Not all our calls are traumas

Not all of our calls are traumas, or involve medivacs, of course.  And not all illnesses are physical either.  The week before Thanksgiving we caught a run to remind us of both.

The call came in the middle of the night, and in the middle of a marathon poker game as well.  (See a trend..)  As I recall, we were sent for an “unknown situation”.  The engine was with us again, and we were heading for an address in our first due.  This particular night, Jen has hopped onto the engine to allow an EMT preceptee who needs time on an ALS unit to get his calls with us.  Just this month, the county installed new Mobile Data Terminals (MDTs) in our units, which allow us to get dispatch information and updates, as well as message between units.  I was still getting familiar with the system, and as Wayne headed for the address, I took the chance to pull up the call and see what was up.  Cat was in the back shaking off the little bit of sleep she had managed to grab before the call.  At this point, none of us are particularly concerned or excited – unknown situation calls usually mean hang-ups or tentative calls and we tend to clear them rapidly, often without anyone actually needing care.  Sometimes they are domestic arguments and that can be dangerous, but there was no indication of unsafe conditions from dispatch…  But, thanks to the new MDT, I see that the call taker HAD put a note in that there was some yelling in the background, and a recommendation that EMS stage for PD.  We’re pretty close at this point, and I have Wayne grab some curb nearby to see what’s up.  “Company 12 units staging…” I tell communications, along with our location.  The engine catches the hint and pulls in behind us.  I’m reaching for my Nextel to raise Matt, when it starts to chirp.  He’s a bit faster on the draw than me.  “What do you know that we don’t?” he asks.  A little smile comes to my face and I think to myself that on other crews the question is “What are you doing?”, but not with this group.  I tell Matt what I see on the MDT and we hang out for just a minute.  “Medic 512, PD is en route, but we have further information that this is a chest pain call.”.  Okay, now we know what’s going on I think (wrongly) and we start into the scene.

Pulling up in front of the house, I see that the police car is arriving from the opposite direction at the same time.  Nice to see, doesn’t look like we’ll need him, but it’s always good to have the coverage, just in case.  The door to the house was open, and two people were standing in it.  One of them must be the patient, I think to myself, noting that they are both moving well, and neither one seemed in obvious distress from the curb, good signs so far.  When you get on a scene and there is one person in the door, that’s the “lookout”, usually a family member who has been assigned by the people inside to “wait for the ambulance”.  They are sometimes an indication of what’s in store.  When someone is bad, or at least when the people there think they are, you get the “Steal second” sign, that swinging hand calling you in.  I always let the folks in the back know when I’m getting that sign as we pull up.  When there is two at the door, one is the patient, usually the one hunched, or with the luggage.  (Wish I was kidding).  In this case, as I walk up to the house, there is a man and a woman, and I see that the man is going to be our patient, he’s walking out to meet me, and the woman, who is now labeled “wife” in my head, is behind, one hand on his back.  Greeting the patient, I note that he’s walking on his own, good even gait, not sweating, good color, closed posture, hands loosely clutched at his belly.  He looks from me to the unit, and glances towards the police car, and then down to the ground.  “The wife” is looking at me with a steady gaze…she’s got something to say.
Okay, we’re outside, it’s cold, something is up, and the patient is moving.  Let’s keep him moving to the unit.  Stopping is almost always bad, stopping becomes treatment on the lawn and carrying and just higher cluster potential.  I toss one arm around the patient and start guiding to the unit, while asking the usual things, “What’s going on tonight?”.  Cat or Matt must have picked up on the wife’s stare, and they hang back to talk to her.  The patient is able to answer clearly, but starts to lapse into a bit of a mumble, something about “My Heart hurts” with a couple, “I’m so sorry” and “I’m okay” tossed in there.  The guy is distraught a bit, but doesn’t have “that sick look.”  I gotta check out the chest pain angle, and make sure we don’t have a full-on MI going on, but already I’m thinking more like panic attack.  As we get into the unit, he does not want to sit back on the cot, but instead is sitting sideways with his feet on the floor to one side.  He is holding his head in his hands and is very closed in his posture.  I pull the doors shut, sit across from him and start trying to sort things out.  His position, elbows on knees, hands on his face, just to one side of me and facing my direction, and me, sitting across from him, leaning forward, talking softly and listening for answers that come back a bit hesitantly, pull my thoughts to a confessional, with him in the role of the penitent.  Instead of asking about his pain, medical history and allergies, I have the urge to ask him how long it has been since his last confession.  At the time, I almost discarded that as my own sarcasm, but then, I always trust my gut on calls, it was pretty much on target here too.

After asking a slow series of questions I only have a little bit of information.  I know his first name, that he feels very guilty, that his “heart hurts”, that he didn’t want it to come to all of this, he is not on any medications, he’s not allergic to anything, and he doesn’t want us taking his vitals or checking his heart just yet.  Consistently, when asked about his chest pain, he says it is his heart that is hurting.  Now, I’m sure someone, somewhere, when feeling cardiac chest pain, has described it that way, but I’ve never seen that.  It’s always “my Chest” or “here” and a finger or a fist to the chest to indicate where.  So I ask, “Is this emotional pain or physical pain?”.  This is an important, but delicate question:  I need to know the answer so I don’t fail to treat a physical pain, but then, I’m not a fan of blindly administering cardiac meds or vasodilators to people to cure a broken heart either. But again, if he is having an emotional or psychological issue, calling it such to his face can be a dicey move.  “Well, I guess it’s physical now” he says.  Great, worse answer.  Now I know it’s almost certainly a psychological issue, but he’s saying the magic cardiac words too.

About this time, Cat is joining us, and Matt opens up the back of the unit.  They are mouthing something to me behind the patient..”B-I-P-O-L-A-R”.  Great.  There is more to it I can tell from their looks, but they don’t want to say it in front of the patient.  Trying a classic move, I get Cat to try to allow us to get some vitals and run an ECG, while I hop out to get the rest of the story from Matt and the wife.  (The move being to get the pretty lady to talk the upset male into letting us do what we need.  Works almost every time).  

The ‘wife’ ( I later learn it’s actually girlfriend, but I don’t know that yet) tells me that the patient is bipolar, but won’t let the doctors officially make that diagnosis, or prescribe anything for it.  Not sure what the ‘won’t let them make diagnosis’ part means, but I know what “no prescription” means. Appears that he was seen in a psych consult just about a week ago, but left it before they got things handled.  Great.

I climb back to the unit, and see that Cat has gotten vitals, AND the ECG done.  (She’s very persuasive when she wants to be.  I know, I married her.)  He’s being monitored, and I see everything looks good.  No surprise.  Okay, I wave to the engine and they start to head for the unit to leave, and the Police officer does the same.  I’m not exactly clear what we were all doing shortly thereafter, but Ron (the preceptee), Cat, Wayne and I were all still in the back with the patient when he looks over at the monitor, sees the tracing and starts to panic.  “Oh no, there it is, oh my God, now it hurts, Oh  Oh…” he starts to say, rising to a yell quickly.  At the same time, he has hold of Cat’s knee and is squeezing.  “ow, Ow, OW, OW!” I hear, and in the tone that  I know is real pain from her.  Bang, bang, I pound on the back window quick and wave for the engine to come back in, and I’m hoping they’ll grab the Cop too.  I spin back, and Wayne and Ron already have the patient by the shoulders, and are pulling him off of Cat.  I dive in, and we quickly have him restrained, pinned to the back of the cot.  The engine crew arrives through both doors, just as the patient starts sobbing and saying “I’m sorry, I’m sorry, I’m okay, It’s okay.”.  Now, We have him held, and I don’t know how hurt Cat is, but I know that we either have to ease up quick, or know that if we keep him held, it is likely to escalate and we are going to keep holding until the Cop cuffs him.  Slowly we back off, and he stays cool.  I tell Matt that we are okay I think, and things settle down a bit.  Cat is saying she’s cool, that it was just a panic death grip, but that his fingers were digging in.  The patient is repeatedly doing the “sorry, sorry, sorry” when Matt tells me that the patient’s dad has arrived outside.  I hop out quick and ask dad if the patient tends to listen to him.  He assures me that he’s seen this before, and that yes, he can calm the patient.  Having seen the positive effect that a family member can sometimes bring, I have him climb in and talk to the patient.

Things settle down rapidly, and Matt tells me that they are going to follow us to the hospital…just in case.  I’m good with that, and glad for the help.  I know those guys are tired, but they are going to stay on this call longer to help cover our back.  You have to appreciate those things.  Wayne gets going, with the patient and dad sitting side by side, talking softly.  Cat is in front of them, keeping an eye on things and noting vitals.  Ron is standing behind the patient causally, but I know he’s keeping an eye on things, and protecting Cat.  I have a phone call to make.

I call in the report, and try to explain that while we were called for “Chest Pains” and there are some pains claimed by the patient, it truly appears that we are looking at a psych patient.  Now, I’m in the back of the unit with the patient, and history tells me that I cannot say things like “Psych” or “nuts” or “mental” etc out loud without risking an issue.  (No, I’ve never said “nuts” in a report, but you get the idea).  I do say that we had to restrain the patient briefly, but that things are calm, with dad’s help and that we are not going to perform any further interventions to avoid conflicts.  I did also get out that there was a diagnosis of bipolar disorder, and no meds taken, and that they would be well advised to get a consult ready.  The plan sounds good to the nurse and we are on the way.  The transport, fortunately, is uneventful.  On the way, I try to look over things again:  “Heart hurts”, “guilty”, “I’m sorry”, and a wife at the door.  He cheated on her, I think to myself, and he’s bipolar, and the guilt is causing an episode.  Interesting thought to me, but I figure it’s not my business, and let it be.

Arriving at the hospital, the patient is pretty adamant that he walks in, with dad.  I’m okay with that, and I’m not looking to get into a scuffle, so in we go.  I see a nurse waiting for us and waving us into one of the “big rooms” usually used for traumas or seriously ill patients.  The engine crew arrives right behind us, and join us for the walk in.  I scoot ahead a bit to try to talk to the nurse before the patient gets there.  “Why is that patient walking?” is my greeting.  Great.  “To avoid a fist fight in the unit” I tell her.  Now THAT got a look.  Fortunately, the patient came to my rescue.  About this time, he’s turning the corner into the room.  He sees Security is there, along with several Nurses, Techs and even the Doc.  I see him glance around the room, and fix on the equipment.  “Here it comes…” I think.  “oh god, Oh GOD, IT’S HAPPENING AGAIN….” He yells, and drops to the floor in a ball.  You know, You can’t script this stuff.  We end up picking him up, still in a ball and carrying him to the bed.  The team gets him settled, as I talk to the nurse.  I give her the run-down, explain that the call was dispatched as Chest Pain, but I believe it’s a psych run, and why.  I know this nurse and she’s a bit of a hard case, but fortunately, the doc is there listening and nods that he agrees, and see’s what’s up.  He asks whats going on, and why does the patient feel bad.  “I’m so guilty….I have such a good woman…” I’m thinking “oh, here it comes...” and I’m kinda thinking the Doc should put it together by now.  But, here we are in a room full of people and he’s sticking to his guns, asking away.  Finally, the patient says, “well…it’s kind of a Scarlet Letter thing…”.  Thank you. Dr. Phil has nothing on me, my work here is done, I think.  I check with the nurse to make sure she’s good and head out the door.  

As I head out to write up my report, the nurse who took report calls me over.  “Hey, I thought you said he was calm?” he asks.  “Yeah, He was.  I also said we restrained him.” He agreed.  “That’s why he’s in for psych…” The nurse was okay with that, and kinda shook his head with a grin.  You gotta love running nights.