Don't stick it out if you're not gonna use it

The last couple weeks have been eventful at the department from a Captain’s viewpoint, so I didn’t get the chance to write last weekend like I had hoped.  But, that is resolved, and life moves forward.  We actually had a relatively quiet week, and there is not much of interest to talk about from a call point of view from this week.

The renovation is coming along though.  The walls are painted, the floors are in, and things are looking better.  I can’t wait to get back in the house.  Maybe I will get some pics up when it is done.  Until then, Tuesday night duty means a single-wide trailer living room full of people on sofas, chairs and the floor watching Denis Leary and the rest of the guys from “Rescue Me” on the idiot box.  It was nice to see everyone drop what they were doing to get together and share comments.  It was even more nice of the Woodies (a term of affection for our local residents) to not call 911 long enough for us to watch it.

It was actually during the mandatory TV session that I was reminded of a call that we ran a few months ago that is of actual academic interest, besides just being odd.  Cat reminded me of it, which is ironic, as it occurred on a night she was at work.  Wayne was there, but I think Tess was gone working that night as well.  It had been a pretty normal night, a few runs, a few transports, nothing more than some O2-IV-Monitor runs as I recall.  (For those still in medic classes, here’s the secret.  Learn ALL of the cool  algorhythms, skills and odd cases…then know that 90% of your life is assess, History, O2, IV, ECG Monitor and transport. Hell, the other 10% is O2, IV, Monitor too, just add a cool step, then transport).  Anyway, call comes out as a possible allergic reaction one due to our north.  It’s the middle of the night and the patient is “adult female”.  

Medic rant of the week:  Dispatchers, “Adult Male” and “Adult Female” translates to “Not a kid, I didn’t care to ask”, at least in my head.  As responders, for many calls we really do care if the patient is 19 (a medical adult) or 99.  I’ll settle for “OLD like Yoda”, “Remembers Vietnam”, “Remembers Vanilla Ice” or “has a MySpace account” if you don’t want to get a number, but work with me some.

We are sent with the Engine from that station.  This crew has been with us for a couple years, and they have their stuff together.  They know their BLS skills and generally I get really good information on arrival.  In this case, we arrive on the scene and before I get to the door, I hear something about airway issue, or her tongue.  The lights are on in the front, and there are a few family-type bystanders.  They are staring inward, but not acting panicked…interesting.  As I get into the house, I see the patient.  She is indeed an adult female (“Yoda’s kid sister” age range..80’s as I recall), and I immediate get why we were sent for a “possible allergic reaction”.  The patient is calm, but a bit scared, has good color (more than a couple of the bystanders and firemen can say), is alert, oriented and has the biggest, most swollen tongue I have ever seen or heard of.  To paint a picture, she could not fully close her mouth, around the thing.  It protruded forward out of her mouth, and spilled on both sides.  Of course, what I noted first and foremost, is that it was THICK.  “Dear God, please don’t let her lose her airway” I think to myself.  I swing around in front of her, and get into my usual Catcher’s crouch in front of her.  As I’m looking at her scared eyes and huge tongue, I’m  thinking “Wow, I’m NEVER getting a tube past that…She gets her airway blocked….damn, what will I do.  Brief thoughts of things like cricothyrotomies (NOT in our protocols, and no real equipment for it either…okay, all of our medics reading this just thought about the scalpel in the OB kit and the suction unit…sickos.) and nasal intubations (Also not allowed, but I can probably do it, call the doc and get the okay to do it en route if I HAD to) flash through my head and I shake them off.  “Well, what happened here?” I ask.  “She can’t talk” I hear from the guys.  Not the best news.  She is trying to talk, but just making noises.  Better news, at least air is moving.  Her color told me that, but still, good to hear.  I notice that her tongue is so swollen it has been cut by her teeth and is bleeding ever so slightly.  Ouch.

Okay, time to fix this…kinda.  I get her on a Pulse Oxymeter to see how much oxygen is getting into her blood with the help of the fire guys and simultaneously start asking about meds…specifically new ones, new foods, new places, new pets etc.  I’m doing the full on, one man medic assessment drill.  I’m hearing that there is nothing new, her meds are all old.  I don’t recall specifics, but at the time I think things like “vitamin, vitamin, hormone, cardiac med, High blood pressure med…” as the names are read off.  Okay, some sort of cardiac issue, but nothing abnormal for her age.  No stokes, no MI’s etc in her past.  Her lungs are clear, and I notice that she is NOT scratching, her skin is NOT red, and there are NOT hives, there are NOT new things, NO allergies.  There is most certainly a sudden onset, wake you up, swollen tounge, and a real possibility of an airway nightmare that we do NOT want to consider.  Her vitals I don’t recall, but were about right for an 80-something woman who woke up, found her tongue so swollen she could not speak, got scared, got a house full of strangers and a (handsome, charming) medic in her grill telling her that it’s all going to be okay, while probably looking at her like the biggest puzzle of the month.  

I get the cot coming fast, and have her put on O2, just cause.  I’m thinking she’s either going to be totally okay, or she’ll suffocate in front of me.  I’m not ready to lay odds at this point either.  I know I need to be thinking allergic reaction protocol, but my inner voice is saying that is NOT what we have going on here.  If it IS an allergic reaction, this sort of airway issue gets Sub-Q epi (epinephrine under her skin), IV Benadryl, and Solu-medrol (a steroid).  Of course, Epi is better known as adrenaline, and does all the things that you are used to thinking of as an adrenaline rush…of course, that is not really good for an 80-something heart patient.  The O2 is just because that is what we do.  I mean, if her airway slams shut, it won’t get to her lungs, but in the event she gets less air, I want it to be all good stuff for her.

We whisk her off to the unit and I get going in the back.  One of the firemen is a pretty solid EMT from elsewhere, and they are all pretty good, so I have two of them hang out in the back with me for a minute.  I’m thinking that if she goes bad, she’s going to go REAL bad, so I want help on hand.  I fumble the first IV attempt..she has little old lady veins…and get the second.  The whole time I’m trying to watch her color, her demeanor, and everything else as I have an internal debate about the right move.  The cookbook part of me says, “you are saying allergic reaction…and there is an airway issue…pump her with meds”.  The wiser (I hope) part of me is saying “hang on now…this doesn’t smell like allergies, and do you really want to hit her with straight epinephrine and give her a chemical stress test to go with the bad tongue?”  By the time I get the line, I see that a bit of time has passed, she is getting more calm, and generally seems to be holding her own.  The voices settle on a compromise.  I give her the IV Benadryl only.  It is called for if an allergy, but if it is not that should just make her thirsty and tired.  (Medic students: ALL Drugs are Poisons, something to remember).  I have the epi out and ready to roll if she crashes, and I really hope I’m making the right call.  That it is not my life on the line with this one is not a comfort against the fact that it is entirely my call.

I get the med into the line and tell the Fire guys I got it from here.  She’s holding her own, and I’m thinking that if anything I should start seeing something soon.  Her vitals stay good, and she is breathing well.  I have Wayne haul freight, just in case, and I give my call to the ER.  I try to convey everything, and offer that I really am not positive on the allergy thing, and am really thinking it is something else.  They are cool with the treatments and patient status and I go back to watching.

Her tongue swelling does go down ever so slightly, and she starts to be able to talk some.  It is hard to understand, but it is an improvement.  That’s when the little cut to her tongue starts to bleed more.  It seems that she was so swollen, she was holding pressure on the wound with the tooth that cut it.  I say again, Ouch.

We get to the ER, and wheel her to a room.  The nurse is over quickly to get an idea of what’s up.  I give her report, tell her about the Benadryl, and the epi debate.  She’s someone I know pretty well there, and is cool with the line of thought.  I tell her that there is some improvement, and the patient says, “Doming Bemmer” which is swollen tongue for “doing better”.  Looking at her meds, she says, “Hey, this is an ACE-inhibitor”…referring to one of the cardiac/hypertension Meds.  (looking back I think it was Lisniopril, not that it matters).  “Yeah…” I say, wondering the significance.  The nurse has clearly had an Ah-ha moment.  She tells me that ACE inhibitors sometimes, rarely, have a side effect of sudden angioedema, even after years of use…Cool.  Well, for me, not her.  

I go back and write this one up carefully.  As I’m dropping off the report and such, I ask, “Hey, what’s the treatment?”  “Take her off the ACE inhibitors” I get back.  Gee thanks I think and chalk another one up to learning.  Interestingly, I have talked to several medics since then about this call and am zero for all of them in terms of anyone getting this one nailed before I tell them.  Good to know, and now we are all smarter.

Follow up:  This lady did fine and was released.  She is on a new hypertension med now of course.  Also, I looked into the right treatment online.  I’ll pass on the link, (I know it’s not exactly a text book, but it IS peer reviewed by definition) for others to see.  Turns out the ACE inhibitor is mentioned at the top, and had her airway slammed shut, the epi is the critical treatment.  Treatment generally is Epi and Antihistamines (Benadryl), so hitting her with everything would have been appropriate too.  I’m good with having done the ‘safer’ med (less likely to tax a risky heart) and standing by with, and planning to rapidly use, the epi at the FIRST sign that she was further losing her airway, but it was still a potentially risky move.  That’s the way it goes.  I can debate a decision either way, the point being to know enough to know that there are issues either way.  In the end, she’s better, I’m smarter, and now so are you.  That’s a good call, and a very good outcome.

A moment of your time

I know this post is coming right on the heels of my last, but I’d be sorely remiss if I didn’t address this too.  There is a story I just put up below, but I would like to interrupt myself, and ask for a moment of your time.

As you all can probably tell from reading here, one of the biggest enemies our patients have is time.  Speed is important, and so is the best care possible.  One of our biggest weapons, and allies, is the use of a strong group of local med-evac crews in the area.  These people are heroes every day.  They get the worst of our worst, and do amazing things enroute; all the while speeding our patients to the right resources as quickly as possible.  They are a true lifeline for us, and our patients.  They are our brothers and sisters.  

Tuesday, in the Washington area, one of these flights crashed while making a routine transport of a very critically ill patient.  Onboard, as the flight medic, was a good friend who ran with us a few years back.  He was the Rescue Captain, just two or so before me.  He has also been a big influence in why I love having newer people on my unit.  When I was a new, curious EMT, he was a new, and rising medic.  He lived at the firehouse and was studying for his medic classes.  He would be up late and still take time to explain the real reason things happened with our patients.  He taught me a lot of the first ALS things I ever knew, and made me really see how important it was to take time with new EMTs to teach and share whatever we can.

The crash is still being investigated, and I only know stories 3rd and 4th hand, but from all accounts the pilot did amazing things to avoid killing a lot of people on the ground and in the hospital.  The patient did not make it, but the crew did, though they were all seriously injured.

He is doing very well for someone who fell a couple hundred feet out of the sky, and I am hoping to visit him soon.  He and the rest of his crew continue to recover, and while he has several fractured ribs, vertebrae and a cracked sternum, he is expected to recover fully.  I ask you to keep all of them, as well as the family of the patient they were trying so hard to help, in your thoughts and prayers.  

I know several of you who read here know this crew.  I will gladly pass any comments, thoughts or wishes you may have along.

At least the beast had a name

Thanks again for all of the comments on the last couple of posts.  Always nice to hear what people are thinking.  I don’t think I’ll do too many more posts of that direct chronological style; it seems too much like a lot of other things out there.  It did convey a sense of a busy day though.  This call came out the next week, early in the shift, and kinda goes to show the sometimes limited scope of what we can do.  It also shows that sometimes the only chance someone has comes from a good assessment and diagnosis in the field.

The shift after the one from the last post, Wayne and I started out right where we had left off.  Cat and Tess were both working, so they were not going to be joining us.  There was a new EMT who needed to run with a medic for her lead training, and Justin, a medic from way-back who was looking to get some time on a unit for re-familiarization after a couple years on the fire side who were going to join us later in the night, but were not in yet.  We did have a young EMT, Hannah, with us who hopped on for a bit, but had never joined us before.  We had just finished checking the bags and the unit when we were punched for an allergic reaction.  It was pretty straight forward, and we were heading out of the hospital, and out for a bite to eat when we get hit for an altered level of consciousness not far from the firehouse.  “We aren’t gonna do this ‘respond from the hospital parking lot’ crap all night are we?” I ask Wayne.  He gives me a smile, gives me a comment like “Just another night at 12” and hits the lights and sirens.  

Now, lest it be said that I only comment on others, I have to confess here:  we were responding without a working MDT, and when I checked the address on my pager, I misread the house number on the address and promptly guided Wayne to a house up the street from the intended one.  As we are hopping out of the unit, the house seems a bit empty.  Hannah looks out from the side door, and asks about the house number.  Checking my pager again, I start to climb back in…oops.  Wayne hadn’t even made it out all the way, and we quickly flip around and head up the street.  I chuckle and look over at Wayne, “Well, haven’t done THAT one in a few years…look how fast we get spoiled by technology”.  Wayne gets us to the RIGHT house and we are in just behind the engine.  Okay, we lost some time, but only a min or two, and considering we started the response already on the road and not at dinner or on the sofa at the station, it’s a push.  And, it’s a good tweak to the ego…those are good from time to time too.

We roll into the house and there are several family members around.  They are all kinda stunned, and they don’t respond when I ask where the patient is.  I start to head downstairs when I am called upstairs by a fireman.  Of course.  We head down the hall to the bedroom at the end, and into the master bathroom.  (The patient is always upstairs, always down the hall, and if at all possible…in the bathroom.  Man, was I having a rookie moment.)  I head into the bathroom, and I’m being told that she was on the throne when she ‘passed out’.  The possibility of her vagaling herself crosses my mind.  Until I see the patient.  Rick, our fire captain is standing in front of the patient, and holding her up in a seated position on the toilet.  She is pale, sweaty, and out.  On the scale from good to bad, she is on BAD.  In point of fact, my first direct assessment is to stick two fingers onto her carotid.  (That’s not where you want to have to start all your calls).

The good news is that she had a pulse, and it even seemed to be regular at that.  Okay, that is something.  I hear that she had been vomiting and had diarrhea before we arrived, and she was talking some to the engine when they first got there.  “wow, she gorked fast” I am thinking as the Capt asks if I want to have her pulled to the floor.  She’s not a code (yet), so I don’t really want to lay her out in a tight little bathroom, on the floor.  I have him keep holding her up and I call back to Wayne.  “Stair chair here, cot to the door”  The guys are off in a flash.  (I’m not sure why I made the call for the chair instead of the reeves…maybe she was sitting and unconscious, anyway, worked out in the end, just odd).  I start pulling out the leads to the lifepack.  I don’t usually do a whole on in the house, but I know I’m going to have a min or two while they get the stuff and I really want to know what is whipping my patient so fast.  

I’m asking questions as I work, and what I gather is that she was fine earlier today, in fact was up eating pizza and making cookies about 45 min ago.  (wow, something took her fast….what can do that?  I start thinking.  It’s a short list medically.)  When you hear hoofbeats, think horses they teach us in EMS.  Okay, I’m thinking I gotta rule out diabetic, low sugar issues, reactions to or between medicines, overdoses and such, low blood pressure for whatever reason, and hear arrhythmias.  She has no real medical history, is not on any major chronic medications, no allergies.  She’s not a diabetic.  (Strike sugar..or move it lower in the list, very low sugar will gork anyone, just more likely in a diabetic.)  She wasn’t on one med recently, but an innocuous one, and she took it regularly.  I can’t even remember which one now.  So, it was not an OD or underdose, or reaction most likely.  I’m still concerned about arrhythmia and I’m getting her wired as fast as I can to have a look.  (hell, I’d do that on anyone I had to check for a pulse on.)  

The monitor is showing a regular rhythm, and it looks sinus on the screen.  I hit a quick print and leave it hanging on the monitor for the record.  I’m still worried this is going to end in chest compressions, and I intend to track everything we see.  The guys are back with the stair chair..and they have it draped in a sheet.  That’s a good touch, since she seemed to be mid-poo.  We are getting ready to lift her, when she partially comes-to and tells us she has to potty.  We tell her that yeah, that is where we found her, when we hear her actively having diarrhea.  (Okay, here’s a dilemma...on the one hand, she may be dying, on the other she has the squirts…to move or not to move, this is my question.)  Okay, so we hang on a beat and let her get that out of her system.  I also make sure we are gloved up.  I notice that she had vomited into a trash can nearby…yup, she’d been eating pizza too.  Nice.  She seems to be done, gorks back out and we move her to the chair.  I try to keep her covered, for dignities sake, and we are moving.  

Now, a brief aside, I don’t really like the idea of taking someone right from the toilet to a cot and hospital without a clean up, but a) she needs to move, and b) I don’t wipe butts.  That is why I’m a Medic and not a nurse.  God Bless them, I love them, they work hard and are under appreciated…and they wipe butts.  I work in the A-B-C area of emergency medicine.  Airway-Breathing-Circulation.  Wiping butts is WAY down at W…and that comes after H, for Hospital.  Cat has wiped a butt on a call a couple times I believe, but she is a better person than I.  She will probably get a better house in heaven than I will.  I have stuck my face down into a dead, puking patient to intubate them, I’ve had a dead baby puke at me while I did mouth to mouth, I’ve been spit on, peed on, and God Knows bleed on, but I don’t wipe butts.  Grin, that seems to be the limit of my goodness.  Here endth that sermon.

We are moving her through the house and I start thinking stroke.  It is on the short list of things that can beat the crap out of you that bad, that fast, and it just “feels” right.  I have not technically ruled out a massive heart attack either, but she didn’t mention chest pain to her family before she went to the bathroom, the engine crew before I got there, or me while she was briefly talking.  Again, not conclusive, but it didn’t “feel” right.  I took a quick look right at her, and I didn’t see a facial droop, but that didn’t mean much.  As we get her from the chair to the cot, she wakes up again.  I ask her to smile for me and she does weakly.  I don’t see a droop, but it wasn’t very big.  I ask her to show teeth and she looks at me funny.  Hmmm, could still be AMI….”Do you hurt anywhere?”  “Yeah, my head…” (BINGO!  I do a little happy dance in my head….I’m feeling much better about that stroke thought now.)  “is it bad?”, “yeah”,  “really bad…like worst ever?”  “yeah, my head is BURNing!” And…gork.  G’night dear.

Okay, so I’m feeling pretty good that I at least know what I’m fighting…I can’t fix it, but damn, knowing what’s up is the only win you get sometimes.  When she gets loaded into the unit, she wakes again briefly.  I ask her to squeeze my fingers…her grip is weak, but equal.  I ask her to say a phrase for me, “You can’t teach an old dog new tricks”, but she gorks out again before she says it.  (An uneven grip and slurred speech are classic stroke signs, but she is not showing them.)  So, I gotta make the decision official.  I can’t totally rule out a number of things, but stroke feels right, fits what I’m seeing, and is the field diagnosis I settle on.  

I get an IV in, (She has great veins, but even still I manage to mess up the first attempt.  I had not advanced enough on my first move and when I try to advance it, I go through the other side of the vein…damn.  I pull that line and a little spirt of blood comes out with it.  I see that impresses Hannah…and pisses me off.  The second attempt is fast, and much better….rookie day continues) double check the monitor and other vitals and I have story for the ER.  I tell Wayne to respond to the hospital and get there quick.  I call the ER and one of the better nurses answers (it’s V from the previous posts).  “Whatcha got?” She asks after I tell her who I am.  “I got a code stroke for ya.”  (well, it’s official now….that phrase starts a series of actions on her end, and I can almost hear her waving behind her to get things started even as I go on to read off vitals, interventions and status)  “…I’m about 4 min out” I finish and we are off.  

On the way, I’m double checking everything.  She is still in and out, but now when she is with us her first and last words are about the headache.  I manage to get that it is up front, it burns, and is spreading into her face.  She has not had surgery anytime recently (A question that affects what can be done to treat the stroke later). She feeling nauseous, and Hannah is stuck holding a bucket under her face because she is generally in and out, and can hold it herself.  She does not leave Hannah hanging, and fills the bucket some too.  Not a nice job, but it has to be done.   The patient starts throwing PAC’s on the monitor (the top of her heart occasionally beats too soon).  It is no big deal, but I’m noticing that they are happening a bit more frequently…not enough to cause a problem, but enough to tell me that the heart is getting pissed about something.  

We get into the ER, and they are ready for us.  A pair of RNs meet us by the door and we are into one of the “big rooms” quick.  I repeat the report, and tell them that she is really stressing the headache now.  I warn them about the fact that we got her off the toilet too.  They have a lot to do, and get after it fast.  I make my way out and go off to write report.  

I’m feeling pretty good that we got things moving fast for her.  With strokes, like heart attacks, time is very important.  I got the hospital thinking that way before I got there, and they were wasting no time at all.  I’m still a little concerned that it could be something else, and I have started the code stroke protocols needlessly, but I’m pretty sure.  I tell Wayne and Hannah “nice job” and get to writing.

The unit is cleaned, the report written, and I go to drop it off at the nurses station.  I hear them calling the ER doc to radiology.  (It has been only about 15-20 min since we got there).  “Is that for my patient?”…turns out it is.  I figure that is bad news.  They can tell the doc all is well over the phone.  I’m not out of the ER when I hear that she has an obvious, and large bleed in her frontal lobe.  She’s having a massive hemorrhagic stroke.  

This is very bad for the patient.  Of the two major types of strokes, ischemic and hemorrhagic, this is the bad choice.  Hemorrhagic strokes are something like 5-10 times as likely to kill you as the other, and she has a big one.  I walk out to the unit where Wayne is talking on the cell phone to his lady, and I notice the helipad lights come on….they are going to fly our patient.  “Hey, is that for ours?” Wayne asks.  I tell him yes, and explain to him and Hannah what has happened.  I feel bad that her prognosis is so bad, but feel really good that we were able to recognize things and get her as early as possible.  We can’t fix that stroke in the field, but seeing it and naming it without classic signs was a good pull.

As always, I don’t know what happened to the patient.  Wish I did, but it really didn’t look very good.  I’ve learned that as much as we like to be the ones to fix the problem, sometimes all we can do is our little part.  Sometimes it is enough, sometimes it is not.  Either way, we do our portion, and that is all we can control.  In this case, recognition, some specific history, and fast action by the ER were all that we could get done on our end.  Maybe I’ll find out later if it worked.  

The rest of the night was very quiet….breaking our streak for a bit.  I don’t know if it was Tess or Justin that played the role of our “white cloud”.  Either way, they are welcome to hang out more often.