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.