The Human Lightswitch

Okay, this is straight from the “wouldn’t believe it if I didn’t see it” file, and has been on my “Calls to blog” list for sometime.  (Yes, I have a list I keep…I’m such a nerd).  It was quite some time ago,  and I don’t have the usual level of detailed recall for it.  Never the less, I submit the Human Lightswitch.

Years ago I was an EMT-Basic, I’m not even sure if I was a lead yet or not, but had the fortune to run many nights in the back of an ALS unit.  MedicJon was the medic on that unit, and I learned a lot of things before my time then.  (at one point, I didn’t know how to properly use a KED, a device used to pull people from cars primarily and a bread-and-butter EMT tool, but I could set up a three lead ECG and tell if a rhythm was “Good” or “Bad” even if I could not name them yet).  Cat was still running Fire at the time, and may have been in EMT class, but I don’t think so.  It was the middle of the night, and we get called out for an older guy who fell and knocked his head.  (That is now known as FDGB – Fall Down Go Boom.)  The engine gets dispatched with us and off we go.  The guy is laying flat in bed when we get there, holding a knot on his head as I recall, and his wife is the one to let us in.  Now, we are fully in the ‘no big deal’ mode at this point, but head over to ask some questions.

The guy is plenty alert, answers everything appropriately, no delays.  He looks a bit pale, but nothing out of the ordinary for a relatively thin older dude at 2-3 am.  He’s got no chest pain, no trouble breathing etc.  He feels a bit light headed, and his head hurts where he knocked it.  Jon asks what happened and the guy says that he got up to use the bathroom, must have passed out and knocked his head on the toilet or the sink when he went out.  (For the record, that means it is not FDGB, it’s a DFO – Done Fell Out, there IS a difference).  FDGB is usually a traumatic deal, often related to failure to ambulate, or sudden increases in gravitation ie: they trip, slip or some other manner of “clumsy” themselves to the pavement.  DFO is usually medical, and can range from a good ole case of the southern ‘vapors’ or “Alleluia breakdown” all the way to no-kidding sudden cardiac death.  Most commonly, both are minor issues.  Since we moved from FDGB to DFO, Jon was explaining that we were going to get an ECG going to see what’s going on with his heart, and asks the fire guys to go get the stair chair so we can carry him out in a seated position.

I’d been around long enough to know about “Vagaling”, and I’m thinking that the poor old guy was having himself a old fashion intestinal grunting match on the thinking seat and the constant ‘pushing’ dropped his BP and pulse rate until he passed out.  It would not be the first, or last time I’d run THAT call.  I hear Jon say that he’s going to do the ECG, and I start pulling out the cables to get that set up.  As the leads go on, the guy is explaining that he was walking when it happened, but he does not remember hitting his head, so he must have passed out.  Okay, so he wasn’t on the pot.  That seemed a bit odd, but hey, I’m new-ish, Jon is the medic, and I’m setting up an ECG.  Everything looks like “Good” rhythm to me, and Jon isn’t puckered, so the dude must be ok.  (He, in fact, was in a regular sinus rhythm with no ectopy…see, you get to use big words in medic class).  His other vitals were normal, or I’d remember what they were.  The stair chair is coming, and Jon is starting the process of sitting the guy up to get him ready to do the stand-up and sit in our special carrying-chair maneuver.  The heart monitor is on, and I’m at the foot of the bed watching it, and generally packing to move.  Cat is in the room too, doing what firemen do on these things.  

Okay, so I said I know “good” and “Bad” on the monitor, so when the guy sat up, and the bumps and squigglies all went absolutely FLAT, I knew that was more towards the “Bad” side.  By flat, I mean, right of the TV, sound the steady tone, call for the doctor, FLAT.  (Yes, that is the sort of thing that went through my head in my early career.)  I know Jon can’t see the monitor, but clearly he needs to know.  “HOLY SHIT the Dude just DIED!” is what I was going to say, but fortunately I managed to censor that one.  As I start to talk, I remember that sometimes the leads would come loose, and you could get flat lines (okay, those are dashed, this was solid, but I didn’t know that then) or strange wiggles from movement.  So, before I yell that the guy with the bump to the head is dead, it occurs to me to check the leads to make sure one didn’t come off.  Oh yeah, and look at the guy to see if he’s moving, breathing or otherwise doing “not dead” things.  So, having started to talk, I look over the patient.  The leads are on just fine. But the patient is still seated, though has this STRANGE look on his face.  What came out was “Uh……..Jon?”  as I spin the monitor around.  The pause being my time checking the patient.  Jon looked over with a ‘bad’ look on his face to see the asystole on the monitor.  Right then, the guy falls flat back and is Not Moving.  Now that’s different.

More different, was the fact that in the little time it took to process the fact that our talking patient just stopped his heart and fell backwards, usually referred to as ‘died’, the patient regained a ‘good’ rhythm and started to move around, and wake up.  I think it is safe to say that all of us, including Jon, went from “yadda-yadda” to “holy shit!” to “woah.”  The guy was fully oriented in just a couple of seconds and Jon was asking how he felt.  He knew he must have passed out, since he was laying down again, and felt like he had been “dreaming”.  “No kidding” I thought to myself…”Was it a good dream, or a really bad one?”  That is a question I didn’t ask then, but really wish I had.  He was in no pain or distress, “just a little light headed”.  

Okay, so sitting up is bad.  Guess the stair chair is out, we’ll use the reeves.  The fire guys go back out to switch equipment and we say silly things like.  “It’s okay sir, just lay there, we’ll take care of everything”, and think things like, “Don’t get up…REALLY!”  The call goes smoothly from there, we carry him out in the reeves, and get him to the unit and the hospital.  I’m sure Jon got a line etc, but I don’t recall his pressure being so low as to get him a fluid challenge.  I know now that if your pressure is low and you go to sit or stand it can bottom out, and you pass out.  Now, that is not usually followed by abrupt asystole either, so there is that.  We take him to the ER, and they have one of the “big rooms” waiting for us.  The doc is waiting too, so the nurses have clearly relayed the story.  Jon and I are a bit puzzled as to what causes such behavior as we transfer care over to the ER.  The bed there is in the seated position and we lower it to move the patient over.  The Doc there is not known as the best on the staff and is insisting that the patient be sat up.  We advise against it, but back off after giving report.  As the nurse starts to move the back of the bed upward, she asks the doc “How far do you want me to sit him up?”   I lean over to Jon and say, “To the off position.”  As we are about to leave, we see the patient go unconscious, and asystolic.  “Lay him down! Lay him down!” the doc yells.  Jon and I share a “told ya so” and walk off to write a report, and get the unit ready for the next one.  Guess the doc believes us now.