Catch and Release EMS

The time has finally come.  The long-awaited cruise with the family is only about 29 hrs away and we are all set.  The timing could not be better and I’m looking forward to warm sands and cold drinks.  Before I go, I wanted to get up a new post and check in with everyone.  

The past couple weeks have continued to be busy and I think it must be everybody.  The station renovation is almost done and can’t come soon enough.  Living in the trailers is really not that bad, but I think the prolonged time in the tight accommodations is starting to take a toll on the people here.  I’ve had to help deal with a number of cases of smart people doing silly things in the past month or so, some serious, some not, but taken as a whole, enough to be a little tiring over time.  Others are feeling some of it too.  That said, life and EMS have ways of righting your compass and keeping things in perspective.  In the past week(ish) I have been able to really help make the critical turn in two different patients on two different days.  Nothing amazing (Yes, I WILL post the big auto accident and extrication from a few weeks back eventually, but not this morning.).  Nothing that any of the people don’t do time and time again, but that’s the whole point.

Wayne and I were alone the first night.  Cat was working her career job, Tess’s son was on his last day home before deploying to Iraq, and another medic that was going to come ride for time had to back out last minute due to work.  We caught a couple of minor runs and were basically just having an easy, hot and humid, mid-summer shift.  The radio played loud between calls and I was just enjoying a nice smooth shift.  The call came out to our second due north for a 20 year old male having a “massive asthma attack”, history of same, at a bowling alley.  Additional was that he had forgotten his rescue inhaler and was having problems.  Sounds like a good run right from the start.  

Asthmatics, when they call 911, are often in pretty bad shape.  As a disease, it is mostly controllable on their own, so by the time they call for us, they have already tried most of the things that work for them and are in some serious trouble.  That a patient would call it a “massive attack”, be without meds, and coming from a smoky bowling alley on a humid night all told me that there were a lot of factors working against this guy.

I tell Wayne what I’m thinking as we rush up the road.  He’s with me on this line of thought and is working through traffic like he has somewhere to be.  I’m thinking of the number of things I may want to get done and briefly think that I’d like to have one more set of ALS hands to attack on several fronts if needed.  I know the guy is going to need a neb, we use albuterol first out, and possibly the solu-medrol (A steroid, methylprednisone).  Of course, one needs a neb set up, the other is IV or a deep muscle injection.  Not that big a deal, but if he is real bad, I’d like to be able to do both at once.  I hit Cat up on the Nextel to confirm that a shoulder should be deep enough for that med, and not just a thigh etc.  She hears the sirens in the background and confirms briefly that yeah, she does that all the time, and call her when I’m done.  (I’m a big fan of double checking things, even things you know, before you get yourself in a decision-making posture.  The response is a great time to double check a protocol or get a quick opinion.  This way, if things are bad when you get there, you know that you know that you know and you can focus, move aggressively and get the job done.)

We arrive at the bowling alley and I find the patient with the engine crew.  They have him on oxygen, but he doesn’t look great.  The guy is about 20, about 6 foot, 280 or so, a big guy, and while he is standing, he is sweaty, poorly colored and clutching the oxygen mask like he’s alone in the ocean clinging to a life-raft.  We get him into the back of the unit and I ask him a few short questions.  He answers them all basically as expected and confirms that this is like his other asthma attacks, only worse.  He is talking in partial sentences, only about 4-5 words between breaths.  I hear wheezes on both sides, but not real loud.  “Is your wheezing getting louder or softer?” I ask, and get  a slightly confused look.  “Could you hear your wheezing more before we got here?” this time I get a nod.  Damn. I’m thinking he is just starting to really clamp down.  In bad attacks, first they wheeze and it gets really loud, but when things are really starting to go over the edge for the worse, they get quiet.  It is NOT a good sign when wheezing stops sometimes.  We are near that edge and things are going to be decided in the next couple minutes.

We move him to our onboard O2 and Wayne helps me get out the nebulizer and the drug box.  I set up the neb and the patient is waiting for it.  “You know what to do here, right?” I ask.  He nods vigorously and starts inhaling deeply and trying to hold in the vapors.  Excellent.  We set up for better vitals and I move over to start a line.  I’ve decided that he is in a fair bit of distress, but since he has had NOTHING to try to fix this with, I’m hoping the neb will work for him.  Basically, I think, if he had not forgotten his puffer, he’d be good, so lets start there.   It will take a min or two to get the IV going.  In that time he’ll either get worse or he won’t.  If he does, then I’ll be all set to bring out the bigger meds, if not, then we are head of the beast and things will be looking good.  He has huge veins, much like my own, and I get a quick line going in his left hand.  He’s a good guy, and kinda embarrassed by having to call us.  He is a little chatty and I keep him engaged in conversation between pulls on the neb.  I’m using his ability to talk as a measure of how things are going.  

I’m pleased to hear him starting to talk in longer sentences and I see his body starting to relax some.  He’s feeling like things are working, and his labor of breathing is improving. It is decision time now.  I am all set to move up the ladder of meds now that the IV is set, but have to see if he needs it.  Often times, the use of the steroids means a longer stay at the hospital for observation, and if he is going to get better, I don’t want to put him through it.  On the other hand, we got to get him better.  He tells me that he is feeling everything open up, and it feels just like when his puffer works.  We’ve turned the corner.  His dad is on the way with his puffer I’m told about the time that dad arrives outside.  I start to pack things up for transport and have Wayne put away the drug box.  As I’m talking about getting going the patient asks if he really HAS to go to the hospital.  (wow, he must be doing better I think)  I see his oxygen level is at 100%, but he’s still getting oxygen, so that makes sense.  I tell him that I can’t force him to go, but that getting checked is always a good idea.  “But I don’t HAVE to?” he asks.  I explain that he does not HAVE to if he is really doing better.  He really doesn’t want to go and we work out a plan.  I take him off the oxygen and agree to watch him for a bit to make sure he’s doing okay.  His dad had been told to start for the hospital, and the patient makes a phone call to have him come back.  I see that he is totally relaxed, his lungs are clear and he’s speaking full sentences.  His O2 levels stay up on room air and all looks good.  A few minutes later, Dad is back, has the rescue inhaler if the patient needs it later and all is still well with his vitals.  I discontinue the IV, have the patient fill out a refusal of care and explain that he can call us back any time if he changes his mind.  He tells me that he never had to call 911 before, but that he’d never been that bad either.  I tell him he did the right thing, shake his hand and Dad’s as well and say goodbyes.  Wayne and I mount up and head back to the hospital to reload on supplies and replace the albuterol I used.  

This guy was only a couple of untreated minutes from having his airway slam shut and he knew it.  It never ceases to amaze me what a fine line between that sort of critically bad condition and a good enough condition to go back to everyday life there really is.  This guy was in a life-threatening state, and we were able to let him go home on his own.  That’s always nice, even if it was an easy, routine, every day type run.  “Catch and release EMS” I joke to Wayne and we share a chuckle as he turns up the radio and the tunes begin again.  Later that night we’d take two people with the flu to the hospital, so everyone that was just sick went to the ER, and the one guy in real trouble went home, figures.

Later that week, while enjoying the department picnic, a call goes out for an allergic reaction to a bee sting just up the road.  The on-duty basic unit is at the park with me and is dispatched with a medic from a second due.  I have my buggy with me and hop in to chase them the half mile up the road to the call.  The other medic hears that I’m going and waves off, so it is just us.  The basic actually has a nurse from the ER doing a ride-along that day.  She asked to get some street time to see what we do, and is going to ride with us in the future.  I’m all for that, and I really hope others will come out and play with us too.  It’s good for us to get some ER rotations in from time to time, and I think getting the nurses into the field will help us to understand the unique issues that we each face.  (Patients don’t appear on cots with IV’s already started in the wild for example).  

The patient is out front of her house on the porch.  She is 81 years old, and was stung on the hand by a bee.  She is allergic to this and the last sting messed her up pretty bad she says.  That was years ago, she tells me.  The EMT on the basic is one of my Lieutenants and I stay back a bit to observe at first.  She looks at the injection site and I see some swelling starting.  The patient says that her throat feels like it is getting tighter and I motion to the driver of the basic, who is also an ER Tech, that it is time to get going.  

In the back of the unit, I’m pretty well set.  I have an ER nurse, an EMT lieutenant who has taken her ALS classes and a driver whose day job is as an ER tech.  Considering that jumping a call with the buggy means that I get a crew at random, this is about as good as it gets.  We get vitals going, set up the ECG monitor and a line is started.  I’ve tossed my drug box keys to the nurse and by the time I look up, she has the benadryl drawn up and ready to go.  An IV is started and in goes the med.  I opt against using the epinephrine because I think we are ahead of things, and I really don’t want to drop a chemical stress test on an 80 year old heart.  (no Xopenex here yet).  I tell the nurse what I’m thinking, and she’s nodding along.  I see that our patient is still very nervous and as we get rolling to the ER, I rub her hand (not the one with the sting) and tell her, “I got you now, we got this licked, it’s all better from here.”  I’m rewarded with a smile and I can see her relaxing.  I warn her that she is going to be tired and thirsty and she understands.

The hospital transfer was enough to spoil a medic.  Scott, the tech and driver, gets her all set up in the room and the nurse goes over and does all the paperwork.  By the time that the patient’s nurse comes to the room everything is done and even the report is just a nod and a smile.  Now THAT is seemless patient care!  Ahh, the little things.  In short order, I’m back at the picnic eating burgers and dogs, and sharing stories with the guys.

Neither of these calls were remarkable for the action involved.  Neither were anything that any of the people reading this haven’t done time and time again themselves.  But they were the type of call where we really get a chance to make a difference for a patient and actually fix a problem ourselves.  It is calls like this that are important to remember after weeks of just hauling minor issues and flu patients to the hospital at 2am.  They are the bread and butter sort that are why we are all out there time and time again.  In a month of bogus administrative issues to deal with, and during a time that just kinda wears on you, these are the types of things that really bring back that perspective you need.  

So, this week I’ll be in the Caribbean, getting plenty of ETOH and Vitamin D, out of reach of cell phone and pager and generally trying to relax away a year of work.  In the back of my mind, I will know that around the world a million kindred spirits will be out there running the calls, and doing the myriad things that aren’t action-packed, aren’t glamorous, but make the difference for the millions of people they encounter in that time.  Cat and I will raise a toast to you all, and will come back with more stories to share in just over a week.

Have fun, Stay safe,
MedicChris