looks over with big round eyes and a bit of a question.

I quietly lean into her ear. “You have to treat it like a near drowning with return of spontaneous circulation. Your only question is do you want to drive close or far away and how fast to drive.” With kids you don’t take chances. Presumably the life guards have their CPR cards and should know what to look for in terms of breathing and pulse. If the kid truly had neither and now she does she needs a full work up and some chest x-rays looking for water in the lungs and ensuring that the CPR didn’t displace any ribs. The driving close or far away only refers to which hospital to go to. The kids’ specialty hospital is 45 minutes away in rush hour traffic. The local hospital is just seven minutes away.

She looks undecided for just a few seconds and then comes to a decision. “I want to drive close and I’ll start off Code-2 and upgrade if I need to.” It’s half a statement and half a question as she looks to me for approval in her decision.

“Sounds good to me. I’ll run interference with the neighbor so you can get out of here.” I would have said any decision sounds good right now. The patient is doing fine and she, as a new medic, just needs the exercise in making a decision and sticking to it. But in this case she made the same decision that I would have made – I guess my old partner taught her well.

As the Medic-20 crew starts to push the gurney with the patient towards the front of the building I step in front of the neighbor and start asking her questions. She’s a heavy set woman in her late forties who walks with a walker and moves slowly like she’s in constant pain. As I question her she’s distracted as she looks over my shoulder at the patient disappearing in the crowd as they head towards the rig. I know the Medic-20 crew just wants to transport as soon as possible. All medics are the same when it comes to kids in this situation. If the kid is fine they just want to get them to the hospital and out of their charge before something changes for the worse. Had I let the neighbor follow she would have delayed them another ten minutes on scene with her slow moving and a long production of climbing into the truck. Not to mention the liability of helping her climb out of the truck on the other end and the overall delay in getting the kid to a doctor is unacceptable in this situation.

Having intercepted the neighbor long enough to give Medic-20 a clean getaway I walk over to the head lifeguard and ask to talk to the lifeguard who pulled the girl out of the water. I want to get a better understanding of how things happened. She’s a very emotional fifteen year old girl. She can barely catch her breath from the sobs and stuttered gasps for air as she attempts a retelling to me. After three or four minutes and a few stops for tears I finally have a story that makes sense and I feel I can leave.

Pulling out of the parking lot I glance down at my computer on the console. Medic-20 is about half way to the hospital and they are still driving Code-2. So the kid is probably doing fine. I punch the Medic-20 identifier into my cell phone and get the driver.

“Hey, so I finally got a good story and some contact info for the family. The little girl was on a water slide between two bigger kids. They went down the slide and the two big kids came up but the girl didn’t. She was under water for approximately twenty seconds when a nurse pulled her out, found her to be pulseless and apneic, and started doing CPR on her at poolside. After 30 seconds of CPR she started breathing again and was taken to the lifeguard room. All I have is a first name for the kid and the parent’s first name and phone number – the neighbor really didn’t know much. I called the father who speaks enough English to understand what’s going on and he said he’s on the way to the hospital.” She thanks me and hangs up. No doubt she is now relaying the information over her shoulder to the medic in the back of the rig so she can tell a better story to the doctor when she does a hand off.

I take a slow drive to the hospital and once I arrive I see Medic-20’s rear doors open and the patient compartment trashed with all sorts of bins and wrappers strewn around with a disheveled monitor propped in the corner with all of its wires hanging out. I spend ten minutes wiping down the interior and putting everything back into place. I then walk over to my little SUV and pop the cooler open to pull out two ice cold gatorades and prop them in the front cab so the crew will find them once they get out of the hospital.

I drive off before they can get out of the ED so they don’t think I’m interfering in their day too much. It’s a fine line to be involved in the call and supportive of my crews yet still allow them to function as the independent Paramedics and EMTs that we value in this service. I try to tread lightly and reward often. If I do my job right they may even forget that I was on the call yet they will remember that everything ran smoothly. I find a quiet corner of the parking lot in some shade and go back to updating my status report.

 

 

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.

Closest Most Appropriate 7/7

Now that I’m committed I pull my cell phone out and punch up the direct line to the University Emergency Department and give them a detailed description of what’s going on and what Josh’s condition is right now. The RN on the other side understands the situation and tells me that we’ll be going directly to the pediatric unit and she’ll have cardiology standing by when we get there.

The rest of the trip is somewhat uneventful as all of our tasks had been completed and it’s just a matter of monitoring Josh and reacting if anything were to change. Towards the end it’s obvious that he is starting to decompensate. He is more lethargic than before, he’s nodding off more frequently, and we have to keep him stimulated with questions and idle talk. His heart is starting to fatigue from the accelerated pace it’s been keeping for the last 45 minutes. His initial rate of 178 has now dropped to 52 and throwing consistent premature atrial contractions (PACs). Josh’s heart was bouncing from bigeminy PACs to trigeminy PACs. This means that he has normal conduction beats interspersed with abnormal beats in which the electrical conduction starts in the wrong place on the heart. This makes the contraction ineffective.

If his heart rate drops any more we’ll be turning on the external pacing pads to override his faulty electrical conduction with stronger electricity that his heart can’t ignore. It’s really an unpleasant thing to watch as someone is rhythmically shocked every second to force the heart to do its job. If I have to do it I already have the sedative ready so I can at least take the edge off of Josh’s pain, but I can’t risk sedating him too much as it will encourage the decompensation that has already started. Nothing to do now except continue the IV fluid bolus to keep his blood pressure up. We even have the pressure bag on the bag of normal saline, compressing it to push the fluids in faster.

Looking out the back window I can see we’re on University campus grounds as the large stadium and athletic fields pass through my limited field of view. The siren has stopped the constant wail and now only chirps at intersections as the cars pull to the right to let us pass. Unlike in the hood, the people here actually know what to do when the flashing lights appear in the rear view mirror.

Pulling into the ambulance bay I see the once familiar Emergency Department at University. My first ever code-3 return was to this ED. Three weeks into my new career in EMS I was working as an EMT doing inter-facility transports in this county. A skilled nursing facility (SNF) called us for a resident with a fever. Upon finding the patient in her room it’s obvious that the SNF called for a basic transport rather than calling 911 so they are not tagged by the county. The woman was septic, hypotensive, and altered. Our protocols said that if we had a transport time less than 10 minutes to the ED that we were permitted to take the patient in code-3, rather than call for an advanced life support (ALS) unit. That was the first time I called up to the driver telling him to light it up. Five years later I’m taking a crashing 8 year old for a 40 minute code-3 drive. It’s a different world yet still very much the same.

We unload Josh and wheel the gurney towards the receiving entrance. The ED charge nurse sees us coming and redirects us to the pediatric unit. There’s a team of six people waiting by the first critical room for us. As we unsnap all of our wires and transfer Josh over to the bed I’m giving a basic run down of how we found him, how he changed during transport, and an overview of his medical history. The pediatric cardiologist sees the 20 foot roll of EKG strip on the gurney and starts from the beginning, evaluating each printout and 12-lead sequentially captured during the last 40 minutes. Mom has her stack of papers and starts talking to doctor who she recognizes and is familiar with Josh.

As I’m about to leave, I look over at Josh, nurses busy connecting him to their monitoring equipment, I wave to him across the room, he gives me a thumbs up.

Closest Most Appropriate 6/7

“Don’t worry about it, just head for the bridge and I’ll get you the address.” This is not the thing that Mom needs to hear right now. We’ve got twenty minutes before we get on the bridge so I have time to make it work.

I pull out my cell phone and call our dispatch center. One of the dispatchers answers and I ask her to send out the University address to our pagers. A few seconds later my pager is vibrating on my hip. We’re on a pretty straight freeway so John is able to program the address into the GPS while driving. I hear the dry female voice of the GPS say, “In fourteen miles take exit on right.”

Moving back to Josh and the fire medic I grab my “Oh Shit Bag.” It’s the bag I clip to the net in the back of the ambulance every morning that has my seldom-used but really critical in a situation like this personal equipment. I pull out the Broslow tape and county protocol book. The Broslow tape is a measurement tool for pediatric patients – you stretch the tape out along the length of a child’s body, and it tells you approxmiately how much the child weighs based on height. Most drug dosages, as well as joule settings for defibrillation and cardioversion, are determined by weight for children, so getting a reasonable weight estimate is really important.

The Broslow tape tells us that Josh is 30kg, so his specific dose of Epinephrine is 0.3mg (as compared with 1.0mg for an adult). The fire medic and I pull out a strip of two inch cloth tape and write down Josh’s specific doses on all the medications and joule levels we could possibly use if we have run a code. In times like this it’s extremely helpful to have two medics double checking math and procedures. A misplaced decimal point can result in the patient getting ten times the dose they should get.

Glancing at the monitor and Josh every few seconds I can’t help but wonder if he is aware of what we’re doing: making a cheat sheet of medications in case his heart stops. I place the tape on the cabinet over the gurney so we can both see it. Josh looks up at the tape with its cryptic abbreviations and numbers, his eyes follow the IV tubing as it winds its way down the wall and into his little hand. “Josh, how ya doing buddy?” He holds up his tiny thumb. Wow!

One last thing to do: open the pediatric defibrillation stickers. It’s just precautionary but if I need them I don’t want to waste time attaching them, much less interrupt CPR to do it. The fire medic leans Josh forward as I place one on Josh’s back and then one on his chest, covering all of the cardiac surgery scars.

I’m keeping a mental note of our position in the county and which hospitals are closest in case Josh decompensates or codes and we have to abort the plan to go out of county. Looking out the back window I see the land fall away in the distance and our freeway turn into a bridge. Well, we’re committed now. Once on the bridge, University is now the closest receiving facility.

Closest Most Appropriate 5/7

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

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

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

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

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

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

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

Closest Most Appropriate 4/7

John, my partner, is a new medic in the county so Scheduling floated him to my unit today because my normal partner is out on light duty from an injury he received while lifting a 600 pound patient. John has to be with a more experienced medic until he gets signed off by a Field Training Officer. Scheduling doesn’t seem to care that I only got signed off last week. Although we’ve never worked together, and honestly just met a few hours ago, we had a good bonding on our last call. Stat calls can bond partners in a way few things can. I imagine it’s similar to people who go to war together but I’ve never experienced that so I can only guess.

Our first call of the day was for a teenage gang banger who got shot in the ass. The large city in our county is ripe with urban violence – gangs, drugs, and everything else that eventually ends with a trip to the hospital. Consistently ranked in the top five of the country’s most dangerous cities, it tends to be a great place for a new paramedic gain experience – fast! The baby gang banger was pretty much okay – single entry wound, no exit, small caliber bullet, able to move all of his extremities. Actually a pretty basic call for the city and John and I executed the necessary tasks and got him to the trauma receiving hospital in good time.

John and I are on the same page about Josh’s treatment and I trust he’ll make the case for the Base MD well enough to allow us to do the right thing. Meanwhile I make a quick call to the supervisor and tell him what’s going on. Company protocols dictate that I alert him if I need to transport out of county. I quickly lay out the scene for him and he agrees that it’s what needs to be done. His parting words gave me a shiver, “Good luck with that.”

I see John hang up his cell phone and I give him the raised eyebrows as I’m helping to wind up the EKG wires and put them back in the monitor. “Okay, I talked to Dr. Finch and he understands the situation. He would rather us take him to Kid’s but said if the mother is insistent then we have permission to go to University by ground or air.”

I turn to Mom, “Which hospital do you want him to go to, University or Kid’s?”

“Definitely University!”

“Okay, we’ll get him there.” Mom, who has had every mother’s worst nightmare in groundhog day repeats gives me a big smile and thanks me as she starts gathering up necessary paperwork and belongings for yet another ambulance ride with her very sick child. I’ll take her with me if I have to drive him, sitting up front of course. There is a very real possibility that Josh may decompensate en route and no mother needs to watch us run a code on her kid from a ringside seat on the bench  – where you can actually hear the ribs break from CPR.

As I’m getting ready to pick Josh up and carry him to the gurney the fire captain comes up shaking his head. “They just flew a guy off the freeway, ETA for the next closest helicopter is 30 minutes.” Crap, that’s too long!

“Okay, it looks like we’ll be driving him, I’m glad that accident was the other direction on the freeway.” The captain raises his eyebrows and gives me the tight chin look that says he understands what the next 40 minutes are going to be like. He’s a paramedic also – keeps his certs current, does the occasional IV or helps out with an intubation now and then. But he’s a captain now and the fire medic that works on his crew is supposed to do all of the advanced life support interventions. He’s put in his years and deserves his position even if he would rather be pushing the Dextrose into the vein of a gorked diabetic instead of writing down the same medications on every call and asking the same tired questions of family members. Yet I can see that this is one call where he’s happy to down his engine and go back to the station to wait for us to bring back his fire medic.

Closest Most Appropriate 3/7

I join the fire medic, my partner (who happens to also be a medic), and the fire captain for a quick huddle near the kitchen.

The fire captain starts, “Okay, here’s the deal. He’s on the list at University Hospital for heart and liver transplants – his base problem is the heart but it’s cascading to other organs and is causing liver failure. Mom wants him to go to University because they know his history. He’s had six cardiac surgeries in the last three years with the cardioversion two weeks ago. But I know you guys probably have to go to Kid’s Hospital because it’s in-county.”

“Yeah, we have to go to Kid’s, but even that is 30 minutes away doing code-3 given traffic. If he starts to crash out I’ve got to take him to the nearest receiving hospital, he’s compensating right now so we have few options. Either way I could use a rider if you can spare your medic.” He nods without having to say the words, we all know how this could play out. It takes at least two people in the back of the rig to effectively run a code.

I do some quick math and take stock of what I have in front of me. Josh’s cardiac history is so complex that even Kid’s Hospital would be calling for a transfer rig as soon as I walk in the door, yet county protocol says I need to take him to Kid’s. He’s still compensating, and therefore somewhat stable for the moment. Yet kids stop compensating very suddenly and he has a very complex medical history, so it’s tough to gauge his compensatory stamina. I can get to Kid’s in maybe 30 minutes; going to University would take 45 minutes, out of county, crossing a very long bridge.

“Do you want a helicopter?” asks the captain. Hell yes I want a helicopter! Let the flight medic take this call, they have more training and  a few more cardiac drugs at their disposal. Not to mention he can get to where he needs to be faster than I can do it. But didn’t they just fly out that motorcyclist? Crap!

I decide it’s my call to make. Josh is getting to University Hospital one way or another –  they know his specific history, they have a cath lab, they have a pediatric department, and that’s where the transplant team is in case he gets bumped up on the list because of this. If Josh’s little heart is beating its last few beats right now he needs to be in the hospital that is equipped for the transplants.

“Okay Cap, can you call for an ETA for a helicopter? If it’s too long we’ll see about driving him there.” As the fire captain turns around to talk into his portable radio, I ask my partner to call our Base MD (the doctor that we call to get permission to break or exceed protocol when we need to) and make the case that we need to drive this kid out of county if we can’t get a helicopter. I ask the fire medic to start getting Josh ready to go, unhook his monitor and secure the IV.

Closest Most Appropriate 2/7

He gives me a quick run-down of the situation.

“This is Josh, he’s 8 years old and has a birth defect in the heart. He was playing with the other kids outside when he had sudden onset 10 out of 10 chest pain described as pressure and associated shortness of breath. He had a similar event two weeks ago which required cardioversion and the Cath Lab.”

“Why cardioversion?” I’m still trying to reconcile the fact that my patient is a kid and not a man in his 50s.

He moves out of the way of the cardiac monitor which has a fast series of even little bumps where the perfect electrical conduction of an 8 year old should be. He says, “It looks like atrial flutter at a rate of 178 a minute and he’s got a blood pressure of 86 over 58 off the auto BP cuff.” All BAD!

I move around the fire medic to have a look at Josh. “Hi Josh, how ya doing?” I say hoping he doesn’t see the very real concern in my face, as I kneel down to meet him eye to eye. He takes a tiny little thumb and gives me the thumbs up. Wow! Josh is a veteran of the medical community at the ripe old age of 8. He has cardiac surgical scars like a 50 year old who’s had multiple bypass surgeries and he knows he can’t talk well with the mask on, so he gives me a thumbs up instead. I give him a smile while I hold his wrist with my fingers wondering if I’ll find the weak radial pulse tacking away at 178 miles and hour. He’s pale, cool, diaphoretic. It’s a term we use a lot yet it still astonishes me when I see it. Sweaty people shouldn’t be cold to the touch and no 8 year old should ever look like this. The pulse is there and presents as I expected, fluttering along like quick rapids in a river under my fingers. We call that thready.

The fire medic kneels down with me, “Mom said that last time he was cardioverted his heart sounded like a washing machine, and that’s pretty much what it sounds like right now.”

I pull the stethoscope from around my neck and place the bell on Josh’s exposed torso next to the fresh scar tissue. Damn, if that doesn’t sound just like a washing machine. Paramedics don’t usually work with heart tones, pretty much every heart tone I’ve ever listened to sounded just like the diesel engine of my ambulance – it’s a skill and diagnostic tool better left to the cardiologist in a controlled environment. But any paramedic could tell that this kid’s heart was not doing the normal “Lump Dump” of a healthy heart. I’ve listened to heart tones of leaky valves – on the internet anyway – and I understand the concept. But this is a leaky valve on steroids. This valve simply isn’t working.

The fire medic was watching my eyes as I listened. All paramedics are similar in one respect: they are trained observers. We get lied to by most patients – people give us conflicting information, exaggerate their symptoms and distort the facts. We quickly develop very acute observation skills with a finely tuned bullshit meter. He saw me play out this scenario half a dozen different ways, most with bad endings, and the resignation that we are on this path together for better or worse. All of that was in just one look but we had an understanding: Josh was our patient and we were going to see it through together.

“Hey Josh, we’ll take really good care of you, just hold tight while I talk to these guys for a second, okay?” He gives me another thumbs up. Wow!

Closest Most Appropriate 1/7

clos·est

1 : being near in time, space, effect, or degree
2 : having a strong liking each one for the other <a close friend>
3 : very precise and attentive to details <close measurements> <a close observer>
4 : decided by a narrow margin <a close race>

uh-proh-pree-it

1 : the determination that the service provided is suited for the condition
2 : being suitable for a particular person, group, community, condition, occasion, and/or place
3 : proper

Walking up the stairs to the front door I take in the neighborhood. Children playing next door stop to stare at the fire engine – all the lights flashing – parked just in front of our ambulance, which smells of abused brake pads. It’s a nice neighborhood, not one I’m called to very often, in a quiet suburb of the county with expensive cars parked in front of well manicured lawns. I’m heading towards the door that has been left open for us and check my pager to make sure the numerics match. It’s an acquired habit from working in the hood where walking into the wrong house wearing a uniform can be a fatal mistake.

Taking the stairs one by one I’m thinking of the patient I’ll be responsible for in a few minutes and quickly brainstorming the possible treatments as compared with the equipment I have on hand. I’m a little tired and frustrated from the delayed response time and the distance my partner and I had to cover to get to this house. Nearly 16 minutes is longer than anyone should have to wait for an ambulance and 20 miles is longer than a crew should have to drive code-3 (lights and siren) to reach a call – at least in this county. But on this day I’m in a back-roads wealthy suburb of a county that is three-quarters urban sprawl. Not surprisingly, this area of golf courses and farmland doesn’t have as much freeway access as the more populous areas.

I recall during the drive that the dispatcher said something about this area being “Level Zero” – meaning no available ambulances in this part of the county – and that we were the closest unit. I’ll take her word for it as all of the ambulances in the county are tracked by GPS and calls are automatically routed to the closest crew. While driving to the call I listened to the radio traffic talking about a collision on the freeway ten miles further away  with multiple patients, one trauma activation, and another crew taking a motorcyclist to a landing zone to be air lifted to the closest trauma center.

The dispatcher was so busy with the high call volume that she didn’t send the call information to the Mobile Data Terminal which sits on the console of our unit. Usually I can get some specifics about the patient I’m responding to from there, but not on this call. So I’m going off the pager that only tells me where to go and gives a generic chief complaint of the caller. In this case it’s “Chest Pain / Shortness of Breath.” It’s a call I’ve run hundreds of times and it can manifest in any number of causes and levels of acuity. From the frequent flyer in the hood who just needs a sandwich and a place to take a nap to the identifiable coronary artery occlusion that requires a cath-lab and a code-3 trip to the nearest Cardiac Receiving Center.

Walking through the doorway to the house I see a few children and family members taking quick awkward steps to get out of my way, the way people often do when they suddenly find themselves unusually “in the way” inside their own house. I’m heading towards the kitchen/great room where I hear the squawk of the fire fighters’ radios. Walking in I see the fire captain talking to a woman in her 30s while he examines prescription bottles and writes down details. His mannerisms are business-like in the way we all turn on the A-game when it’s a real call. I’m starting to think this woman’s husband may have had a heart attack when I turn to see the small boy sitting on the sofa with a non-rebreather oxygen mask on and a fire medic kneeling at his side staring at a monitor. Another fire fighter is standing next to him holding an IV bag – the small boy already has an IV going.

Okay, now they have my attention. Sure it was a long response time but fire medics don’t usually start IVs before I get there unless it’s serious. And children don’t have chest pain! As I walk up the fire medic stands up with a relieved look in his face. Crap, this is a very real call!