Night Runs

BACK in the Saddle

2008-06-22T20:18:00.001-05:00

So, over 300 days later….

I am finally finding myself in front of a keyboard typing to get started, while my mind races over all the things to say. Many things have changed, and many more are always the same. I'm struggling to balance how to discuss everything that has happened, and still focus on the calls…the real reason I started this almost 2 and a half yrs ago now. But enough pre-prologue.

When last I posted, almost a year ago, I was Rescue Chief of a large department, enjoying my 9^th year of service there. The blogging had suffered from the fact that the position kept me off the street somewhat, and I was NOT about to blog about budget questions and company meeting dramas. I was working on my Master's in System Engineering, and am still doing that today. (This time next yr, it will FINALLY be done!) I had what was by my own, and by others, estimation a very successful year as Chief and was honored to be re-elected to that position for 2008. Unfortunately, due to what I can only characterize as an inexcusable lack of character by the senior leadership above me on a number of critical issues, I found myself unable to stand beside them or see my name alongside theirs in front of the membership or the community. In the early weeks of this year, I made the painful decision to move on to the neighboring department to the south and start running as 'just a medic' again. As a result, I sleep better at night knowing my character is intact, I still get to save lives, and I make a difference in the ways that matter to me. Several others came to the same conclusion, and we have been warmly received by a department that is long on pride, but short on staffing, and we are setting about making the most positive impact we can. The department is smaller, but the calls are the same, and I think we are on a team that is rebounding, and rebuilding. I am as happy as I have been in a while.

Since then, we have run a number of calls of the sort that make Cat and I say, "That one goes in the blog". We started in typical fashion, and while not medically interesting, it is the way we started, and so it is the story I'll share today. We have had a conscious and talking man in V-tach, an 18 month old febrile seizure that wasn't, someone who crawled unharmed out of a car that flipped multiple times and was crushed (did that twice), a lady who "done blowed up", and a lady rapidly filling her lungs up with fluid and the doctor that really let us 'slip the leash' to save her. All in all, it's been great to see the wild ride was waiting for us, as it always has been.

Our first night at the new station came with a lot of anticipation and unknowns. The department was a new one, and here the fire-side is a collocated, but separate department, and we run with a rotation of fire crews, not the same one every night. There was a bit of anticipation from others who knew the group of us from other departments as well, and from the overwhelming number of comments, calls and emails of support, I know that hearing us running again was something that quite a few people were interested in…at least in an "EMS community gossip" way. Cat and I were given a 'new' medic to precept from day one, and we were approaching the night with a strong sense of setting an example, and doing our job professionally. Our preceptee had been a member here for something like 5 years, and had earned her ALS certs about a year prior. She was still precepting due to a lack of ALS personnel, not due to any fault of her own. Hardly a rookie, she had an interesting role in the first few weeks as we learned how to work together. I was the new guy to the department, but every time we ran into another unit on scene or at the hospital, I was greeted with "Hey Chief", and once with "Got a rookie already huh?" I know that created an interesting situation for her, but she handled it very well.

The three of us check out the unit and talked about how we'd get the precepting accomplished, what our schedules were like, running styles etc. All the topics that start to turn a collection of trained individuals into a high-functioning unit. I knew it would take a few months to 'gel', but I knew the sooner we started, the better it would go. I was anxious to get staffed and 'on the books', and was very much ready to make the radio call announcing our return to service…having made the decision to do that over the air, not via the more quiet computer system. (I am a medic, no lack of ego at play here). The weather turned bad fast and a steady rain was falling by the time we had the equipment ready and were good to go. Cat had not driven the model of unit that we now use in quite some time, and rather smartly requested that we drive around a bit so she could get a feel for it before we were off hauling balls to a call in the rain in a new unit. I put Katie, the preceptee, up front with her to show Cat around (it WAS her area for the last 5 yrs after all) and hopped in the back and chomped at the bit to get officially staffed. The rain let up and Cat quickly got her groove with the unit. We resolved to head to Panera to grab sandwiches for dinner, and then staff with food in hand. While not exactly the way we'd normally do things, it did make sense and we were almost there anyway. I'm riding in the back, getting back 'into the groove', thinking that I just want to play my role, stay low key and not try to pull rank on the preceptee much, no waves, just calls, as we come to a stop in the parking lot next to the Panera and Starbucks. I hear Cat set the brakes, and I pop out the side and into my new career.

No sooner do my boots hit the pavement than I hear a woman scream. I whip my head towards the building and see two guys starting to jog along the side of the Starbucks drive-thru yelling "Hey, Hey, You can't do that!" Katie starts to open the door of the unit to get out and I jut my hand out, all but slamming it back on her. "Stay here…give me a radio…something's up". So much for low profile and not pulling rank, I'm already protecting the crew and taking over a call, or situation, or whatever the hell is going on here. I snag a radio, and walk a circular path to get a look at what's going on. There is clearly activity in the drive-thru, but a cinderblock wall surrounding the trash dumpsters are blocking it from my line of sight. I need to get a look at what is up, but know enough to stay back too. As I come clear of the obstacle, I see that there is a woman and a man standing there, the two guys I saw before were workers from Panera on break, and they are standing nearby, telling the guy to leave. He is not acting threateningly, and she is holding her face and walking towards the parking lot we are in, headed for her car as it turns out. This is good, as they are separating. It doesn't look like the two guys from Panera are going to pursue this so all in all, things look like they are settling down…on the other hand, it looks like I've walked smack-dab into a domestic…the most volatile place we ever end up in EMS.

I head back to the unit, and talk to Cat and Katie. They came to the same conclusion from the unit that I did. Katie's day job is with the Communication's Center and she is already calling them on her cell. I walk over to the woman, keeping an eye on the guy, who is walking away, and around the corner of the Starbucks. I'm thinking that if she is hurt, and I can get her into the unit, then at least we can drive off if he returns. As I approach, I see she is holding her eye, but doesn't look obviously injured. She is on the cell phone as I approach, and I can tell from the conversation that she has smartly called 911. I introduce myself as a medic and offer to talk to the dispatcher. She accepts and hands me the phone. Now, I'm not officially staffed, so they have no idea the unit is out and about, or that we'd be there, and the people on the other end of the phone know me as the Chief and Medic from the old department…this promises to be interesting.

"Hello, this is Medic Gardner on M517…yes…yes…I'm on 517…yes, used to be at 12….no, not there now…no, it isn't staffed yet so you won't see it on the CAD (Computer Aided Dispatch computer) yet…" I'm not getting anywhere. The dispatcher is a bit confused, but I really can't catch her up on all that right now. "I'm on the scene of a domestic in progress". THAT got her head cleared…there was a pause and I hear her typing. "We are at [address], and there was a domestic here. Scene appears secure at the moment..you may as well show us staffed for the night and on the scene". So much for staffing over the air, probably better, but still disappointing. She says she has us on scene and is starting PD. I thank her and hang up.

I hand the phone back to the lady, now my patient, and ask her if she is ok. She tells me she was punched in the face. I ask her to come with me to the unit where we can look to make sure everything is okay. She agrees and heads over that way. I hand her over to the ladies for evaluation. I'm figuring a guy just punched her a few times in the face, perhaps she's not looking for another one in her grill right now. There is a bystander that comes by in a truck and says he's seen everything. Asks if he can help. I ask if he's willing to stay put for the police and he says yes. I don't see the guy anymore, but I keep an eye in that direction while the bystander and I chat in the parking lot and wait for police.

PD gets there while Katie and Cat check out the patient. I point to where the guy walked off, and show him the two Panera workers and the bystander. He asks them to hold tight and drives off to find the guy. He is not successful, and comes back to interview everyone. I stick my head into the unit and it appears that our patient is fine, does not want to go to the hospital, but will take a cold pack for her eye. They are doing the refusal paperwork and everything is calm. It turns out that the guy's car is parked next to the patient's and they live together. She has another place to go for the night, and he works at a spa right in this area. He lives within walking distance and is probably there. The police are all over it, and the patient is good to go. We wrap up our first call as quickly as we walk into it.

Cat and I share a look and the comment that, "Well, it wasn't the station we were at, must be us" that attracts these calls. I grin ear-to-ear, looking forward to a second career, and she just rolls her eyes. She isn't as stoked as I am, but she's clearly amused that I'm excited. We head into Panera for some sandwiches, and start joking with Katie. The county lets us eat in peace. And things began to feel comfortable. We left Panera, a full belly, and our first call under our belts and head back for the station. Almost made it too…

Good to be back on the blog, the rest of that night next time!

-Chris

One more Sunrise

2007-07-16T20:45:00.001-05:00

Okay, so another month slipped by me yet again. Part of me thinks that it is just because of everything going on at the Firehouse etc, and that is at least partially true. We got through our inspection (two years of reports re-entered), handled our semi-annual big standby and somehow two more people got turned over as leads. Hell, we even got ourselves someone through the National Registry process as an EMT-I. There is a general up-tick in morale for the first time in a while among the EMS providers and it is actually starting to spread. I'm starting to dare to think that this 'thing' may work. The 'thing' is the general remake of the way we get things done, and working on the little things to help make the Firehouse the place we know it can be. I know, sounds cheesy, but there it is.

I know that all of these things would be reasons to blog more not less, yet here I am months from a posting. I promised a while back, both here and in person to some people to post why I really run. In light of the things going on right now, it is more 'why I kept running'. See, almost every EMS provider I know, certainly every Medic seems to go through this period. Call it burn-out, worn-down whatever. The truth of it is that we start to struggle between wanting to go in to duty because of the things we love, and wanting to stay home. It becomes a job, a weight, whatever. A friend of mine is still in that right now, others are coming out of it. It is almost impossible to explain how you can love running the calls, meeting the people, being with the crew, and still dread the next call, the next night of broken sleep, the next BS run that you know you need to care about, but somewhere inside you really don't, maybe it is the needless politics surrounding the one thing in our lives that is clearly 'a good thing'. I've been there, seems everyone gets there. It's different for everyone, and it comes at a different point for everyone, but on average, I'd say "Show me a Medic with 5 years on, and I'll show you someone who knows what I'm talking about."

So, why stay. Everyone has their own reasons, but when confronted with it, as a friend recently put it: "I love this….I'm afraid if I leave I won't come back". That works. It is possible to wonder if the love of it is enough. Been there, asked that. This post is about my answer to the question, and why I stayed. I'm glad I did now, but at the time, this is what drove me. I have had this post in me since I started this blog well over a year ago, and it is the one I have hesitated to post, the one I don't know how you will take. This is my post, and what's in it I have only told a very few. Hell, Cat was married to me before she knew the whole thing. I don't tell people as a rule, and I don't push the ramifications on it on anyone. This story is mine and nobody else's, take it or leave it, it's mine all the same. But, it is time (even if I don't know why it is time now). If only because I seem to be up against a world-class writer's block and every time I start to post, and this is the one that sticks in my mind. Maybe it's my calling….

I was in college and EMS had never entered my mind. My whole life was laid out in my mind though. I was majoring in Astrophysics and engaged. I was going to graduate, get a job saving the world by killing ballistic missiles and get married to what I thought was the person I was meant to be with. The world was very black and white to me. Apparently, that wasn't to be. My fiancée left me for a fireman in the town surrounding her college, and everything I was so sure of crumbled. I dropped into a deep, and clinical depression. I missed classes, slept all day and generally was miserable. My grades slipped, my health declined, my friends didn't really want to be around me, and I didn't blame them. In truth, it got the better of me. Weeks went by, and nothing seemed right. So, one night I took a lot of pills. I won't say of what here as now that I'm a Medic it seems silly, but at the time I wasn't so sure. In fact, that was kinda the point. I felt pretty sure that what I took could kill me, but I wasn't sure. I took the pills etc, and went to bed. The 'plan' such that it was, was to go to sleep and possibly not wake up. Did I really want to die? Now, I dunno. Like I said, I wasn't sure if I would or not. I did think about family and friends dealing with it, but really, at that time, the foundation of what I believed was shattered, and I just didn't have the reserve to count on them. I just wanted to stop hurting.

So, I climb into my bunk, and lay down. And I prayed. I didn't pray to live, or to die really. I had stopped praying to 'fix' the relationship a while before. I prayed that I didn't know what the point was, and if there wasn't one, that God would forgive me for being weak, and giving up, and accept me broken as I was. Being raised Catholic, suicide has some serious implications. I don't know everything I said in that prayer but I do remember one part. I didn't know if I'd make it or not, but I said, "God, if there is some plan, some purpose to my life, some reason I should stay here, then let me see the sun rise. If not, then let me end it here."

Well, I cried for a bit, and called to say goodbye to my Ex. A literal call for help a shrink may say, but I swear that I had no intention of letting on what I had done. In fact, I don't fully recall the conversation. She clued in to something in the end, I think she once said that I said goodbye instead of good night and it stuck to her. Anyway, she would not hang up and pressed for what was going on. Eventually I told her, though not everything. She was hanging up and coming over. I hated that she thought that that is what I wanted, but then, looking back I resented that she never showed either. She called my parents (Narc…grin) and they called another girl I knew from High School who was at my University with me. She came over right away, just to sit and to talk. My folks were on the road, 2 hours away. It took a lot longer than that, they had to stop and compose themselves several times I heard later. Sherri, the friend, stayed up basically all night with me. Just talking, and not much about that night even. Eventually, my folks got there. I don't remember it really. I guess I grabbed some things and Sherri said she'd talk to my roomies, and I was headed home. (I had made myself vomit out whatever I could)

It's two hours home, and I don't think much was said, I can't remember now. In fact, I don't remember much of the surrounding days to be truthful, but I do remember this. I was staring at the back of the car seat heading home. In my own world, just in a daze, and something had me turn my head. The night was over, and the sun was rising. The sky was a classic, orange/pink/blue combo with wisps of clouds like a painting, and not thirty seconds after I turned my head, the top edge of the sun broke over the horizon. I knew then that I had made the deal, and I'd have to keep it.

That day, or the next I was evaluated by a psychologist, and incidentally, when in that situation and the doc asks, "Are you on any medications?" the proper response is apparently NOT, "Well….I've been known to take [insert OD med here]" No matter how much you have to stifle the laugh, and even if your mom chuckles, it is NOT funny. Even if it was the first sign that others saw that you were nose up and climbing again. I was in therapy for a few months and learned to feel not just observe life. Funny lesson that and I'm not explaining it here. Trust me when I tell you that I FEEL life as I live it now, and I think those who know me know what I mean. Therapy was a good thing and eventually I was cut loose. (See, this IS me well adjusted!) But the whole time, I knew that it was just a matter of 'getting better', that there was no going back. I mean, I made a deal with a God I wasn't even sure was there, and it was met with a literal verbatim response. I didn't pray "let me live…" or "let me wake up…" or whatever, I said, "Let me see the Sun rise." I never imagined that it would happen that literally. SO, while I think I only mentioned it once during the sessions, and as I recall it was kinda dismissed, I knew then that I was going to have some purpose, some time, some where.

Now, does that mean that when I started EMS I had this big "AHA" moment and said "this is it?" No. Even I'm not that sappy. But I do get the feeling that it is something I'm SUPPOSED to do, even if I only ever express it as "It's called Duty, not 'wanna be there?'. I do feel that it is a purpose, even if I don't get to know if it is THE purpose I saw the Sun rise. Deep down, in the place I don't share because I'm not here to push any belief on anyone, and I'm not out converting people, (hell I'm nobody's saint), I see it like this: I made a deal that night and I gave up my ownership of my life…maybe by saving a few I get the grace I need for giving mine up. I don't get to ask anymore, but then I don't need to, I've already been answered. And that's why I kept showing up. I still feel that sense that this is where I need to be, even if now I get to feel pride just in helping other folks get what they need to do the job night after night. When/if that feeling stops, then maybe I will stop too, maybe not.

In the mean time it is enough to give a few people every year one more sunrise.

I'm Alive

2007-06-14T21:53:00.001-05:00

Yes, I'm alive, and yes, I will continue/restart this blog. I'm not really sure why I haven't posted in so long, but about the middle of March I was told that my department had to re-type and submit every call record for the last two years to get the demographic data to the state...and it had to be done by 21 June. Well, it's all but done, and here I am again....coincidence?

This thing is still pretty important to me, so I'll get more here soon. If you have stuck around this long, thanks. What Can I say, I'm the Soprano's of the blogging world. But I promise not to end a blog mid

Shock me all you want, but save my shirt!

2007-03-14T13:31:00.000-05:00

So the pace of my life has not let up at all, and just when I think it will settle out, the next challenge arises. I’d be lying if I said I didn’t love it, but I know the cup runneth over at this point and I find myself only able to stress a couple areas at a time, then leaving those areas alone for a while so I can go address another. Nothing new to many of you I know, but I fear I have left this blog for too long, and I am so happy to be back in front of a keyboard doing something other than emails, homework, or mindless arcade games to unstress. The weather has broken (for now), and it is in the 70’s here by day, and upper 50s at night. Everyone is coming out of their winter shells and it is good to see. I swear I have SAD and the boost that comes from the sunshine and warm weather is one I very much needed.

Last night the bay doors of the firehouse were open, a breeze passing through the firebay, and the old hands were at the bay table laughing and telling stories again. The stories were mostly of the youthful behavior of folks that are moved on, or life members. Some things never change, and kids in the firehouse are always that. No matter how old they get. I just sat by and listened and swore again that I’d get a blog out. The stories they told are theirs, not mine and I couldn’t do them justice here, but there is a run I have been meaning to post for some time, and now I finally will.

It was the tail end of last year, Cat was “riding the seat”, with Jenn driving. This was during the time that we knew they’d be together this year and so they were acclimating to each other ahead of time. Michelle was with us as a preceptee as well. We got punched for a chest pain call on the interstate in the late afternoon. I climb in the back and generally try to be there, but out of the way for this run. The response doesn’t take long and we pull up in front of a silver sedan on the side of the highway. The engine from one of our other stations is already there, and they have begun an assessment. The girls pile out to see what is happening, and hang back in the back of the unit to get ready for them. We normally have an IV line pre-hung in the back, but didn’t for some reason, so I was going to loiter back and get that set up for them when they arrived.

The back doors pop open as Michelle climbs out, and I sneak a peek out to the patient. He’s a fairly athletic guy in the early-40’s sort of way. Good shape, but not extraordinary, hair just starting to gray. I see out the unit, and through the windshield of the car that he is sweating badly, is pale and is clutching his chest. “OH, THAT sort of chest pain call”. Now, all chest pain calls are serious until proven to be muscle pulls, panic attacks etc, but there are the no-kidding, I’m having the BIG one and I’m doing it RIGHT NOW calls for ‘chest pain’ too. I know Cat had already run a ‘chest pain’ on the highway that turned into a code while she was on scene once this year and I’m not looking to repeat the performance. Though, just looking at the dude I have to admit I figured it was possible. I shift gears from “loitering” to “prepping” in the back and quickly have a line hung and the life pack set to go. I see that Cat and Michelle have come to the same conclusions as nobody is messing around out there. The guy is quickly loaded onto a cot, given O2 and is inbound to the unit as I’m heading to open the locker for the drug box.

The closer this guy gets, the worse he looks to me and I’m not really liking it. “Sure hope you got veins, man” I’m thinking as he is lifted into the back. “Lifepack is ready for a 12-lead” I’m saying as he is coming in, and Cat and the rest of the crew is piling on in rapid order.

“I’m not having a heart attack” the guy says. “Yeah, and I AM at my ideal weight” I think to myself…wow denial is a powerful thing. “Well, we will find out for sure in just a minute, sir, but I gotta tell ya, you sure look like you may be having one”. I say as I set about my work of getting vitals and generally mentally prepping for an ACS run. “No, No, I have SVT” he says, stopping my mental train dead…even if I do keep moving.

SVT…SupraVentricular Tachycardia. It means that some part of his upper heart goes haywire and keeps sending signals to beat to the rest of the heart. (there is a whole cardiology about automacity in the heart, but I’ll just add links to it here if you want to read about it later). Bottom line is that in SVT your heart beats fast, real fast, like more than 150 times a minute, though I’ve seen people tachy in the 200’s before. That’s bad. Not just because, damn, that’s real fast, but because your heart doesn’t refill with blood between beats, so your pressure drops all to hell (Firemen go ask a pump operator about cavitation, same thing) and your body and brain aren’t oxygenated and you can die. Now, that’s oversimplified, but the main points are valid…heart too fast, you die if it isn’t fixed.

Now, symptoms of bad SVT include: Chest pain, diaphoresis (Sweaty man), shortness of breath, pale color etc…you know, like exactly everything this guy has. The bad news is, that if random-dude off the highway knows how to use “SVT” in a sentence, he likely has it. Good news is, I can verify it with a 2-fingered ECG. So, as I’m pushing the BP cuff to start, I lay on the two fingers to his radial artery and hot-damn, he’s thundering right along. So there is that.

About this time the ECG is showing the same thing. My boy has SVT, with a pulse and heart rate about 180s as I recall. He’s obviously having increasing shortness of breath and is generally looking BAD. Now I’m on both ends of a related thought, “Sure hope this guy doesn’t die” and “WooHoo, I’m gonna stop this man’s heart”. I’ll explain later on here. As we get an IV established, we ask him about his history of SVT. Turns out that he hasn’t had an episode of it in 2 years, since a heart ablation surgery to stop it. No problem there. He was playing basketball when it started…that explains the sweats and tee-shirt and makes sense. Then he starts into telling us how hard it used to be to stop the SVT once it started. “Now don’t starting with the negative vibes” I think. I tell him to bear down like he’s taking a poo, but DON’T actually poo (Learned that last part the hard way on an 80 yr old once…GOTTA tell them not to actually crap their pants!) “I’ve already done all the vagal stuff” he says. Okay, so he knows what he has.

Cat is drawing up the adenosine now and I start to explain to him that we are going to give him a medication to fix his heart rate. (Truth is, it stops the heart completely for a few seconds, then hopefully the heart re-starts, and hopefully, it goes into a good rhythm after that…hence my thoughts above). I’m telling him that he is going to feel funny, and that it is described as a rushing or pressing down feeling. He knows the drug, and tells me that it usually doesn’t work for him. Great.

Cat is ready to go, and we have a good IV, up in his bicept with a nice big catheter. We have a saline flush hooked into a second port on the line and we are all set. (The drug only lasts a few seconds in the body…thank god, did I mention it stops your heart? And so you have to get it in close to the heart and as fast as you can before it degrades). I push in the Adenosine, Cat slams in the saline behind it to flush it into his body and we have the ECG print a strip for all the promised coolness of his heart stopping and restarting and us saving the day. After the better part of a minute passes, and ECG tracing paper is pooling on the floor of the unit, we realize it is a bust. (looking back we found ONE beat that looked delayed on the strip). Well poo. We start transport in a quick way after this. The hospital is called and we tell them we are going to run this all the way down the line if need be, but he has a history of SVT that just won’t break.

Now our guy starts getting full on negative. He’s still talking, but looking worse and worse. How bad? Bad enough that I’m getting out the combipads to put on him. (The big sticky pads we use to shock you. I can use it for cardioversion, to shock the heart into behaving, or for defibrillation if the heart decides to give up…all in all, it is NEVER a good thing to have a medic put them on you!) He starts talking about how the last time he did this, the ER ‘screwed up’ when they shocked him and his heart stopped and he coded and they almost didn’t get him back, and it has caused all sorts of other problems, and they were incompetent etc etc. “Great, why not be a litigious ass on top of everything else?” I start to think. Cat and I share a brief look as he describes what sounds like a textbook cardioversion attempt that just didn’t work out good. (Side note: I put cardioversion into Google while writing this and the first Sponsored link up top was for a lawfirm under the title “Failed Cardioversion?”…sigh) This is concerning to us as we are about to embark down exactly that path if he doesn’t improve but soon. He briefly closes his eyes getting a “SIR!?” from me. He pops right up and responds. “Okay, here’s the deal, I don’t want to shock you, or jam a tube in your throat, but if you pass out, I promise I will do both and sleep fine after.” I tell him. He says that is a good deal, and promises to stay conscious for me. Michelle is looking to cut off his shirt to put on the pads, but he really adamant that we don’t do that. It is his new basketball team tee shirt yadda-yadda. She gives him a quick shave of the chest and on go the pads. The shirt remains but is pulled up. This whole time, Cat is drawing up a second round of Adenosine, double the amount from the first time (6,12,12 for you medic-folks), and I’m talking to him. He’s starting to give me things to tell his wife….NOT good and I’m generally just planning to have to electrocardiovert him (Shock him) and/or code him. By protocol, I could have blasted him right out of the chute, as he was clearly ‘unstable’, but the first pop of adenosine was preferred since he was still pretty much ‘with it’ and we just now got the pad to shock him with in place.

Cat is about ready to go for round two, and I’m double checking a pressure to see if I don’t just make a liar of myself and shock him anyway when Michelle has had enough fighting with the shirt and tells him we are just going to have to cut it off. “No, don’t do that!” he says, then he stops. “Hey….” He says. I notice his color start to pinken and I look at the monitor. He has self-converted…his pulse is now 110 and dropping fast. He takes a deep sigh and doesn’t move for a minute. We all just stare for a second that seemed like forever. At about 85 beats a minute, his heart settles in, and everything is fine. “It’s gone” he says and smiles. His color comes back fast as his pressure rises and his body gets back to normal. It is one of those really cool medic-moments when you realize how cool it is that our bodies work at all, and how resilient we are as humans. (Okay, what appears to have happened is that he got so stressed about his shirt getting cut that he tightened up…remember the ‘bear down but don’t poo’ thing?...this stimulated his Vagus nerve which results in slowing the heart. Again, overly simple, but true enough. This time though the stress of his shirt being cut worked where the bearing down, a vagal maneuver, did not.)

“I see that, how do you feel” I ask. He tells me he feels tired, but the pain is receding and he feels much better already. We chuckle and tell him it is no wonder that he’s tired, his heart just ran a marathon. We check vitals and reassess everything, and no kidding, we have a healthy 40-something male in the back of our unit now. I have Cat stand by with the adenosine that she drew up…just in case, but all in all, everything is looking great. Besides, we are at the hospital now anyway.

We arrive at the hospital to find the staff waiting outside one of the cardiac rooms in full combat mode. They are standing in that tense-ready position of a crew that knows bad things have just arrived. We come through the doors chuckling about some little comment and get puzzled looks. “All better” we say as we wheel him in. It takes a minute to explain what has happened, but the nurse even chuckles when I explain that Vagal maneuvers, Adenosine, and the threat of electrocardioversion did not stop the rate, but that the threat to cut his shirt did. The doctor actually didn’t believe us at first and thought we must have rubbed his carotid when going to cut the shirt. (Doing that also stimulates the Vagus nerve, but can result in a stroke in some patients, so we don’t do it.) I explain that she was going to cut bottom-up and that the carotid massage wasn’t a possibility. He just chuckles and shrugs as he signs off on the report.

We swing by to swing in to say hi after writing the report, and the guy’s wife is with him. He thanks us and smiles, but again makes some comment about the ‘idiots last time’, which makes us wince for the ER staff. “Yeah, he’s thanking you now, but wait until we have to rip off those pads you put on him!” the nurse says as we leave.

The patient was treated and released a few hours later with a referral to his Cardiologist for followup. He did not lapse back into SVT at any time. So three Medics, an EMT, front line cardiac drugs and thousands of dollars of equipment – Zero, a man’s concern over a $10 tee shirt – one. Whatever, I’m still taking credit on this one too!

Giving back

2007-03-05T21:08:00.000-05:00

Okay, I owe a post. Thank you all to the continued support during this inactive (on here) period. I promise I’m digging out and will be back. In the mean time…I have a request

Every year the St. Baldrick's foundation holds a series of events to raise money for children's cancer research. The Fire department I volunteer at is participating again this year and I have agreed to sign up.

To show support for the kids with cancer, I will be having my head shaved at the event to raise money. This is a great organization, and you are free to check them out on your own.

Please contribute, and if you would like to see me get my head shaved (I'll post pics here) then signup to contribute at:

http://www.stbaldricks.org/participants/shavee_info.html?ShaveeID=10160

I receive none of the money, nor do I want any of it. For those wary of things internet, check out the organization, they do great things for great kids.

Hats off to all of you out there.
Chris

I'm alive

2007-02-13T14:12:00.000-05:00

I’m alive, I swear, and I’ll even be posting soon, this week even. Thanks to all of you who keep checking in, and even more to those who are picking on me in the background to post. It’s been a month and a half, I know, but this is not going dead just yet!!

It would take a miracle

2007-01-01T00:38:00.000-05:00

Oops, so much for getting more blogging done over the holidays.  Things kinda snowballed on me instead of settling down for the year.  First, I was honored to be elected as the Rescue Chief for our department for 2007.  That starts in the first week of the year, but had me busy from the first of December.  Officers and crews had to be selected and assigned to stations and duty nights.  That is always a busy time of negotiations and trades, and then we had a bit of an emergency develop over getting our people updated with the new CPR protocols for the first of the year; that consumed just about every free minute for a couple weeks getting sorted out.  In the mean time, I actually did catch a couple of calls worth talking about and I intend to post them both here…with any luck over the next couple days even.

I’ve been taking it easy for a few days at my uncle’s place in the woods of east-central Tennessee.  A nice place here, enough to make you wish you were retired and living this life but it will have to remain something to work towards for now.  I almost bought the top of a mountain ridge, with views like something out of a postcard. A valley below, and the next range a few miles off in the distance.  Cat had already planned where the garden would go, and we were talking about how to lay out a down payment when we found out it was already sold.  Ah well, turns out there are other mountain tops, and other days coming.

We had duty on a Saturday shortly before Christmas.  I only have a few assigned shifts left before Chief-dom starts, and I’ve been really enjoying the last few days with “My Crew”.  Cat was leading for the shift, Wayne was driving as always, and I was reliving my EMS youth in the rear, with the gear.  We had breakfast with the Engine crew at a local deli place, good food and good company.  Afterwards, we were all standing outside the place chewing the fat while some of the guys had a smoke.  I joked that we looked like some sorry example of a new Fire and Rescue street gang. Someone from a neighboring department had Santa on a firetruck and since our radios were on scan, we could listen to them discussing how much candy to distribute and which streets to take first.  All in all a pretty low stress start to a really pretty day.  We had been back at the station for a little while when the call goes out a couple of dues away for a possible stroke.  The closest engine, from the neighboring department, was sent with us and was certain to get there well ahead of us.

I am, as I said, in the back on the way and generally amusing my self with thoughts of riding as a rookie when I faintly hear the radio up front saying that the patient is unconscious and, oh yeah, CPR instructions are being given.  “Go ahead and add the third piece” I think to myself as the dispatcher announces that they are doing just that.  That means that we will arrive just after two fire engines from a different department on a code in progress.  Sounds like a crap shoot to me.  Cat yells back the news in case I didn’t hear, but I’m already starting to toss bags of supplies onto the cot.

As I mentioned before, the CPR protocols are set to change on the first of the year, and we are all rolling out the training to our people.  Of course that now means that in addition to showing up with two crews of people I don’t likely know, we also will have people of a mixed training background.  None of this is anything negative, just natural conditions of the state of transition.  I suggest to Cat that we assume nobody has the new information and run the ‘old’ rules, which are after all, still in effect.

It takes several minutes to get to the scene, pretty much in the center of our 4th due or so, and we hear that they are working the code well before we arrive.  I spend the time making sure we have everything we will need on the cot, ready to roll, and mentally reviewing the code protocols in my head.  We finally do come to a stop in front of the apartment building and I hop out to grab a backboard and the kit with the straps needed to use it.  I’m coming around the back of the unit to join up with Wayne and Cat as I am met by one of the firemen from the units on scene.  He tells me that they have gotten him (the patient) back after shocking him twice and he has agonal breaths.  They aren’t doing compressions anymore, and are assisting his respirations with the BVM.  “Wow, this stuff NEVER works” I tell him and grin.  I know that that is not true as I say it, but it does provide a small moment of levity while I mentally switch gears on the call.  I had no idea at the time just how many times I’d be doing that in the next 15 minutes.

I have the board and the lifepack in my hands as we climb the stairs up to the apartment.  (upstairs again).  The crews from the engine are surrounding the patient.  He is in the lower 50’s, thin, and unconscious.  There is someone breathing for the patient with a BVM, and I note that it looks like he has a good seal on the mask and doesn’t appear to be having any issues…a good sign.  I’m a bit relieved to see that the engine officer apparently running the call as we arrive is the president of that department, and also a medic.  Good signs abound.  I mentally force myself to take it easy at first and get information and fight the urge to dive into the call.  We learn that he collapsed suddenly, there is a language barrier that is inhibiting communication for a history, he has been defibrillated twice, and that following the second shock, he showed signs of breathing.  All this comes to us in just under a minute.  Cat has swung around by the airway with the oxygen and the lifepack, and I’m working over to the patient’s side.  I’ve noted a scar on the patient’s chest and start asking about that, and I’m watching for signs that the patient is improving.  We learn that he had a heart valve replaced, and the guy working the BVM says he is breathing when the patient moves.  Cat has put on the 4-lead for the ECG and I’m starting at the beginning, feeling for a pulse.  The hairs on my neck twinge and I can’t place it…then I realize that while the patent’s chest is rising every time the bag is squeezed, it is no longer being led by his abdomen.  In other words, I don’t think the agonal breaths are still there, and I know that I’m not feeling a pulse.  I start to say something just as Cat has turned on the lifepak and is spinning around with the same news… Behind her I see two lines wiggling chaotically across the screen, V-Fib.

Ventricular Fibrillation is what happens when the heart is stopping.  There is no organized pulse, and the heart quivers.  I have heard it said that if you could see the heart at that time, it would look like a bag of worms writhing.  I’ve always thought of it that way.  The bad news is that it means our guy is pulseless and apneic (not breathing)…dead by most standards.  The good news is that there is one thing to do..shock him.  That IS, after all, why it is called a defibrillator.

Now, I know he has been shocked twice already, and that the electrical dose, in joules, increases for the first three shocks.  So, I think to myself, since the pads attached to the patient are still attached to the AED, and since that AED has already shocked him twice, it knows through its programming what dose to use.  “Hit him again” I say as I start to back away from the patient.  No need to tell ME to clear!  There was some talk at that point, but I didn’t hear it.  “He’s in V-fib. Shock him”.  I hear the AED talking and analyzing.  “Come on, come on” I think to myself as I’m checking to make sure everyone is clear.  “Shock advised” the AED says.  “No shit.” I think.  The Fire-Medic from the engine checks that everyone is clear as the system charges.  “Clear”…Thwump.  The patient flops quite a bit.  Good sign…really dead people take the shock without moving much.  I’m back on the patient just as fast as I can get there.  I look over at the monitor and I see that the rhythm is nearly flat.  “That looks about right” I say and start chest compressions.  “Well, there goes that save” I think, and I’m hearing someone say “30 and 2 right?”  Well, someone has the new training.

We go into our compressions and respiration cycles and people are moving now.  I jokingly think to myself, “Hey, I’m the medic…I’m going to need to hand off these compressions to someone at some point here.”  Cat is getting set up to do the intubation, and the Fire-Medic starts looking for IV access on the guy’s arm.  There is not much there, no real surprise…he’s dead, so there is no pressure supporting his veins.  Cat confirms my compressions are showing on the monitor and I’m noting that the guy on the BVM is counting my compressions.  This actually helps because in the conversing about all that needs to go on, I’ve lost count….nice.  I hear him hit 30 and I stop so he can breath twice for the guy.  I tell him to keep counting, that I am losing count while looking for a vein in the guy’s arm etc. and I get a nod.  We are getting into our code groove when at the next pause for respirations I note that the monitor is showing some narrow complexes on the monitor….his heart is trying to get its act together.  “He has a pulse” I hear from in the room.  I’m already checking that with two fingers…but there is nothing there.

We are briefly caught in a conversation about the fact that there are “beats” on the monitor, but that I’m certainly not feeling a pulse.  “Until I feel a pulse, It’s PEA, (Pulseless Electrical Activity…the signals are moving through the heart, but the muscle is not reacting in a beat) everyone okay?” I ask and end the conversation by restarting compressions.  I’m hoping that I wasn’t overly abrupt, but I also know that we are both facing a possible save (the heart is trying) but burning a clock too. “Get the Epi” I say and Wayne is on it.  A vein is found on the underside of his arm and we are almost in business there.  Cat is ready for the intubation at the next respirations.  The breaths go in and she gets the blade into his throat…and he gagged, or coughed around the blade.  Cat later said that she was visualizing the cords and saw them close.  I’m noticing, at the same time that there are more of the complexes on the monitor.  They are still too slow, about 30-40 per minute, but now I can feel a pulse with each complex on the monitor.  “Well, hot damn.  Welcome back.”  I think to myself.  “Okay, he’s Brady not PEA anymore.’ (told you…gear shifts).  “Lets get the line and atropine”.  Cat briefly suggests that the Epi is not in, but then shifts mental gears herself and agrees.  “Damn, this is more like a code in class than a ‘real’ one.” I start thinking.

‘Mega-codes’ the practical tests we run in classes.  They usually jump at random from rhythm to rhythm to see if we can switch protocols on the fly.  ‘Real’ codes are done on living room floors like this one, involve a real, dead person, and proceed down a predictable line from “Mostly dead” (everyone think Princess Bride…okay, enough of that) to “Really dead”. Our guy has been in four rhythms in two minutes…Coarse V-fib, asystole or fine V-fib (I didn’t check which and didn’t care), PEA and now bradycardia.

The line is in place on the first try, (nice job to the fire-medic), and flowing well.  Wayne had the atropine out and opened the box, but now I’m noticing that the patient’s rate is up in the 70’s…not brady any more.  Hot Damn again.  Cat is suggesting we not go for the tube against his gag, and I’m not looking to sedate the dead guy we just got back, so I’m all for it.  And, oh yeah, we have great compliance and the airway is open and good oxygen is getting into his lungs etc etc etc.  The Atropine goes back into the drug box, I note that the oral airway is still in place and we are ready to move.  We get the backboard placed at the patient’s feet, and I suggest we just lift him up and slide the board under him.  We get that done in short order, have him strapped.  As we are getting ready to move, I hear that he has a oxygen saturation of 100% on the pulse ox.  (Okay, I’m fully alive, and I have a sat of 96-97% on a good day).  The guys get him moved to the cot and over to the unit pretty quick.  I tell the crews that it looks like we may have a save, that I want them to fax me a list of the names of the crew members there, and I’ll try really hard to not lose him on the way to the hospital.

On the way, I am handling the respirations on the BVM and Cat and I reassess everything.  His rhythm is fairly stable, and we even get a Blood Pressure of 130ish over 50’s.  Well Merry Christmas to this dude.  We take the chance to double check doses and push a bolus of Lidocaine per our local protocol.  Honestly, I had never had someone come back on CPR and shocks alone and had to double check…but that is why we have that stuff on the unit.  We did get him on our end-tidal CO2 detector and find that he has a reading of 40-41.  That’s right in the middle of the idea range and a very good sign.

We get to the hospital before we hang the drip, but we can deal with that.  We get in and assist the ER staff in getting the patient transferred over to their equipment.  They confirm a pulse, and the blood pressure and even the O2 saturation.  He is put on a ventilator in short order and we give all the limited information we have to the doctor, along with a bag of all of his medications.  They are glad to hear about the lidocaine bolus and take over from there.  Our biggest miss was not getting a blood sugar level, and frankly we know better, but the number in the ER was over 130…more than fine.

I get into the report room where Cat and Wayne are already talking over the call.  I find out that they actually had had some trouble finding the place due to the ADC map showing two roads connecting that don’t.  (That is actually kinda common, but that’s another story).  In the end, I don’t know if he walked out of the hospital or not, but I know that we arrived on the scene of someone who was dead by any normal standard, and left a patient with a pulse, blood pressure, signs of great respiration, ventilation and perfusion.  He was taken to the ICU later in the day, and appeared to be stable whenever we checked in on him during the shift.  A nice way to start the season indeed.

Don't shoot till you see the whites of his eyes

2006-11-20T22:13:00.000-05:00

Well, that month went by fast.  Work continues to be busy, and this semester’s class is finally wrapping up.  I’m looking forward to a few weeks with Tuesday nights back as my own-ish.  Cat is staying busy with her new job as the EMS Training Lt in the career department in the county where we live, and it looks like life will be staying very full for a while.  Last week was EMS Symposium here in Virginia, which is traditionally a big week here.  There are lots of different classes to take for CMEs all day, and the evenings, nights and early mornings are taken up in the hospitality suite.  Stressed EMS providers and ETOH, quite the combination, and the source of many great stories, some of which never get lived down…..like this one…

Okay, Breathe, I’m kidding.  (To those of you not from this area, a lot of local people got a bit nervous there.)

I am, however, starting to think that the Trauma Gods are after us.  Not that it is a bad thing at all.  Generally speaking, traumas can be more fun than medical runs, but they each have their points.  A couple of weeks ago, we caught both on the same call, kinda anyway.

Cat, Wayne and I had been having a fairly quiet day with pretty much only a morning DOA behind us.  (Start your day with a D-O-A, Doo-dah, doo-dah) We were making jokes about needing a save or a birth for the day as we were 0-1 for the day right out of the chute, and THAT just can’t stand.  The weather was pretty nice, sunny, and somewhat warm for this time of year.  All in all, not a bad Sunday.  The unit was clean, the bay floors were washed and we were generally taking it easy when the call went out.  First due sickness, us and the engine dispatched.  Nothing serious based on the information waiting for me on the MDT…a 50 something male had been sick for a couple days, and the only thing that sounded like it could be anything was some lightheadedness, but even that is sounding benign.

We arrive on the scene and are met at the door by a nice and very proper older gentleman.  I ask if he is okay, and he requests that we talk inside the unit.  “By all means” I think to myself as I smirk.  If you are well enough to meet me at the door, and walk in without the cot, I’m all about it.  I wave off the engine, placing them in service and we start walking to the medic unit.  Inside, our assessment finds a nice guy, very proper, almost British in his speech, who has had a flu for about a day or two, and wants to go to the hospital.  His vitals are good; he’s been vomiting, but doesn’t need to now. (No puking in my unit rule is explained) and just needs a ride.  I have Wayne start the meter on the taxi, and off we go.  I have a brief chat with the charge nurse at the hospital, and get our gentleman caller a reserved chair in Triage.  On the way I explain that the Blood Pressure we got is a bit elevated, but not to worry….Yes the little red light on his finger is measuring the oxygen in his blood…yes, it’s fine.  Eventually, he is a bit calmer, and seems reassured that we are competent to take care of him.

We arrive at the hospital as a dispatch goes out in a neighboring due for a shooting.  I hear the call go out, and some follow-on traffic.  Sounds real, units are staging and the Police are figuring out what was going on.  Cool.  The ER is busy and filling up pretty quickly it appears as we walk through.  I let Wayne and Cat push the patient on the cot, through the ER to an area outside of triage where we will transfer him to a wheelchair.  I stick my head in by the charge nurse, “Hey, heads-up, they just dispatched a shooting in  (nearby area).  Sounds real, but I’m sure they’ll fly anyone that is serious…just a heads-up.”  That gets me a “Great. Thanks” from the charge nurse, and a look that says, “that’s all I need right now.”  I smile, and head back to my patient.

He’s in his chair, and I wheel him to the triage area and get him signed in.  The form is a short one, and I have all his info ready to go.  All that is left is to stick my head in with the Triage nurse to give a quick report before I can get back into the sunshine.  I’m standing there waiting with my patient, and the triage tech has to go back into the ER for something.  No biggie, but in retrospect, that was clearly because Murphy called them back.  I say that because no sooner do they disappear and I’m the only health care related person in the room than it happens.

The front doors slid open at their normal pace, but the guy that comes in is moving much faster than normal.  He takes about two steps inside and stops dead…staring at the empty registration counter.  Now, whereas his eyes are about the size of tea cup saucers, and he is focused only on the one place that someone from the hospital should be, a small voice in my head whispers, “Hey, there is someone shot on the front ramp”.  It takes exactly that long for this guy to look over, see me standing there in uniform and ask, “Hey man, you work here?”  I feel myself smile and I think (and yes, this is actually what runs through my head), “There’s someone shot in your car isn’t there?....No, but I DID stay at a Holiday Inn….No, I’m a medic, but that’s not really what you mean….Cool, I get the shooting call after all.”  What came out was, “Uh, close enough” as I was already starting to move for the door.  “MY BOY’S BEEN SHOT” he says a bit too loud and kinda panicky.  I’m heading for the door and to the SUV waiting on the other side.  I turn towards where the triage nurse is and vaguely see one of the admin people walking by.  “Walk-in shooting, get help!”  Amazing how that gets things moving…

The patient is laid out across the back seat, and when I pull open the door on the passenger side, his head is towards me.  A quick look shows that he has been bleeding a bit profusely, and I see that his hand and wrist on his right is shattered and likely the source of the blood.  Okay, bleeding is serious, but not going to kill him right now.  He’s talking and clearly a bit exicted… you know, like a guy who’s been shot.  “Hey, where else you hit?”  I ask.  “My leg man, my leg” he tells me.  “Okay, let’s get you out of here” I say as I finish gloving up.  I turn around and Cat is emerging from the doors, word must be traveling through the ER I think.  Cat is gloving up and sees what is going on.  She pivots back to get our cot which is just on the other side of the triage area when the doors open and an ER nurse comes out with a hospital bed.  Nice.  “All right, we need to get you out of here, and onto this bed.”  I explain.  “Man, my leg, don’t lift my leg” he says as the guy who came into the ER in the first place starts to help from the other side of the SUV.  “You are shot, bleeding and in the backseat of a car….you are going to be moved.  We’ll be careful, but you are coming out.”  I say a bit more sternly to get through the panic.  We wheel the cot to the door and with a bit of help from Wayne, we slide him out to the bed.  He grabs at the door frame briefly, which is not helpful, but he gets with the program pretty quickly.  His right leg is internally rotated, I note as we move him.

We move quickly back to the ER, and Cat and I are moving at “Field EMS” speed apparently.  “Hey, I like you guys, but if you run me over I’m going to be pissed” says the nurse at the head of the bed as we roll.  I look up and it is the ER Nurse that accompanied us to the pediatric center on that choking call not long ago.  I grin up at her and slow down a notch.  “No problem, I ain’t shot” I think to myself.  The guy is conscious and alert and is answering the usual history, med and allergy questions as we head for the trauma bay.  There are a couple of nurses and techs waiting, and more seem to be on the move as word has spread that we are coming.

The wheels of the bed hit the floor mounts and just that fast Cat has her trauma shears out and working on the patient’s jeans.  My shears are in the unit so instead of starting on another leg, I take the cut Cat starts and rip the jeans all the way up by hand.  “Don’t cut through the holes” a nurse calls from behind us.  She’s thinking evidence preservation and is worried that we are moving a bit fast, but we are thinking about it too and the rip is away from any tears in the jeans.  The guy has basketball shorts on under the jeans, but not for long.  I grin as I realize that Cat, Wayne and I are the only ones hands-on with the patient, surrounded by ER staff.  They are getting organized and are quickly involved, but I note the difference in reaction to a “Field Environment” call in the middle of the “Hospital Environment”.  The staff just needed one minute to shift gears to the situation, but this was happiness and home for us.

Cat is working up the right leg and comes across the first hole in the patient’s lower right lateral thigh.  We call out the wound to the nurse taking notes and keep going.  Further up, she finds another GSW (Gun Shot Wound) in his right Buttock.  (Okay, all at once in our favorite Forrest Gump voice….”Butt-ock”…you know you were doing that anyway).  We are starting to think we have a matched set of wounds, possibly an in-and-out when Cat finds “a protrusion” (that’s careful medical-type talk for a bullet) just under the skin of his upper right thigh.  I check for a pulse in his right ankle and finding one make sure that the note-taker is aware of that.  (That one gets me a smile from one of the nurses…we may be working quickly, but we are looking out for them).  On the left leg I find holes through his basketball shorts, and find matches in his jeans, but there is no trauma to the leg.  That gets noted too.

During this time, Wayne is working to get him exposed and with a nurse, they pull of a leather jacket that he is wearing and REALLY does not want us to cut.  His hand is pretty jacked-up with a hole just below the wrist and another between the ring and middle finger of his right hand.  Now, we don’t guess on the entrance and exit of bullets, but it really looked like the bullet blew out through this guy’s hand.  He was bleeding pretty bad, and it looked like that hand was going to a surgeon to me anyway.

At this point the police detail from the ER was in the room, and there was plenty of hospital staff doing their thing.  An IV line was being placed and the normal rhythm of a trauma in the ER was setting in.  Time to gracefully back out.  I tell the patient that we are going to go, that he is in good hands and to hang in.  He is still a bit worked up of course, but is getting the idea that he’s where he needs to be.  I make sure to check in with the note taker to go over everything we found etc and ensure nothing is missed, then Wayne, Cat and I head out, double checking that the ER staff is good with us leaving.  They are, and we do.

I head back to triage, and my original patient….you know the one I’m actually here for…and find him already in with the triage nurse.  “Hey, He’s mine, I just brought him in and got pulled off…” I start.  “Yeah, the shooting, no problem, nice job” the nurse says.  “Okay, well, you probably already got it, but stable vitals, general sickness times two days, vomiting, No Hx”  Etc etc. I ramble off.  “Got it, thanks” the nurse says and I get a very nice smile from our gentleman.  “Thank you for helping him” he says as I start to go.  “No problem, you get better” I say back.

Wow, now for the paperwork, I think as I head for the report room.  Cat catches me on the way….”Hey, got one for the blog” she says.  THAT gets a chuckle.  I see the guy who first ran into the ER standing in cuffs outside the trauma bay, and I get a “thanks man”.  He’s not arrested, just secured until the Police figure out what is going on here.

First order of business for the report room, I make sure we get a piece of paper with all of my crew’s names and contact information for the officer that is working the case.  I have Cat run that to the officer and explain to her that he’s going to realize he needs that information in about 15 min, but it is probably a good thing for us to do now.  When she gets back, she tells me that the officer got an “Oh yeah…thanks” look, and was grateful for the information.  Hope he’s grateful enough that we don’t get to tell this story in court too.  We’ll see…..

Invasion of the Body Snatchers

2006-10-16T21:08:00.000-05:00

So here I was, just after my last post and thinking I knew what I was going to write-up next.  Of course, I spent days running around as always (This class is taking more time than some in the past) and a couple weeks passed by.  Then, two duties ago, we had us a “blog worthy” winner.  I got a really nice comment on the last post about the covering the interventions here…so, I’ll have to cover the other end of the spectrum…

It was a Thursday night, which meant two things were for sure:  We were hoping for a quiet night so we could go to work in some semblance of a rested state on Friday, and there was no way we were going to get any sleep.  The unit was the usual suspects, Wayne, Cat and I and we had earlier run a call for something or another, and heard the neighboring unit come into our due for seizures.  Our engine crew went to support them, and they were gone quite a while.  In the end, I saw that the call was a refusal, so when we got back from the ER, I asked them about it.  The guys told me that the patient was a guy who had a history of seizures, questionable compliance with his meds, and was pretty out of it when they got there.  Thing was, he kept saying “I Feel Fine, I’m okay” over and over and resisted efforts to get him checked out.  Oh yeah, and he was BIG.  I asked how much they thought he weighed, and I got, “not big fat, big ripped.”  Apparently, this was a large, muscular guy, with a loose grip on reality while they were there, who didn’t want to go anywhere.  The medic had seemed uneasy letting him stay, but ultimately got a refusal.  “Great” I think, “so much easier to leave this dude in MY due.”  I comment that we’ll likely be back later and the Engine crew agrees.

It sucks being right sometimes.  Not long after (like under an hour), we get punched to the same address…40 year old male…seizing.  Great.  I think, and probably mutter, a dark and vile curse on the previous medic as I walk over to the unit.  Cat had just laid down to bed about 15 minutes before, so I’m thinking she was just drifting off…I HATE getting calls that soon after laying down myself, so I know she’ll be feeling perky.  We head out, the engine right behind.

As we are arriving on the scene, dispatch comes over the air and updates that the patient is now reported to be unconscious.  Dispatched asked if we’d like another unit dispatched (Unconscious calls get a medic and two support units here).  I wave that off for now, and tell dispatch that I’d advise when I saw what was going on.  I’m thinking he’s just postictal, a period of time after a seizure where the patient’s brain is basically ‘resetting’ from the electrical storm it just went through.  Patients are often drowsy, very slow to respond or react etc during this time, and sometimes when they stay out for a while families think they are even dead.  Then again, sometimes they are right, so we go in ready for either end of the spectrum.

We enter the house and are led upstairs….back bedroom…of course.  Our engine guys weren’t lying.  In the bed was a BIG man.  He looked about 6 foot 4-5 inches, and somewhere north of 240 lbs (110 kg) and about 4% body fat.  He was unresponsive, but breathing well, and generally looking postictal as expected.  The room we were in was pretty small, with the bed the patient and an electric keyboard on it, a small nightstand with a light, an corner entertainment unit with a TV and some obviously very well used free weights on a barbell.  I notice all of this because we are having a hard time getting many people into the room to get the patient on a board to carry downstairs, and because I’m thinking that if this dude starts flailing, we are pinned in a tight area with lots of other big objects and people are going to get Hurt.  Wayne, Cat and some of the engine guys are moving pretty quick with the board and straps, but I start to notice some movement in the patient, and I start to encourage speed over pretty.  This gets me some pretty classic looks from my partners, and they make clear that no further encouragement is required.  Grin.  (Okay, so sometimes I verbalize more than I have to, good thing I’m so terribly cute doing it).

About that time, our patient looks up, sees straps across his chest and over his arms and proceeds to remove them.  Let me be clear, he was well strapped down, with his arms under the straps and he pushed them off with very little apparent effort.  He starts to lay back down, but notices the leg straps…..”Okay, Okay, Easy, easy….we’re taking them off, you’re fine…take it easy” I start saying as I’m popping off the straps.  We missed our window to get moving, and now that he’s kinda flaying around, we are never going to be able to go down the stair in any safe way.  The straps come off, and we roll him onto the bed.  He pulls the blankets up and passes out.  Nice.  I take the blankets off of him, and he doesn’t move…yep, he’s out again.

At this point, the siege begins.  I radio out to dispatch in the midst of the strapping attempt to confirm that we don’t need the extra unit, then have them radioed later to start police our way.  Nothing has gone wrong yet, but I don’t know how violent he is going to be, but I know he has the potential from the engine crew, and while he agreed to the previous medic that he’d need to be seen if he had another seizure, I’m not sure that he’ll be okay with it.  Sometime the Police being around telling someone to go seems to motivate people.

Okay, the aside here:  A seizure patient that has a single seizure that ‘breaks through’ their meds is not an emergency by itself.  In fact, the transport can be BLS by our protocols.  A patient having multiple seizures is ALS, and needs to be evaluated.  The issue is that seizures that occur in multiples have a nasty habit of getting closer and closer together, and may start to overlap into one long big seizure (Status).  This is bad, as often a patient is not breathing during the seizure, so the big long one leads to hypoxia, brain damage and death.  Oh, and all that muscular movement does really bad things for your blood sugar…also bad for continued existence.  So, that is why I am a little worried about this guy, and why he needs to go for evaluation.

So, as postictal patients do, he slowly starts coming back around.  As he does he is looking confused, coming in and out of responsiveness, and he keep saying “I’m okay, I feel fine”.  At first slurring badly and then slowly he starts getting clearer.  I decide to use his speech as a measure of his recovery.  Over a few minutes, Rock, (a firefighter off the engine) and I get the patient sitting up in bed, and I notice that he is rubbing his hands together in a repetitive motion, like he’s trying to dry them.  I point it out to Cat and she nods.  This repetitive motion is it self a type of seizure, called a complex partial seizure. And it goes to confirm my assertion that he needs to go for evaluation.  Rock keeps talking to him, trying to get him to come along, and I let everyone know that he is going to ‘seize’ again and when he does we’ll grab and go.  I get nods all around.

About this time, PD arrives.  Two gentlemen arrive to the room and promptly have an “Oh shit” look appear on their face.  Told you this was a big dude.  As Rock and I keep working to talk our patient downstairs, they start talking options.  I hear the officers say things like Sergeant, and then Tazer and I start to get a little nervous.  I whole heartedly agree that if the patient decides we are a threat, that a Tazer is a good idea, but I shudder to think about what blasting the seizure patient with electricity will do to him.  More officers arrive shortly there after and I think we end up with 3-4 officers and their duty Sergeant in pretty short order.  All this time, Rock and I are doing two steps forward, one step back with the patient.  We get him sitting, then he lays down and pulls up the blankets.  We hide the blanket and get him to sit, then start to stand, but he looks at all the people and sits back down.  This repeats several times.  Finally, we switch tactics.  I ask Rock if he’s good to go with the patient, as he seems to be developing a “rapport” with him…at least while he’s lucid.  I get a nod, and I have everyone back out of the room, and get a cot down the stairs.  The Police officers back out of the hall, but there is an officer in every door along the way..just in case.  Rock starts telling the patient he needs to sit, then stand, then walk…all to show us he is okay.  After 15 min or so, he has the patient coming down the stairs, and I’m stunned.  The patient goes all the way downstairs to the cot even.

Of course, he steps OVER the cot, and gets water from the refrigerator.  I’m just happy we are downstairs.  I’ve taken the time to explain to the officers that he needs to go to the hospital, he is NOT lucid enough to give an ‘informed’ consent to refuse, and so we are stuck.  The Sarge tells me that they can’t put him in custody because he’s not actively trying to harm himself or anyone else, so they are in a jam too.  I explain that his not going is a choice that could result in his demise, but that doesn’t cut it for them.  So we are left with Rock the Negotiator.

The patient eventually sits on the cot, but will not lay back in position.  He gets a better idea of what’s up and eventually stands up and starts for the stairs.  I stand in his way,  but turn my back to him, and take the most non-threatening posture I can as I block him.  He’s still giving the “I’m okay, I feel fine” mantra, and the hand rubbing happens but has slowed, but he’s still not totally back.  I’m not too proud to say this guy could hurt me, Wayne, and Rock and never get out of his postictal state, and if the situation goes violent, we’d eventually win, but a lot of people would be hurt doing it and we do not want that.  Knowing that only his most basic mental function was working, I avoided eye contact, slumped my shoulders and stood with my back to him as I slowly moved back and forth with him…blocking the stairs.  All the while, Rock is talking and trying to work him.  I can tell though, that he has had enough, and will not be headed back to the cot.  When the patient taps me on the shoulder and says “Excuse me” I really have no choice but to move aside.

The PD briefly block his advance up the stairs, but the Sarge steps in and has them back off too…he’s thinking like I am and we don’t want a lot of patients here.  So, the patient is back upstairs, back room, and in bed.  We are all exhausted and we’ve been here almost an hour…back to step one.  PD asks if we can knock him out, and I tell him we don’t have the meds for that, and even if we did, HE could go after that guy with a needle!!  Cat calls the ER for ideas, and is met with a busy, and unusually rude nurse, who does NOT put the doctor on as asked (Another issue I’ll address later), and basically doesn’t bother to hear the whole report before giving the “He’s walking, talking and refusing, there’s nothing you can do”.  Cat tries to explain that he’s still postictal, but is cut off and all but hung up on.  Great, now I got a big, disoriented seizing dude, and a livid, tired, annoyed (and fine looking) wife/partner.  Wonderful.  We take another survey of ideas, end up empty, and we collect the refusal signature from the patient’s mother.  I’m angry and tired, and I document the hell out of the fact that Nurse Wratchet provided our on line medical support in getting the refusal.  We pack up and I thank the Police profusely for their help.  They are supportive and agree they were needed.  We all agree that we’ll be back here, and they ask to be called for again if it happens.  No Problem!

We leave the scene and head back for the hospital to pick up a supply we were missing, and I’m generally hoping Cat doesn’t just show up and kill a nurse right there on the floor when the MDT jingles.  Same address…Seizures….”It’s him Wayne…GO!”

Wayne had already slapped the lights back on, and was pulling a high-G U-turn as I spoke.  Dispatch calls for us on the radio.  “M512 is direct on the dispatch and responding…please add PD to this call” is my response.  As we turn, I see the engine flipping around and leading the way.  Communications confirms PD is on the way and I yell back to Cat, “You take the cot to the stairs, we’ll get the patient”.  She’s okay with that plan, and frankly, I want her downstairs just incase things don’t go by plan.  I radio to the engine to just send in manpower, don’t grab any equipment, that we are just going to evacuate the patient as fast as possible.  Dispatch updates that he is unconscious again and I smile.  (See, I can’t legally take a competent patient to the hospital no matter how bad they need it.  We can argue his competence on the first call later.  An unconscious patient is legally assumed to want treatment and transport under “Implied Consent”.  SO, as long as he’s out, he’s going to the ER…and it’s only a 5 min drive away…without lights and sirens.)  PD is right behinds us as we slide onto the court where the townhouse is.

As I’d later tell the story, we hit that house like a SWAT team.  Wayne and I are met going through the door by Rock and Rick off the engine.  We all run up the stairs and right to the bedroom.  Our patient has seized himself off the bed, knocked over his lamp and lacerated his forehead.  He’s out cold, and snoring as he breaths.  “Okay, he’s breathing, let’s get out of here.”  We try to grab him by the blanket he’s wrapped in, but it’s a loose weave cotton thing that stretches all to hell.  We roll him out of it and I grab his ankles, they grab shoulders and hips, and we take off down the stairs like the building is on fire.  It is not pretty, but it works, and we get him on the cot.  He’s quickly strapped down…hands under the straps…and we are on the move.

Rock rides with us, and I tell Wayne to take off as soon as he gets into his seat.  We just secure the patient to the cot, for his safety, when I feel us starting to move, sirens blazing.  I’m sweating like a fat man, and we are all winded, but here we are.  The patient is still unconscious, but he’s breathing and everything looks good.  He’s got a laceration, but it is very minor.  He’s not seizing, so that is a plus.  We have a  SHORT talk about getting an IV etc, and decide that we are going to rapidly transport, and not do anything to stimulate the patient unless he starts to actively seize again, in which case we’ll hit the IV on the run and push Ativan.  I call the ER and tell them I’m coming, coming fast, and will be there with a postictal patient, 3 seizures tonight, with no vitals or interventions, unconscious and promising to be uncooperative when he wakes up.  Fortunately I have a nurse I know on the line, and she knows that something’s up.  “Okay, see you in two.” Is all she says.  I look up and see that PD is having to respond lights and sirens just to keep up as we get to the ER parking lot.

Our patient wakes for a second, looks up, gets pissed and pulls on the straps, and then falls back again.  The clock is running out as we stop.  I hop out and we rush him into the ER.

I see the nurse that talked to Cat and she’s surprised we have the patient.  “We got your refusal, he seized again like I said, and he’s here unconscious under implied consent.  He’s waking up and is uncooperative…now which room was ours?”  She’s not thrilled, but I have her cold and she points to one of the big rooms in the back.  We are there with two techs, a couple nurses, the PD that came with us, and hospital security.  Moving him over to the ER bed wakes him and we are forced to hold him back, but per the ER doc, they get a fast IV and have him sedated in short order.  The doc knows the patient and agrees with our assessment of what is going on, and that this guy stays postictal and is uncooperative every time he sees him.  (So that went our way…finally).

We give what report we can and go off to do the paperwork.  We are real careful with the first one of course, and it takes a little while to clear.  We leave with a chuckle.  “Well, sometimes you help and it’s pretty, sometimes you help and it’s ugly” I comment on the way out.  On the way back to the firehouse we wonder if SWAT needs any new members, and chuckle at how we must have looked to the PD or any bystanders rushing into a house, then flying back out with a guy in our arms.

She was just 17, if you know what mean...

2006-09-20T19:49:00.000-05:00

Wow time keeps slipping by me, but thanks to everyone who keeps checking in here, swinging by the myspace page, sending email and prodding me in the street to “Update that blog”.  I’m coming up on one year doing this and I’m still surprised anyone reads it.
I have a couple things I’m working on offline, but I just can’t get right.  May be that they are the ones closest to me so that is taking some time.  Anyway, this week’s duty made the choice of story easy.  Cat and Wayne were with me, as always, and we had a new guy getting some time on a medic with us, Brian.  Tess has been given the opportunity to go to the ER in Baghdad as a paramedic for a year, and has said her goodbyes for now.  May God keep her safe as she heads off to help others in an area of the world not known for that.

We had just marked clear of the ER from a bogus sickness call and had not even made it out of the parking lot when the MDT terminal jingled and the screen was filled with a dispatch.  Wayne heard the sound and looks over as I tell him we are headed for an auto accident down between the gates to Quantico.  He gives me a nod and pulls up to the light in front of the hospital.  The dispatch has not even hit the radio yet, and I’m acknowledging that we are responding.  I know Wayne will wait on the light in the intersection then hit the sirens and away we’ll go.  In the mean time, we are waiting to hear more information.  That information comes as an update to the MDT as the dispatch just starts going over the radio.  “Two cars, head on….ejection” I say.  Wayne doesn’t look over this time, but I see him slapping on the lights, and feel the unit accelerating…so much for waiting on the lights to turn green in the intersection.  Cat and Brian are in the back, and our headsets aren’t working, so I turn and yell back to them.  I get them up to date and get things going  “…Hang two 1000 bags and get your vests”.  The trip is a fairly long one for us, and I know we are probably 8-10 minutes out from the dispatch.  There is a medic that is based closer but they are already on a run, so too is the closest engine.  There is a Battalion Chief that should get there fast, and apparently a Utility is in the area.  I check the computer and it looks like we are going to be the first in EMS piece, and the updates that keep popping up on my screen say we are going to be deep in it.  Possibly one ejected, reports of people in the roadway, 2 ALS patients, 3 BLS patients…all before the first unit is on scene.  (Yeah, a patient count by severity before a unit on scene…must be a bystander with some experience there).  The first pieces get there and we hear confirmation of one entrapped, all lanes closed.  The Batt Chief is asking for more EMS pieces, (only us and a basic on the initial dispatch) and it sounds like they are going to be coming from a ways off.  He has communications call onto the Marine Corps base for their units.  Good plan, they should get there shortly after we do.  We are closing on the scene now, and it sounds like it is busy there.  I radio ahead to command, “We are 30 seconds out, where do you want us Chief?”  He directs us to get behind the utility as we crest the ridge and get our first look at the scene.

There was a green car of some sort off the road and against a tree line.  On the driver’s side, there were several bystanders, and while I couldn’t see into the vehicle, I can tell something bad is inside.  Laid out along the northbound lanes are patients, four of them.  They all have lacerations that I see from the unit, and a couple have someone with them.  At this point, we (the EMS providers) are still outnumbered by patients.  I hop out of the unit and head over to size up what we are facing.  Quantico’s engine is just arriving, and their Medic has to be close.  I walk through the people laid out on the pavement.  As I told someone later, I’m reminded of scenes from the 80’s hit squads in South America.  They are all laying perpendicular to the road direction, about two arm’s length apart, and bleeding from various places.  I notice two things, 1) None of the bleeding is really bad and 2) they all look at me when I go by.  That makes them conscious/alert and the lack of severe bleeds or obvious deformities is a ‘good’ sign.  I move past them to the car, here things change.

The car is mangled, the front end is toast, and the driver’s side is not any better.  The driver’s door is almost ripped off, the windows don’t exist.  The driver is female and she has been knocked back in her chair so hard that she almost exited the vehicle out the driver’s side REAR window.  A bystander in motorcycle gear is holding her head and I can see that her face is grossly deformed.  My initial assessment is that she has fractured her left orbit and temporal region of her head.  She already has a golfball sized hematoma right at the middle of her forehead.  Her right leg is folded under her hips, but her leg looks intact.  She is clearly unconscious and is bleeding from her face and probably her airway from the sounds I’m hearing from her.  The patient is clearly going to need to be cut out, but all we really need is the door ripped the rest of the way.  I yell for someone’s attention and give them the circular finger in the air…time for a helicopter.  The guy holding her head is doing a good job with C-spine stabilization, and I ask him if he is good to go for a bit as I quickly make sure the rest of the car is empty.  off.  He assures he me he is ok, and I turn to get Cat’s attention.  She was back at the road starting to work with one of the guys there.  I wave her off of that and have her come over right away.  “Hey, this one can’t wait, she’s ours, let the next units finish sorting things out.”  (Ok, not PC, but it does get Cat and our guys moving.)  Cat nods as she comes around the car and starts working on the driver.  I ask if she’s cool for a minute, that I want to check in on command and make sure we have a handle on the big picture.  She nods and gets to it.

I jog back to the buggy where command is and make sure he knows we are going to need a chopper.  The officer off of Quantico’s engine is there and assuming Operations.  I give him my quick count and tell him we are focusing on the driver first.  The Medic from Quantico arrives as I’m walking back and one of those guys is clearly getting a good scene assessment going.  I tag up with him and we agree that he is going to coordinate the incoming units and sort the patients on the road, we are going to finish with the driver.  Cool, Okay, the big scene is handled and I can go get back to Cat.  The Tower is pulling in and I grab the officer as he gets out, “Hey, the driver in the car over there is bad, I need her out yesterday.”  I get a serious nod and they start pulling equipment.

I get to the car with our cot in tow.  Wayne has retrieved the backboard and straps, and Cat has done her initial workup.  She has had no reaction from the patient, and has organized the mix group of rescuers and bystanders into a plan of action to pull the driver out.  (She rocks).  The door is quickly cut free and we are in business.  Cat tells me that we are going to intubate quickly, and I agree.  Wayne says he already has the kit open in the unit.  We get her on the board and quickly strapped down.  It is not a pretty job, but it will work.  As everyone is moving her free, I lean in to Cat, “Does she have a pulse?” “Yeah.” She says.  I look again and I’m not so sure.  “Check again”, I’m asking softly so as to not set off the bystanders that are helping.  “Got a carotid, but no radial” Cat updates.  (BP low probably around 70 that means…makes sense).  We carry her to the waiting cot and head off to the unit.  Her arms are flopping free at first and Brian does a good job helping get her contained.  She’s out cold, but still breathing….I can hear it…not good.  As we are rushing to the unit, I notice the looks that we are getting from people we pass.  They are having the same thoughts I am, and I’m not sure that she’s going to make it long enough to make it onto the chopper.  I have yet to see her respond to anything, and while she is moving air, her airway is clearly in jeopardy.  At least now we are going to be somewhere where we can attack her problems and see if we can’t keep her alive long enough to get to the Trauma Center.

The door slam shut and we get to it.  Wayne asks for trauma shears and starts to strip our patient.  Cat is setting up suction and the ET kit and Brian is getting out a Bag-Valve-Mask (BVM) so we can breathe for her.  Cat asks for a 7.0 tube while she starts to suck the blood from the patient’s throat.  I get the ET tube and stylet set up, lay it across the patient’s neck and ask Cat how it looks, “We’ll see” is the response.  From Cat, that’s bad.  Brian is good to go with the BVM and we are starting to get some pure oxygen into her.  Everyone has a task to work on so I give the girl a quick once over and set up for IV access on her left side.  I see that she is going to have a fracture on her right ankle, and Wayne is doing good exposing her.  She has decent veins, and I reach from my 16 gauge (one of the big ones), as I talk Brian through getting her on the ECG.  Cat is going for the intubation as I am ready to go for the IV.  “Well, that’s an artery” I hear behind me.  I turn back and Wayne is standing over that fracture, and it is shooting blood back on him and the back door area.  “Let’s STOP that” I say as I reach back and grab the wound, applying direct pressure to the bleed.  Wayne reaches for a trauma dressing to get things controlled.  Damn, I really don’t have time for this I’m thinking.  I’m now stuck holding an arterial bleed on an otherwise minor fracture, knowing that Cat is likely to need a hand on the ET and that I really need to start some IV fluids going.  I have Brian come around to the back to help Wayne, and they are quickly on the bandaging.  A fireman from Quantico I’ve never seen sticks his head in the side of the unit.  “Bad luck for you buddy, get in here and do whatever she tells you.” I say to him and point at Cat.  Cat is having a tough time getting the tube.  The patient’s breathing is agonal, and she is gasping like a fish out of water with each breath.  I wish we had RSI for the millionth time.  The gasping combined with the internal bleeding is making it about impossible for Cat to keep a visualization of her vocal cords.  At least now she’ll have a set of hands to help out with.   I pull up the patient’s arm and notice that I can’t hold her wrist, it too has an open fracture.  Sigh.  The IV slips in, and I get a great flash.  Just then her arm twists in mine and pulls the IV right through the other side of her vein. Shit, the line’s blown….Hey, she’s moving…no she’s posturing…SHIT.  I notice that only her left side is moving, which is odd, but I just file that away for the moment.

Just then John, the guy off the Tower, and a former ALS certified provider sticks his head in.  I start to have him switch with the Quantico guy and help Cat, but he has to do something else outside.  I must have looked stressed.  “Hey…Breath” he says and gives me a smile.  My first thought was an indignant, “I’m not panicked yet”, but I take the mental pause, give John a wink and say, “I’m on it, I just need SOMETHING to go right here.”  John grins and is gone.  “Sorry, you’re stuck here” I say to the Quantico guy.  He’s cool with it.  Okay, change of tact.  Wayne just about has the ankle bleed under control.  I tape my blown IV attempt, wave Cat off the ET attempt and we all rotate one position around the patient.  Cat sets up for an IV on the patient’s right side, and I take over airway.  The ET is out until the flight crew shows up with RSI, but I’m a BIG believer that a lot of butt can be kicked with a solid BLS airway.  I clamp a solid seal on the BVM mask and start to sync my squeezes of the bag to her gasps.  I’m getting good compliance as long as I work with her natural efforts and I’m happy for the moment.  Cat finds nothing but lacerations on the patient’s right arm up through the A/C area where she was going for the IV, so she moves up to the bicept.  That IV goes smoothly and we suddenly have something for access and a decent handle on an airway…for now.  Cat moves to the patient’s left for more of the same.  We have a driver hop up front and we are on the way to the Landing Zone.

Being at the head I can see the entire patient and everything going on.  Since we have one IV going (an 18 gauge) I ask Cat to try with the 16 for this one.  Wayne’s bandage job seems to be doing the trick and that bleeding is controlled.  I have him double check to make sure he has a pulse in the foot…we don’t want things TOO tight.  He assures me he does and all is well.  I’m impressed with the considerable pool of blood I see between the patient’s legs and dripping on the floor…wow, they had their hands full.  There is another pool that formed from the wrist fracture, but it wasn’t arterial.  Brian gets on that and Cat quickly has the second IV in place in her left bicept.  The ECG is showing the ugly tachy rhythm that I have seen in several traumas it seems, and is running along in the 130’s to 150’s.  (She’s lost/losing blood, and her heart is racing to keep pressure up…it’s compensation, and the next step is BAD, the heart slows and down she goes).  The hematoma on her head is huge now, and Cat’s secondary assessment says that she may not have the orbital fracture on the left side, but she’s sure there is a right sided jaw fracture and dislocation to the left.  The patient’s eyes are constricted and bloodshot, more bad news…her ribs are intact, but she’s exhibiting see-saw respirations, her abdomen is becoming rigid…she’s bleeding inside too.  (The B/P machine on the lifepack gave some high BP number, but didn’t get the pulse right so we disregarded that number.)  Her pelvis was stable, and all her long bones seemed ok.  She had open left wrist and right ankle fractures, and that controlled arterial bleed.  She’s still in deep weeds, but we are suddenly ahead in the sense that we have done what we need for the flight and have a minute left to restrap her to the board and get everything secured.  Wayne raises the flight crew on the radio and we tell them to come with the RSI kit.

We get to the LZ just in time to see the chopper landing.  The flight crew hops in and gets a quick report.  They set up fast for the RSI intubation and pass on a complement on what we’ve been able to do so far.  The flight nurse has an issue with the intubation even with the paralytics and sedation, and says that the airway is covered in blood about as fast as we can suction it.  They rotate, and the flight medic gives it a try.  He is in quickly and while they work to secure the tube, I swap out an IV bag and get the patient onto their monitors.  I also manage to cut away some bracelets off the fractured wrist for transport. The four of us (Cat, the flight crew and I) are pretty busy for a few minutes getting things ready.   The crew agrees with our assessment of the patient (real bad) and passes on several complements on getting her set up.  Always nice to hear from the flight guys.  The patient is transferred to the chopper and just that fast, they are on their way.

As the guys come back with the now empty cot I see the puddle of blood that is left on the cot and turn to see a unit that is truly messed up.  I know I’ve gone through 3-4 pairs of gloves myself, Wayne has blood on his pants, I have it on my pants and shirt, and Cat has her share as well.  Brian had his bunkers on the whole time, so his uniform is spared, but the bunkers are in for a good washing.  We have a LONG cleanup coming.  The Cot is in bad shape and ultimately, back at the hospital, Cat and Brian end up all but taking it totally apart cleaning it….the mat was removed, the slings removed, the frame cleaned piece by piece, and everything hosed.  Somewhere in the mess inside was my watch which I had removed to save it from the blood….too late.  Between report writing, cleaning and restock, we get back on the road in only 2 short hours.  Cat ran home for new clothes for us and the rest of us went off to scrub Brian’s bunkers.

Once again, I have no idea what happened to our girl.  I never got any more info.  In fact, I didn’t have her name the whole time, she had no id on her, and she clearly wasn’t talking.  Only after getting to the ER did I find out that the other folks from the car were in our local ER, and was able to ask them for her name.  We had thought that she was about 22-24 yrs old, and we found out she was 17.  So too, were the four others in her car, all in the ER.  One of the mothers of a patient was able to give me the name, and she came to a halt when she realized why I wouldn’t already know it….she had to be unconscious the entire time.  We don’t know the cause, but it appears that they had been horsing around in the car, lost control, hit an SUV head-on then swerved off the road into the trees. Again, just a guess, but it fits what was seen.  Another young life that is going to be drastically changed if not ended.  Between us on the scene, we think her odds were bad, maybe 75/25 against on survival, and in any case certainly has a lot of rehab ahead.  I’ll let you all know if I ever find out.

The Smelly Man

2006-09-04T14:01:00.000-05:00

Recently I was reminded of a call through the winces and moans of another crew while we were at the hospital.  If the firehouse is where you bond with the other guys on your crew, then the ER and the report room is where you catch up with the rest of the EMS folks in your area.  Information on classes, gossip and “Whatcha just run” stories are exchanged as crews write reports, restock and clean units and equipment.  Often, the report room is the first line of defense for frayed nerves or emotional decompression after a tough call as well.  If nothing else, you know that everyone there, wherever they are from, are there because they just ran a call too, and they’ve been where you are, or will be someday.

I was in the report room, pulling times for my report from the computer, when an EMT from a neighboring department came in bemoaning the smell of feet that was going to be with her for a while.  I had not seen her in a while, but consider her a friend, and it wasn’t until after a hello hug that she clarified what had happened.  They had gone out to pick up a guy, from a local shelter I believe, for some benign reason or another and to hear the crew tell it, he had some of the most foul feet ever to be found on the ends of a live human.  Now I knew he was tall right away, and they quickly confirmed that he was.  Now, I’m not maligning tall people and saying they have rancid feet, this is just a deep understanding of Murphy’s role in EMS.  You see, tall people’s feet extend to, or over, the end of the cot.  This just makes sense.  So, when you are lifting them into or out of the unit, you will tend to have them brushing your chest as you do it.  And it is safe to say that for this particular EMT, that is a more likely risk than it is for say…me.  So, knowing the way Murphy owns us in EMS, clearly the more fetid the toe cheese, the more certain to be a foot-hanger as well.  So, she pulls him out of the back and gets herself a good dose of foot-jam smear on herself, insuring that that while the patient is gone, his essence remained.  She was anxious to get back to her station to change to say the least.  Now, you and I both know that Murphy’s follow-on is that this crew is about to run their butts off and won’t see the station for HOURS…and of course that is what happened to them.  I’ll admit, I heard them dispatched time and again that day, often right from the hospital and I chuckled.  I felt bad for her, but not bad enough to not enjoy the situation.

So, her plight that day reminded me of a call that our crew know simply as “Smelly man”.  I’m not sure I’ll be able to do justice to this guy in words, but if you’ve run EMS for any time, you have surely had your smelly patients, as have we.  However, given all those runs, understand that this guy is know at The Smelly Man and no other description is required.

It was a weekend duty and it was sunny and hot, a real mid-atlantic summer day where the temperature and the humidity raced each other into the 90’s every morning.  It had been that way for a few days in fact; typical for this area.  We get punched on a call for a sickness I think, maybe it went as an overdose, but it is us and the Engine from our second due.  Wayne, as always is there, and in the back I have Jen and Kelly is with me getting some medic precept time for class.  So, it was a fun group and a group of solid providers.  I was feeling good about the day.

We arrive on scene at a middle of the row townhouse and I notice a pretty good police presence right away.  This is not the best neighborhood, so that doesn’t key me up too much as we roll into the house.  There are kids in the front room and all the activity is clearly out the back.  The engine was in ahead of us and I’m getting looks that could best be described as “not good”.  It wasn’t the amped up, “uh oh” look, just a bad look I could not place…that started to concern me.  As I exited out the back door, I see several folks looking down at a Hispanic male, late 20’s I’d guess, marginally responsive laying on the cement slab at the back of the house.  There is this little shed thing attached to the back of the house, like many townhomes.  The shed is like 4’ x 4’ in size and opens to the outside patio area.  The door is open and it looks like this guy had been in there and flowed out when the door was opened.  I say ‘flowed’ because there was also a good flow of a noxious, foul liquidy stuff also flowing out of the doorway and over to where this guy is.  About this time it hits me.  There is a wall of stench that sucks the oxygen out of your lungs.  I recognize it as human waste, but there is more to it that I can’t place.  My eyes almost water and I notice the fire guys already starting to rotate from the patient to the rear of the yard for air.  The guy is kinda responding to questions, but is in a bad way, perhaps even worse than he looks is my thought.  I ask what happened and the story I get explains a lot.

This guy had been reported as missing to the police about 2-3 days prior, by his wife.  Turns out, he was living in the shed on a bender.  He’d been in this little hot box, drinking alcohol, drunk out of his mind and oh yeah, all he’d been eating was the Turtle Wax car wax they had stored in there.  The ooze was his two day baked urine and poo cocktail that he’d been sitting/laying in.  That was the smell: old, baked excrement, sweat and stale alcohol, box for 48-72 hrs and serve hot.  Oh man.  This was one of those times I did not want to be the medic on the call.  There was nobody else to fix this one and I just wanted to run.  It did occur to me that the lady crying just inside the door was the wife, and most likely the kids in the front room were his…nice.  At least they weren’t coming back here.  Okay, let’s just get through this and do what we can to help this nipple head.  I ask the fire guys to get the cot brought around back and they are more than happy to GO do anything.  The fire officer and I agree that we are NOT going through the house, but will take him out the back yard and around the side to the unit.  I don’t want to parade Dad past the kids like that, and he is literally dripping this ooze still and I’m not looking to leave that trail in there either.  At least I didn’t have to tell anyone to glove up on this one.  I try to get some information while the cot is coming and I’m trying to hold this guy up while I assess him.  Jen is starting to dry heave and is not going to make it.  Now the smell is repulsive, and the thing that is my personal puke-trigger is not a patient usually, but if another provider loses it, I’m in trouble.  Jen is turning green and it is going to be an issue I can tell.

We get the cot around, pour him into it, and start to move.  On the way to the unit, the engine officer asks if we should decon him prior to loading him in the unit.  Damn Fine Idea I think to myself and agree.  I don’t want to delay his transport much as I know that the heat and alcohol alone are really bad, his level of consciousness is severely depressed and he is flat unresponsive at times and the last dude on the planet I want to have to code is this one.  (The thought of that intubation, even today, has me gagging).  I figure I can keep his head clear and on oxygen while they hose him and the time spent is going to be minimal.  I’m concerned that we are just going to create a big, wet, dripping, sloppy mess, but then I see that we have already achieved that so there is not much to lose.  (the Solution to Pollution is, after all, Dilution).  We stop just outside the ambulance, and right there in the street, in front of God and the neighbors he gets a shower from the water can off the engine.  Frankly, he could have used a few minutes under the inch and a half attack line, but I was glad for what we did.  I hoped that it would cut down the stench.  As we loaded him into the unit, I quickly learned that it was not to be.  Jen was in a really bad way and we had to send her up front for the ride.  She simply was not going to be able to stand it.  I pulled my Vick’s out of my gear pocket and spread a layer of it under my nose.  I’ve never had to do that before, and I was just hoping it worked.  We opened all the windows in the unit, turned on the blower, had Wayne and Jen open the front windows and run the fan full tilt up front to try to create a rear-ward airflow.  Jen tells me that it didn’t help, they were still feeling it up front.

In the back Kelly and I are doing our best to do what little we can for this guy.  He’s covered in his slime, now dripping and somewhat diluted but still creating a challenge.  We towel him down some, and as I recall the little alcohol prep pads were not close to up to the job.  We ended up spraying the alcohol foam we carry on his arm for an IV site and on his chest to dry him enough for the ECG pads.  The whole time we are fighting dry heaves, at least I know I was.  I tried not to look at Kelly directly, just in case she was looking bad too.  She got her line, and his vitals were not remarkable I believe (don’t recall now, so must not have been THAT out of whack), but his heart rhythm was a bit irregular.  I think his sugar was elevated too, we didn’t give him any en route.  O2, IV, Monitor and transport…there wasn’t much else to do.  He was in a very lowered level of consciousness, but protecting his own airway.  He looked BAD, and not just from the slime he was covered in.  My gut was telling me that, smell aside, we were in a “You may die at anytime, and there is not a damn thing I can do to fend that off, just hang on to the hospital, and I hope you haven’t screwed yourself too bad” situation.

Wayne takes off for the hospital and the breeze through the windows is welcome, but not enough.  We monitor the patient, keep taping to secure the line over a very wet and slippery patient and try to get as much fresh air as we can on the way.  I call in the report over the phone on the way and I try to give the hospital fair warning.  I get a chuckle and an Okay.  “Hear me now, believe me later” I think as we hang up.  Every couple of breaths or so I try to sniff up some of the Vicks..it helps, but only for that breath.  I hear you are supposed to lose a smell after four minutes or so…didn’t happen.  I picture this cartoonish image of the unit flying down the street, Jen hanging her head out the window like a dog getting wind, and a noxious green cloud pumping from the back and sides like we are on fire, plants wilting in our wake.

We get to the ER and Kelly and I bust out of the unit.  She dives out the back, and I shoot out the side.  We must have looked bad, because a couple of the techs and nurses sitting out side on break start laughing when they see us.  I’m sure the dry heaves didn’t help our cause much.  “Laugh it up, we’re bringing him to you.” I tell them as we recoop and start to pull him out.  They are still chuckling as the go to open the door for us.  Then we pass by them and head for the Trauma and Cardiac bays.  “Oh God….oh no” I hear one say as we pass.  Yeah, you were warned I think.  I find the charge nurse and tell her we are here,  I ask about stopping in the decon room, but she poo-poos that and sends us to a cardiac bay.  Your call lady.  We pour him over to their bed, and there are puddles waiting for us on our cot after.  The crew quickly heads out to start hosing down everything and I give report.  I see the nurse in charge here has the same dilemmas I did.  He’s bad and there is a lot that needs to be done, but he has got to be cleaned the rest of the way too.  She gets lots of help as he slips even deeper and is fully unconscious.  I give report, and go out for some fresh air on the way to the report room.

It took the better part of the day to get that smell out of my nose.  No matter how much you wash, change clothes whatever, you still smell it.  I think they did eventually decon him again in their room, I can’t imagine that they did not.  I do know that they quickly got him moved from the ER to the ICU…and that he coded in the hall on the way.  Had to figure that was possible, and it was a big concern of mine while he was with us.  His blood work was all screwed up, turns out you shouldn’t live on Turtle Wax.  He eventually made it, and so did we.  Jen works as an autopsy tech now and deals with dead people and decomps all day.  She confirmed, at the time of this writing that he is the worst smelling live person she’s ever encountered.  Some of the worst decomps beat him, but not all of them.  So, now I have a scale on which to base “Smells bad” and also one for the biggest alcohol bender.  I still carry that Vicks too, just in case.

Video Link

2006-08-14T19:10:00.000-05:00

Oops, as someone pointed out to me on the street, I didn’t post the link to the video mentioned in the last post. My mistake, mind was elsewhere.

Now that's a bad parking job

2006-08-11T20:24:00.000-05:00

Hello, Hello, Hello.  Cat and I are back from the cruise, and Yes, it was the Mariner of the Seas cruise where a bunch of people got sick.  We did not get sick.  We did get drunk, overfed, rubbed down and wrapped in seaweed though.  (THAT was a new experience for me too).  We cleaned up okay, and I even put my formal night dinner pic up on my profile, just to show that I WAS sober and charming at some point along the way.  I saw our friends from the Doubloon down at St. Thomas again and if you ever get a chance to go snorkeling with them DO IT.  They haven’t posted the pics from that trip to their website yet, but I will be sure to link it in when it is posted.  In St. Maarten the 12 Metre Challenge was awesome and once again Cat and I got to crew an America’s Cup yacht in a race.  All in all a week of taking in easy and recharging.  Of course all sorts of “real life” was waiting when I got back, but it was worth the trade.

Someone asked me in person if I was going to post a blog about our 9/11 response (That is 2001, in case you are part of the 30% who couldn’t name that in the recent poll. Morons.) in light of the 5th anniversary coming up and all.  The answer is yes, that I’m working on it, but I’m trying to figure out what stories to include and how to put them.  I did find the video thing I had made and I put it up on youtube a while back.  I forget who asked me for a copy of that, so there ya go.  A “Job well done” to our British friends for kicking ass and making sure that it wasn’t the bad guys who reminded us of the meaning of “Never Forget” this week too!  So, we can’t bring liquids on planes anymore, I can deal with that.  Maybe we can uncover a plot to use small children who cry constantly and kick the seat in front of them for the whole flight as WMDs and air travel will be perfect.  (I kid of course.)

I promised to post a specific call last time, and so I shall.  It happened a month or almost two ago now.  At the time, we were in the middle of a nasty heat and humidity wave (called summer in Northern Virginia).  Temps were in the mid-90’s I believe and so was the humidity.  Basically, you walked around all day feeling like you had huge, hot, dog breathing on your neck everywhere you went.  If you had to be outside, you didn’t want to move, and just sitting around made you sweat like a whore on a slow Saturday night.  Of course, around here, that sort of heat and humidity means afternoon thunderstorms and lots of them too.  “Gulley Washers” was the term I’d heard for them, spotty, hard, fast rains that blow around trees and lawn furniture, drop all sorts of rain, and then disappear in about 20 minutes.  Sometimes they’d cut the heat and humidity, but not that evening.  One thing they did do, was erase any memory of how to operate a vehicle from the good citizens of our county.  You can actually tell where the squall line is by listening to the dispatched for the auto accidents some nights, and that’s what happened here.

The dispatch wasn’t a surprise when it came then, but during the short response, things started to sound interesting.  Cat was working, and I had Wayne, Tess and an EMT named Jon with me (as opposed to MedicJon).  Jon had been doing “good call voodoo dances” trying to gin up something before this, and it sounded like it worked.  The first description was for a head on, then it was three cars, then we heard that there was one car under another one, and that there were people entrapped also, there were injured people walking around as well.

As we are rushing down the road with the engine, I am talking on the headset to the folks in the back.  “Don’t forget your vests”, “watch for other cars” followed by the game plan.  The multiple reports gave the dispatch credibility and it sounded like it was going to be serious.  I knew going in that if someone was trapped a) everyone would focus on them and b) there was going to be very little we could do until they were out.  I didn’t want to miss everyone else on this one.  We had a lot of people coming, Us, our engine, a Squad, a BLS unit and a Battalion Chief on dispatch, and en route the Rescue Chief marks up as on the way.  I knew the first thing we needed was going to be information:  “When we get there, I want the two of you to make a quick pass through the scene and get me a count of how many people we have.  Just ALS and BLS is fine, don’t do the whole ‘Red, Yellow, Green’ thing.”  (We use START Triage here for Mass Casualty calls, and while effective, it would be a bit of overkill on this one.  I just wanted to know how many injured, how bad, and where so I could call for more help, or send people home as needed.)  I told them to get the count and come back to me in person with the numbers so I could request anything else that was needed from command.  So, before we get there, we have a plan.  (Fuster Cluck avoidance 101)

Arriving on scene, I can tell we are going to be busy.  My best guess as to what happened was that two cars traveling in opposite directions hit head-on, and then a third rear-ended the one going north.  This third car was sitting with its entire hood up under the trunk of the car it struck.  There was a cluster of people standing outside the vehicles by a guard rail, and at least one of them had a busted nose that was bleeding like a busted nose. (Clever that).  There were people visible in the front of the north-bound car, and it was clear they weren’t getting out.  The back end, while busted up and on top of another car, was far and away the ‘good’ end of the vehicle.  The front of the car was smashed way back into the engine compartment and there was no appreciable distance between the driver’s front tire and the driver’s door.  (Never good).  The south-bound car was also smashed and sitting off to the side where it ended up. Wayne pulled us past the accident and into a relatively safe position and it was time to go to work.

Jon and Tess hop out of the unit and set about executing the triage for the call.  I walk back and try to take in the ‘big picture’ and sort out what might of happened and what our challenges here could be.  I tag up with the Engine boss, Rick, face-to-face and tell him I’ll have a count and a prioritization to him in a minute.  He’s good with that, and is setting about calling in the situation to the incoming units, securing the cars, checking hazards and setting up for the extrication that we are obviously going to need.  I stick my head into the window of the north-bound car to get an eyes-on on the folks trapped.  There is a 30-40 year old man in the driver’s seat and a 9-10 year old girl passenger.  They are conscious (a real plus) and talking to me.  They are also staying pretty calm, which is surprising, possibly concerning too, but I’ll take it.  He says his legs and chest hurt.  I can see that his legs are clearly pinned under the dash of the car and it looks that while he was wearing a belt, he may have hit the wheel too.  There is blood coming from a laceration to his head, too, but nothing too serious at first blush.  “Okay, you are ALS, probably a fly-out, but lets see whats going on first”, I think to myself.  I know I COULD call for medivac right then and there, but I also know that he’s going to be a while getting out, so there is not much advantage in starting that yet.  The girl says her arm hurts, and lifts it up to show me.  She has a classic “silver fork fracture” to her right wrist.  She’s doing well considering and I have her place it in a way that will support it until I can get her some help.  She’s been in a doozy of a wreck, but was belted, oriented and other than the wrist, in apparently good shape.  “ALS, but can go to the local hospital if need be” I think after the quick check.

About this time, the count is coming back.  I’m trying to recall the first count, but as I recall, the other cars had about 3-4 BLS injuries, all from the same car I think.  During this time, the BLS unit arrived as had the Squad.  The squad was setting up for the cut, and I had pointed the BLS crew to the group huddled by the rail.  I find the Engine IO, who had command, and tell him that I’m going to need another Medic unit and I give him the count.  He asks about the helicopter and I tell him to hold off for a minute, but it looks likely.  He’s getting ready to radio that in, and I’m headed back to direct the EMS activity when I hear someone else calling in patient numbers on the radio.  It seems the BLS lead has done the same thing (Triage and count) and is making a call directly to communications.  I later learn that the combination of radio calls, combined with the slightly different numbers gave the impression of considerable confusion to the Battalion and Rescue Chiefs as well as the additional medic that would be sent to help.  I didn’t focus much on it at the time, but have Jon get into gear so he can climb in and help with the girl in the front car.  Firemen are setting up to hold C-spine, shore-up the car etc as well, and things are moving.  I check in on the trapped driver who is holding up okay, and have the BLS unit sorting through the group of BLS injuries and start treating.  Wayne and Jon are tasked with getting the girl out of the car and ready to go.  She does not need to be cut out, but the car is very close to the guardrail and that is going to give them a bit of a challenge.  I have not put on all of my bunker gear yet, and am trying to coordinate things without lingering in the “hot” zone around the crushed car.  A police officer asks if I can ‘characterize’ the patient.  “Sucks to be him” I think to myself, but I know what he’s asking.  “Right now, he’s serious, but not life threatening.”  The patient count is starting to drop, as some of the people initially identified as BLS are choosing to refuse care for minor scrapes.  The driver’s door has been pulled back, though not entirely removed yet and I can tell from where I was standing that he was going to be in bad shape.  I can see his lower left leg now, and the shinbone that is clearly protruding from his skin.  Any hope that maybe he was uninjured under the dash was gone.  “Okay, get me that helicopter” I tell Rick, and wonder about my ‘characterization’.  I don’t think we’ll be ready for them when they arrive if they leave now, but with the storms in the area, I’m not sure if we will get one at all.  I’m really looking to find out if I’m going to have to drive to the trauma center more than anything else.  The skies are dark and cloudy, and I hear the rumble of thunder in the distance.

About this time, I get a tap on my shoulder and turn around to see one of our Chiefs, Dave, standing there.  “Why is Tess in that car like that?” he asks and I see him pointing.  Tess is leaning in over the girl and doing an assessment.  While she is wearing her vest, she doesn’t have her bunker gear on and I know that is the issue as soon as I see it.  Oops.  Lost track of her assignment, and should have reminded her.  Jon, meanwhile, is fully geared-up but can’t get into where the girl is because of the limited room, and the people already there.  I jog over, pull Tess out, yell to get Jon in there and have Tess go suit up.  Problem solved, and back to work.  Time to suit up myself too, the Rescue Chief, Ed, is arriving on scene, as is the other medic unit and it’s going to be hand’s on time fast.

I point the incoming medic unit over to the little girl, and try to recall Wayne, Tess and Jon so we can get set to take care of our patient, the driver.  His door is coming off I have them get the cot and backboard ready to roll so we can move fast when we get access.  I brief Ed on everything that is going on, and he tells me that he is on it, “Go be medic” he tells me.  I give him a smile, nod and head over to the car feeling like a kid who just heard the bell for recess sound, just as everything is clear and I’m waved into the car.

This whole time the driver has been with the firemen holding his head, talking to him and covering that cut to his head.  Getting back in, I see that my patient is still oriented and talking to me, there is blood on his chest, but it looks like it came from a considerable laceration to his head.  I’m glad the chopper is coming now and I know I’ll have to move fast not to leave them waiting.  All of that occurs to be before I work my way back down to his legs.  I see that he clearly has an open fracture to his lower left leg, just below the knee, and the bone was visible from 5 paces.  His right leg is not clearly visible from under the dash, but looks like it is in bad shape too.  His pulses are good, he’s got clear lungs, is fully oriented and remembers everything.  The squad guys, who came from the neighboring department, did a really good job of clearing things out of driver’s door area, but I have a problem.  The rear of the car is still elevated on the hood of the other car, and this guy is supporting his weight on the one good bone in his lower left leg.  I can’t move him in either direction without pivoting him around that leg.  Thing is, his shin is protruding a couple of inches out of his leg, just below the knee; if I turn him on it, I will de-bone him like a chicken leg at a bar-b-que.  I have the board ready to go next to him, and he’s collared and ready to go, but I just can’t work out the logistics.  I take a step back and look at things again.  Dave is behind me and is pretty straight to the point, I think he sees what I do. “Can you get him out?”  he asks.  “Don’t think so, that leg is going to come off if I turn him.” I respond.  “Want to just take the roof off and pull him out the back?”  is the offer he makes.  I tell him that I think we have to do it.  I know the squad guys are hot in all their gear, but it has to be done.  I’m feeling their pain as I say it, but I feel a bit better when Dave says, “Hey, we always get fancy, and it’s always the simple ways that work.  Shoulda done that in the first place.”  With that, he picks up the tools and starts cutting posts.  “Hey, someone wanna help the Chief cut your car?” I hear from behind me, I think it was Wayne goading the guys on.

In no time, the roof is off and it’s time to try again.  We are going to lay back the patient’s seat (while supporting him), and slip a backboard down behind him.  Then it’s the simple matter of sliding him up the board and into place as we move him backwards over the trunk.  Not all that uncommon a move for an extrication, and one I’ve done before.  Oh yeah, but in this case the trunk rises about 5-6 feet above the ground, and to get him on the board, we will have to lift him until his head is about 8 or so feet up before we can lay him backwards.  One more challenge in the heat.  So, bottom line is, we do it.  It takes a bunch of people and we are all covered in sweat when it is over, but with people standing on the back seat, and someone on the trunk, and two people doing nothing but supporting and stabilizing his mangled legs, me on the ground lifting one side, and someone else in the passenger seat, the job gets done, c-spine precautions and all.  To his credit, he dealt with it really well, you KNOW that hurt.
Okay, I hear two things now:  Chopper is on the ground at the LZ, and the thunder is closing as the rain starts.  The extrication took a total of about 20 minutes, so we really had to move.  Thing was, his legs came out in a slightly crossed position, and he had obvious bilateral open fractures to the lower legs (Bone visible on the left, and a tell-tale opening and deformity on the right, almost certainly an open Tib-Fib combo), and a likely femur fracture as well so I’m not really looking to move them much.  It just means that we are going to have to work around it.  It adds a minute or two in securing him to the board and loading him, but we do it.

Inside the unit, I have myself, Wayne, Tess, Jon and the lead from the BLS unit also named Chris (He ended up with refusals from all of the other folks, even the busted nose which was a bit surprising but I think the folks saw how bad the others were and declined).  Ed sticks his head in to see if I need a hand, notices all the people and tells me that he’ll be right outside if I need him.  Good man.  The doors close and everyone starts asking the patient questions.  My CF alarm sounds in my head and I stop everyone.  “One person will talk to my patient.”  I assign Jon to his head, taking care of oxygen, watching for airway and consciousness issues and documenting answers to my questions as well as getting history, meds and allergies for me.  Tess I assign IV duty.  He is in good shape, or was 0.4 seconds before impact, but has really deep veins that are very much not visible.  She’s the hospital tech and the best ‘stick’ so she draws that duty.  Chris and Wayne get the legs.  I assign them the job of bandaging all openings that were not there before the wreck and splitting/stabilizing in place everything from the pelvis down. (I had exposed him by cutting of his clothes outside).  I am doing vitals, specifically Blood Pressure and ECG, and secondary survey.  About this time I note the pool of blood forming on the floor.  “Where is that coming from?” I ask.  Jon shows me that the laceration to his head is an avulsion, a loose flap of skin, and now that he is laying down, it’s bleeding pretty profusely…More tasking for Jon, but he did well with it.

I find that his head is structurally intact, airway is clear, pupils are good, he’s fully conscious, arms and hands are good, ribs not tender…and I keep getting stopped with information flowing up from the guys on his legs.  They are doing well, and finding deformities and lacerations, and trying to keep me up on in, but we already know that his legs are busted and this is throwing off looking for things that will kill him.  “Okay, wait, I know his legs are busted, you know his legs are busted, Sir,” as I look at him “I’m sure you know this, but both of your legs are pretty badly broken.  I know they gotta hurt, and I’m hoping to be able to help with that.  These guys are doing a great job taking care of them, but I gotta check the rest of you so I don’t miss anything.”  I tell the guys that basically, if it isn’t pumping blood into the air, I don’t want to hear it until later.  About then the Battalion Chief sticks his head in the back.  “Hey, I know you are working here, and you do what you gotta do, but I just want you to know, the storms are really close and the chopper may not be able to lift off if they don’t get going soon.  I don’t want to rush you, just let you know.”  In my head I’m laughing, no pressure.  Oh, and Tess now reports she has missed her first IV attempt.  I tell her to look again, and finish the assessment.  I find his abdomen to be very rigid and tender on one side (Left I think now).  Damn, that’s the thing.  The head avulsion is bloody, the legs are going to take a lot of surgery to fix, but this possible internal issue in his abdomen can kill him right now.

I take note that his ECG and vitals are about right for someone in his shape, tachy, but decent pressure etc.  I try for an IV on my end, and blow it too when he flinches a touch.  I tell Wayne to drive, and as much as I hate rolling without a line, we GOTTA go.  Tess and I are searching on opposite sides while we go to the Landing Zone and she gets hers.  It isn’t big, but it is in and I’m happy.  The flight medic and nurse hop in and get report.  It takes a while to list all the fractures and lacerations, but I make sure to point out the abdominal issue as well.  I note as we get to the LZ that I’m getting less lung sounds in his lower lobes, another sign of  possible internal bleeding and pass that on.  The flight medic give me a little “no shit” as he listens behind me.  We all move quick, once again racing the weather.  The crew is out in it longer than they probably should be, but they are glad they are here to help.  He gets moved to the chopper and off he goes as the rain gets a little heavier.

We head back to the unit and start to the hospital to clean up, restock and write report.  I hear the ambulance get called back to the scene for that guy with the busted nose as we start to move.  All of our bags from the scene had been tossed in their unit, so I radio to tell them not to worry, we’ll meet them there and sort it out.  It was only after I unkey the mic that I realize that what I said was, “Go ahead and pick him up, we’re going to head back to [the hospital] and start hosing out the unit, we’ll meet you there.”  Hmm, ‘hosing out the unit’ is not normally heard on the air, but whatever.  Ed has been asking about the patient’s birthday for the police I think, and I didn’t get it.  I also advise him that he can tell the cop that he is in a life threatening condition now…Ed already had.

Okay, now the punch line:  So, we are at the hospital, Wayne and company did get the hose out and everything cleaning up etc.  The little girl was there and looked good but with the broken arm.  Ed meets us at the hospital to make sure everything is cool and has some news.  It seems that the patient’s girlfriend or wife (Forget which) works as a nurse too, but wasn’t with them because she was working…at the Trauma center we just flew him to.  And I thought I was under pressure with that call that night.

Catch and Release EMS

2006-07-22T00:28:00.000-05:00

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

A clarification

2006-07-06T16:50:00.000-05:00

To those of you who have been emailing and/or calling me wondering about my copious use of the third person, Cat was telling the story for the last post, The not so calm before the storm. She had a problem with the software we use to push the articles, and was logged in as me. While Chris is not immune to the Medic Ego, Chris has not reached the point where he must now refer to himself in the third person just yet. Grin. I was on the bench for the business end of that call, and it was Cat's story to tell. That group did a great job and I'm proud of them. -- Chris

Not-So-Calm Before the Storm, continued

2006-07-05T11:02:00.000-05:00

The elation of saving a life was being tempered by hearing that our patient was deteriorating. We know we did our job and did it well; we cleared and secured the child’s airway and he was stable with good vitals upon turning him over to the ED staff. So what was happening? Respiratory had intubated the patient and had been suctioning secretions from the patient’s lungs. With airway trauma it is not unusual to see such secretions, however as time went by the secretions became thicker and darker – an ominous sign. The patient had most likely aspirated a piece of hot dog down into his lungs; the lungs react to such an irritant by producing secretions that the body tries to cough out, taking the irritant with it. However, these secretions can become thick and difficult to cough out, and patients who are unconscious (like our patient) cannot cough at all. Secretions in the lungs build up and block oxygen from getting into the blood, and can develop into pneumonia over time. Our patient needs to be in a pediatric ICU but our local community hospital doesn’t have one, hence the decision to fly the child out.

While the charge nurse was waiting to hear from the last med-evac service, we made the decision to wait for that call and be available to make the transport by ground if the helicopters can’t fly. By department policy we do not do interfacility transports. As an emergency service we have an obligation to our community, and therefore don’t like to take a unit out of service for the time it takes to transport a patient to a facility 30 minutes or more away (and that’s at response speed without bad traffic). In this case, however, we as a crew felt like this was still OUR patient to some extent and wanted to be a part of his continued care. Chris called our chief, made the arrangements, and made a new best friend when Chris relayed this information to the charge nurse. She knew her hospital wasn’t equipped to deal with this patient and was worried about how long it would take to get the child to an ICU if a helicopter wasn’t possible. By this point the rain had begun and shortly thereafter the call came that there would not be a helicopter coming; we were a go for ground transport.

An ED nurse was assigned to travel with the patient in our unit, an assignment she was less than pleased about. First of all, she was a half hour from the end of her shift and this transport was likely to take an hour and a half or more. Second, she had already made this run earlier in the day with another patient and another unit, an apparently the driver was new (actually, he was first day new) and got a little excited during the transport, throwing the crew in back (including the nurse) all over the place. She half jokingly asked Chris if this driver was new. Chris responded that as Captain he gets his pick of driver from anyone in the department, and he chose Wayne to driver for him. At this point Wayne walked into the room and pointed to the embroidery on his uniform shirt that said “Captain’s Driver”. The respiratory therapist got a chuckle out of that one. The nurse’s other concern was the level of training she would have helping her in case the patient crashed on the way. Chris grinned as he informed her of the credentials that would be traveling with her. Three nationally registered paramedics and one intermediate-paramedic, one of whom is an instructor, all of whom are PALS (pediatric advanced life support) and PEPP (pediatric education for prehospital professionals) certified. Combined we brought just under 40 years of EMS experience to the table. I believe that helped the nurse feel a bit more comfortable.

So for the next 10 minutes or so while the ED was preparing the patient for transport, we got our unit ready. Our patient was sedated and intubated, so we assembled every piece of airway equipment we might possibly use in the appropriate size for a 2 year old and set them out on the counter so they’d be immediately at hand if needed. BVM, suction and airway adjuncts were staged on the counter beside the cot, low oxygen bottles were replaced will full ones and the main onboard tank was checked. Monitor batteries were changed and Chris got the phone number for the PICU we were transporting to so we could give report en route. The nurse got orders from the ED physician for additional paralytics and sedatives (in case the meds wore off and the patient started to fight the ET tube), and collected the medications and syringes she would need. This can be dangerous because if a patient starts to wake up and strains against the ET tube it can become dislodged. This would require us to extubate and reintubate the patient during transport, a situation none of us wanted to be in. Meanwhile, we had been listening to radio traffic from the west end of the county that were reporting heavy rain and wind and numerous road closures due to flooding. This was the storm heading in our direction. No pressure.

The transport went smoothly, in part due to diligence in monitoring our patient and in part due to Wayne’s driving. He had to weave us through a massive construction zone at the junction of several major highways just south of Washington, D.C. (locals refer to the area as “the mixing bowl” due to all the exits, overpasses and signs concentrated in the area), which he navigated with precision and confidence. So you know, Wayne used to drive big rigs and now does mechanical work on fire apparatus so he really knows the unit inside and out and can maneuver it through traffic like no one else in our department. (Remember Chris hand-picked him to be his driver, and for good reason.) Anyway, despite one idiot driving a sports car who tried to whip around and cut us off on the highway (unsuccessfully, by the way, thanks to Wayne), the transport was smooth and uneventful. The patient’s oxygen level remained between 98% and 100% throughout with us bagging him, and we used capnography to help maintain proper breathing rate and ensure that the airway remained patent. Blood pressure and pulse were also stable. Arriving at the ED we were relieved that no problems arose while on the road. Enter Murphy. Just as we were sliding the cot out the back of the unit the patient started to wake up and fight the tube. Time for more meds, NOW. The nurse whipped out her “goodie bag” and gave additional doses of Versed (a sedative) and Vecuronium (a paralytic agent). That did the trick, and within seconds out patient was comfortably asleep again. A quick check confirmed that the breathing tube was still in place, whew. Ahhh, such wonderful drugs we have. It reminds me just how much we can really do for our patients in the field. As I like to put it – better living through chemistry. But I’m getting off track….

We found an employee to guide us to the PICU because only one of us (the nurse) had ever been there before. When we asked if she remembered the way, she said no and then told us that the only time she had been to the PICU was when her own child was being taken there, so she wasn’t exactly paying attention to the route; completely understandable. (Her child is fine, by the way, and has made a complete recovery.) So we make it to the PICU without any further changes or complications. We gave report to several pediatric nurses and an MD as we helped transfer the patient to the hospital bed. It felt good to be able give complete and accurate answers to every question the doc asked including drug dosages, tube size, CO2 levels, vitals (we had about 5 sets of complete vitals) and a complete history of the patient’s condition since the incident occurred. The doc asked about the hot dog the child had choked on and seemed pleasantly surprised as I said, “Here you go”, and whipped out a specimen jar from my pocket containing the hot dog and handed it to him. Now it really was job complete, time to relax.

As we left the hospital to return to our own area, the western sky was black and moving in our direction. We were exhausted and decided to make a coffee stop on the way back despite the approaching storm. I suppose someone up there decided to take pity on us because the rain held off until we had gotten our caffeine and made it back to our base hospital. Within minutes of pulling into the ambulance bay, however, the sky opened. It was quite a show; a very active storm with lots of lightning and swirling clouds. Kind of fitting I suppose, watching the storm release its pent up energy while we were decompressing from a very stressful call.

After the call while we were restocking the unit, Chris was pulled aside by the ED doc who treated the patient when we first brought him in. The doc praised our crew for a job well done and said that the call went perfectly, and that we had without a doubt saved the child’s life. He went on to suggest that the entire EMS crew and engine crew members (who had jumped on our unit to assist) should be commended, and offered to write a letter to that effect. It’s not often that we get to make such a significant and immediate impact on a patient’s life, and having the treating physician take time to give us such positive feedback really made us feel great. Calls like this are why we do this job.

(As of this posting we haven’t gotten any follow-up information about our patient from the secondary hospital. I’ll certainly post an update if and when I get any information.)
-MedicCat

No-So-Calm Before the Storm

2006-07-04T15:44:00.000-05:00

Storm clouds were gathering that day, a typical occurrence for Virginia summers. The weather man was calling for possible severe storms. Doesn’t take a genius to figure that one out, just go outside and look up, duh. We were running a stacked medic unit that day, me, Wayne, Tess (who just passed her national registry paramedic exam!), and Scheila (a veteran medic and our department’s training coordinator who was getting some time on the unit with us). Notice Chris is not on the roster, and remember what happened last time he left me in charge of the unit? (See posting titled “Marines Rock!”) The call was for a choking. Typically the choking part is over by the time we get there and the patient just needs to be checked out. Not this time.

En route, we find out the patient is a 2 year old choking on a hot dog, and instructions were being given by phone on how to remove a foreign body from the airway. Now it’s time to change gears. Approaching the scene we see a large group of people in the area, apparently there was a barbecue going on in the neighborhood. A woman (the patient’s mom) rushes over with a limp, barely breathing child in her arms and hands him to one of the guys on the engine who promptly turns and rushes the child into the back of the ambulance while doing back blows to try and dislodge the hot dog. Unfortunately, while this was happening on one side of the unit, I had gotten out of the other side, grabbed bags and was headed towards the group. One of the medics I was working with that day yelled to me that the patient was coming to us, so I turned around, but not before 4 or 5 of the patient’s family members had gotten in front of me and were piling into the back of the ambulance. So while 3 members of the engine crew and the other 2 medics with me that day were beginning care for our patient, I was trying to remove all non-EMS personnel from my unit. Anyone who has run a serious call like this knows that you don’t need family in the back with you while you work on your patient. Family members don’t need to see what we need to do to save their loved one’s life, and in addition to being an emotional mess and therefore a distraction to us, sometimes family can interfere with patient care. It’s hard enough to focus on all the details of our work without a parent getting in the way or arguing with us about what we’re doing. So bottom line, tickets for the back of my unit are reserved for my crew and my patient only.

Once I was able to get into the unit I could see that the crew was busy; being aggressive in cases of airway compromise are key to being effective in our interventions. This poor kid was in a bad way. He was limp and listless, skin had taken on an ominous grayish color with blue creeping in around the lips. His breathing was coming in short, gasping breaths which were slowing down. The BVM was in place and we were ventilating, but could tell there was an obstruction. Out came the laryngoscope to get a better look. The airway was full of sputum and blood. Apparently the frightened mother had gotten a little carried away trying to do a finger sweep and remove the hot dog before we got there, and based on the amount of trauma in this kid’s mouth and throat I’m betting she had some serious finger nails. Suction cleared most of the blood and revealed a good sized chunk of hot dog almost completely blocking the child’s airway. The problem was compounded by the fact that it was lodged behind the epiglottis in the opening of the trachea. It was too big to fall completely into the trachea (thank God), but it was big enough to block the opening and the epiglottis was holding it firmly in place. That explains why the back blows we did were ineffective. Spontaneous breathing had all but stopped and the child’s oxygen level was in the low 80’s and falling. Scheila grabbed the Magill forceps and went after the hot dog. At first only a small piece broke off, but on the second try the rest came out. We immediately got O2 back on the patient and bagged aggressively. Then we heard one of the most wonderful sounds a medic can hear when dealing with a non-breathing child – crying. Yes! Crying means we’re moving air. Crying means breathing. “Wayne! Fast but smooth, GO!” I yelled through the window. Within a minute the gray color was being replaced by a pleasant pink and our patient was breathing on his own.

The low rumble of thunder was audible in the distance as we pulled onto the road and Wayne lit up the siren and stomped the gas. At this point I got on the horn to the ED to give them the heads up. Our patient was still breathing adequately, the crying was decreasing and he appeared sleepy which wasn’t too worrisome considering what he’d just been through, I’d be exhausted too! We roll into the ED a mere 7 minutes after marking on scene. Hey look, there’s Chris! He had been listening to the radio traffic and came up to the hospital POV to meet us. Chris had gotten there ahead of us and gave a heads-up to a nurse outside the ED. Upon hearing that we were rolling their way with a pediatric patient with an obstructed airway, the nurse sprang up and asked if we had called in to notify the ED yet. Chris assured her that we would if we hadn’t already, he was just trying to give them as much warning as possible. About that time our sirens could be heard approaching the hospital. The MD, respiratory therapist and nurses took over as we gave report. We also gave them the offending hot dog piece (.

A sigh of relief and high fives all around. There is no doubt that this child is alive today because of EMS. This was definitely one of those calls that reminds you why we do what we do. We all took a minute to decompress and then started cleaning and re-stocking. Life saved, job done. Well, not exactly…

The rumble in my tummy was second only to the thunder as I remembered that before this call we had been making dinner plans. The crew had decided to splurge tonight and order dinner from Outback Steakhouse, and Chris walked outside the ED so he could get a cell signal and call the station to start coordinating food orders. A staff member outside pointed to the lighted helipad and said to Chris, “They’re flying your kid.” “What?!? He was stable, what happened?” Chris asked. She told him that the patient had gone unconscious and his vitals were deteriorating, the ED charge nurse was waiting for a call from the helicopter service to see if they were flying. Chris looked up at the darkening skies and doubted that any helicopter could fly. As it turned out, the services to the north were experiencing a downpour and could not take off. One of the services to the south was pinned between two storms and couldn’t fly. The other service to the south had still not called back yet. The charge nurse was hopeful though, the pilots of this particular service are mostly retired military, specifically Vietnam combat chopper pilots who fly under most any conditions. Chris returned to the EMS room to give us the update.

And you thought the story was over…. stay tuned, there’s more to come.
- MedicCat

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

2006-06-16T19:27:00.000-05:00

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

2006-06-03T23:52:00.000-05:00

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

2006-06-03T23:31:00.000-05:00

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.

Anatomy of a Butt Kicking pt 2

2006-05-24T21:42:00.000-05:00

Well, that was a long post.  I’m going to try to keep the individual calls short here, and focus in on the more fun or interesting points.  I’ll list them all though, just to lay out a timeline.

Okay, so last time we left our dashing hero leaving the hospital and heading out for a well-deserved meal (notice no mention of lunch in that last post), after saving the damsel in distress from vehicular doom.  The crew was feeling pretty full of ourselves, and ready to take on most anything.  Wayne had the radio playing and we were jammin’ in the cab of the unit.  Wayne was thinking a sit-down dinner was in order in light of our day’s adventures.  “At what point in the last 4 hours did you think we were going to get to sit down somewhere and eat?” I ask him and laugh.  All I get is a smirk from him.  We agree on Thomas’, it’s a small Italian deli type place in a strip mall with good Calzones and tables.  I figure we can get things to go, and just sit and eat.  Of course, as we are pulling around to the parking lot….

1752 – 1805:  We get hit for an auto accident in our second due to our south.  The intersection of 234 and 1 is a good site for them.  This one is just up the road from there, but means that while the response down is not too long, the ride back in traffic will take a while.  As we pull out of the parking lot, I notice a lady laying in the grass next to a Checkers.  Nice day for it, the weather was perfect, mid 70’s (not Celsius ya ozzie) and sunny, breezy too.  At any rate, better than driving today I think.  “Put on your vests!” I yell back to Cat and Jon and we are off.

The engine is already there, along with PD when we arrive.  The second due engine is staffed with a bunch of guys from our department who have gone down to fill in while that station does training or some such.  It’s odd to see them running calls in the wrong unit, but good for a chuckle.  There is not much to the wreck, and everyone is parked in a gas station now.  One guy is an asthmatic, and the dust from the air bag messed him up some, but he hit his inhaler and was feeling better. Cat said his lungs were clear and he didn’t want to go to the hospital.  I smile at Jon, and hand him the refusal form. “I believe you know how to use this…” and off he goes to collect the signature.  I chat with the PD Sergeant on scene, and comment on the rash of accidents going on all over.  Must be the nice weather…start of stupid season.  We get the paperwork signed and start the slow drive back to Thomas’.  I start sending a text message to MedicJon when he calls me.  No kidding.  We are enjoying a chuckle, and he is telling me I’m a puss for not running calls as we pull into the lot at the restaurant.  I notice the lady who was in the grass before walking up the sidewalk with what could only be described as a very ‘unsteady gait’.  She’s drifting towards traffic.  “Wayne, that’s a patient” I say to Wayne, and “Uh, I gotta go…no kidding” to Jon.

1821-1849:  I hop out of the unit and jog up to the lady.  “You okay?” I ask.  She turns and smiles.  She looks dirty in a “I’ve been outside all week” kinda way, and has white something or another on her lips.  She says, “I’m TIIIIIIRed.  I been up THREE days.”  “Wow, space cadet.  Helloooo Major Tom” I think (Some people call her Maurice maybe?).  Well, it’s a call anyway.  I radio back to communications that I’m on the scene of a sickness, and pick one of the stores as an address (Actually, I used Thomas’ address).
I have to help hold her up as we walk back to the unit.  Cat and Jon are coming over, surprised that there is a patient and not a pizza in their immediate future.  She climbs in the unit and proceeds to tell us that George Orwell told her that there is no such thing as liberty, and (more to the point) that she stopped taking her psych meds.  (Winner!)  A look through her bags finds Haldol and Cogentin bottles, both full.  My mind trys to think of how big a party that represents, and wonders how psychotic you are to get a big bottle of anti-psychotics.  Her vitals are stable, and she likes the cot.  She rambling about reality or something, and laughing at her own humor.  I smile as I dial the hospital…they are gonna love me.  “Picked one up off the street…” I start my report.  That went over well.  I explain that I have one for “room 10”, the psych room.  When I get there, the Charge Nurse asks how gone she is and I explain that while I’m not a shrink-ologist I believe the DSM-IV would classify her as “Nucking Futs.”  The nurses get a chuckle and go meet me in 10.  We get her dropped off, and she tells us the hospital beds are even better than the cot.  The charge nurse tells me “Enough of the Good Samaritan stuff…stick to the ones that call..okay?” and she laughs.  Jon tells me that he has never had a psych patient, but the grin on his face tells me he enjoyed his first time.  The turnover and report go fast, and we are back for dinner….again.  This time, we don’t even clear the parking lot when the MDT twinkles the “You’ve got calls” tune.

1850-2003:  I hear Jon and Cat moaning at the sound of the alert, even as I am giving our battle cry de jour, “Put on your vests!”.  MVA, same intersection as before.  New wreck, this time word is two kids are out on the grass, unknown if ejected or removed.  Wayne has a special gear for that, and I hear the unit shifting into it as we clear the parking lot and dive into traffic.  The engine crew was there again, and we got a basic too.  A buddy of mine who is the Rescue Captain of that department came along…calls with kids will do that.  A quick size up shows only the kids as possible patients, and it is very clear that they were NOT ejected.  Grandma took them out of the car and set them on the grass.  The basic crew, some of the engine the crew, and Cat and Jon were checking out the kids.  I chatted with the Captain for a bit, and bemoaned a lack of dinner.  I was thinking refusal or BLS transport, but then they said another lady had an ankle injury…three patients, means two units to transport…we got business.  The basic asked for the ankle, so we got the kids (age 5 and 7)  They looked and behaved fine, but had said that their back and necks hurt, so had people holding c-spine.  We have to Pedi-board them.  They are NOT happy about it, and are screaming.  They start swearing they are okay, and we check with Grandma.  She wants them checked, so we slide up behind them, lay them back and board and collar them as they try to fight us off.  I’m not fired up about traumatizing a couple of kids, but we gotta do this right.  Long, tearful, wailing story short…we haul them to the ER.  The older one wants out bad and pulls at his straps and squirms as we re-secure him a few times, the younger one gives us a scare by using sleep to cope.  He opens up when we call him and all is well.  We take them to minor care, and give parallel reports to the nurse.  Okay, Dinner…really…

We get back to Thomas’, even get to order.  Good thing too, because we are all starting to loose our sense of a good time here.  Blood sugars were getting low.  They toss in the drinks for free, and having seen us drive through the lot and respond off a few times, they promise to take good care of us. Mmm, Calzone.

2020-2023:  As we are waiting for the food to come up…the call comes.  Auto Accident, of course, this one just up the road.  Groaning, we pile back on the unit and put on our vests of course.  We make it just up the road when the engine gets on the air and declares the accident PDO (Property Damage Only) and we are put in service.  “Thank God for small miracles” I think, and Wayne pulls a u-turn and we go back.

This time dinner is waiting, and smells GREAT.   We even got to eat it back at the station.  Calzone and Onion Rings are NOT on the diet, but sure tasted good.  Jon is saying that he is getting some calls he has not had yet, and is pretty excited about the way the day has turned out.  I plow through dinner and head over to the radio room to log the days events, when I see the guy on the ramp.  “Dear God, please let him need directions.” I think.

2106-2114:  I open the door, and the guy asks if we can check him out, and look at his blood pressure.  Sure thing, come on in I say, and I have Cat walk him back to the unit.  I go to the CAD terminal and message communications that we have a walk-in, we are on the scene and don’t need any help.  They acknowledge, and I hear the dispatch hit the air.  I go back to the unit, and climb in to hearing Cat talk to the guy.  It seems he was in an accident (of course) a few days ago, and is feeling stiff in the neck.  He was checked out at the time, and has a bruise to his right ribs, but was okay.  He was concerned about his pressure, and while a little elevated, it was not bad.  Looked like someone in pain.  He said he’d take something over the counter for pain and see his doc on Monday.  Another refusal and we are good to go.  It has gotten dark and we walk back to the trailer to finally relax.  For a solid seven minutes.

2122 – 2140:   We get sent with a basic unit (a good sign) to an injury in our first due.  Injuries from a fall.  Further information is a baby of like 10 months fell from bed.  No, another message says Dad dropped it.  (Paging Mrs Spears…)  Baby is crying the dispatch conveys.  Sounds odd, but the description makes it sound pretty minor.  The ambulance gets in ahead of us and beats us to the scene.  (Wayne later explains to Jon that that was not a coincidence, they ALWAYS seem to be able to “smoke us in” on BLS calls.  Must be something about the roads….).  En route, we all make the critical patient care decision to go to WAWA for coffee after the call.  We enter to find mom holding a baby, still sniffling some, but basically calm, curious and wary of strangers.  There is no laceration, on consciousness issues, and everyone but mom seems calm.  Dad is downstairs in the basement apartment, and I have someone take me down to see where it happened.  The BLS crew is checking the baby, with Cat peering over their shoulder when I get back.  There was nothing remarkable about where it happened, though Dad seems surprisingly disinterested.  (Something I passed on to PD when they got there.)  The basic crew said they were good to go with the call and we head out.  I hear them marking clear with a refusal a short time later.  Coffee time!  (I recommend the Kenya AA, good stuff when it’s fresh…kind of a warm wine taste to it.)

A bit of time passes and things are a bit more calm.  I know there is more to come, so I lay down with my boots on for a couple minutes.  I have 8 years of station 12 living, and I know how these days go.  It’s far to early to stop, and you rest when you can.  Wayne, Cat and I are starting to share inside grins and comments.  Jon is hanging in so far, but slowing just a touch.  We know we are not likely to sleep much, and we know it will hurt, but then, we are also sharing a bit of “good old station 12 butt-kicking” veteran camaraderie too.

2317-0035:  We aren’t disappointed.  Just after 11pm, we get hit deep into our 3rd or 4th due for and unconscious diabetic, 23 or so year old female.  It’s going to be a bit of a haul there, so I’m hoping she’s not out TOO bad.  The first due crews are there fast, but I don’t hear anything over the air.  We eventually arrive to find 5-6 20-somethings standing outside a townhouse.  They are all hammered.  They were at the chili-cookoff in DC that day and I smell the alcohol at 10 paces.  I’m starting to think the diabetes has little to do with it.  Upstairs we find the girl laying in bed, with LOTS of people around her.  A dexi comes back okay, so we know her diabetes is not the issue.  She apparently talks some, so I weave in and ask her what’s wrong.  She eventually moans that she is tired.  No shit.  She reeks of stale beer.  At one point she says that she does not want to go anywhere.  Well, To F’in Bad.  I’m not letting her refuse.  I am thinking that there is no way that one holds up in court.  I have the crews bring up a reeves and get the cot ready.  We flop her onto the reeves with no reaction.  I’m asking about possible drug use, and she swear no.  She did say that she was the Designated Driver, so she only had “3-4”.  Nice, the unconscious one is the DD and the ‘sober’ one.  Good plan kids.  The girl is best described as “pliable”, she basically sleeps the entire time we haul her through the house, down the stairs and out the door.  (the halls were very narrow, and we could only get one person on each end of her.  I had to carry her head directly in front and beneath me.  I described it as the “tea bag carry” to the ER Tech…that one got a chuckle. For a visual, but not at work!  Okay, bonus points for the dude’s tee shirt…that’s funny!  She didn’t react the whole time, she was out.)  We get a stable set of vitals, good ECG, and a line. No trauma, good dexi level.  She’s really gorked, and we start talking about why on the way up to the hospital.  I let her boyfriend, who I put at a BAL of .2 up front with Wayne.  (I love the look the truly wasted get when they are trying to be serious). Everyone there, including boyfriend, says that there was no chance she got slipped something in a drink too.  She takes a med for low blood pressure (pressure is fine) and has flexoril for back pain.  She said that she didn’t take the flexoril because she was drinking.  Jon is thinking something heat related because of some sunburn she has, but we kinda doubt it.  We are really leaning toward the beer + Flexoril solution.  When we get to the hospital, the boyfriend tells me that HE gave the girl her B/P med that night…making me even more confident in the drug mixup.  The techs at the ER get her prepped pretty fast, and she does not react at all to being disrobed.  The Nurse comes in and I am able to give report.  As we get ready to head out, Wayne thanks us for giving him the boyfriend.  It appears that when Wayne hit the first intersection and turned on the sirens, he started to hear “woo, WooooOOOoooo” from the guy in the passenger seat.  My Boy played siren all the way to the hospital.  THAT got a laugh from all of us, and a plan is immediately hatched to use the PA system and a “woo WoooOOOoooo…I’m am ambulance” up the street on some early AM call, but only past a Police car.

I actually got into bed and started to drift after that one.  Of course..that only makes it hurt more when..

0107-0206:  Damn, woken up, JUST drifted off, and I hear those words we at 12 hate…”Box 12-01, for a sickness…” Wayne, Cat and I all say the address in unison…the Fossil Farm.  This time it is for a lady we have taken to the hospital before.  She’s a former nurse, is deteriorating fast, and has a real issue with the staff there.  I don’t blame her for that, of course, but she is developing a pain med issue and has a habit of calling us directly without letting the staff know.  This time the staff is calling us, and they are pissed at the patient.  We get in and out fast so they don’t argue.  The stories don’t match, of course.  Staff says she refused her meds all day, She says she was in dialysis and they forgot to give them when she returned.  Staff says she is on fluid restrictions, but drank about 32 oz of Orange Juice.  She says she has no restrictions.  As we get in the unit she is telling us she may code.  I’m telling her she better not.  She says that the last time she went to the hospital, she coded, and she remembered it all. (she didn’t like being shocked).  She was in A-fib, rapid ventricular response, and a blood sugar that read “HI” on our unit.  Lungs clear, BP good.  I thought I recalled her having crap for veins, but I it it on the first run.  Well Hot Damn.  “you got good veins after all.” I say…”Like hell,” she says, then looks over, surprised, at the access in her arm.  I reach over to get the end of the IV tube from Jon, and he’s zoned for a minute.  I bust his balls a bit (verbally, not literally) and he snaps out.  He’s just tired, and hitting the wall some.  I see Cat start to dive towards me and look down to see that my finger has moved, and I’m no longer blocking off the catheter correctly.  I have blood flowing off her elbow, down my shin, over my boot and on the floor.  (told you I got that line!)  A pretty solid stream of obscenities  go through my head, and I snare the line and place it quickly.  Cat blots up the blood with a towel, and I spray my pants with a disinfectant.  It seems fatigue is sneaking up on us all, but I’m displeased.  The patient is stable, if unpleasant, and we get her to the ER.  I give all her paperwork and report to the RN, and explain the possible stories.  The unit gets a quick mopping as well as restock, and we get back to the house.  We enjoy a grin at our day again, and know we are showing Jon what running a Medic “is really like”.

0218-0234:  We aren’t back long when we get sent with the engine for an assault.  Some dude has shown up bloody at a 7-11.  We are told to stage and head over to a nearby McDonalds to wait and see.  We are sitting there a while, tired and bored when I look at Wayne.  “Hey, look into the cab of the engine…they look mostly asleep?” I ask.  “yeah.”  Grin… “Okay, when I say…turn on the lights, haul ass forward and circle the McDonalds.  Don’t go to the call, just come back here.”  “yeah, right.” Wayne responds.  I explain that I’m dead serious, and a big ole shit-eatin grin comes over his face.  I grab the PA mic, turn it all the way up…”LEROOOYYYY JENKIIIIIIINS!” I cry into the mic, and Wayne takes off.  He whips around the building, lights on, no sirens, and about half way, I have him kill the lights.  (Turns out there are other cars in the lot over by a bar…ooops)  As we come back to the start, we see that the engine has moved, and started towards the call.  Oh Shit!  “Turn on your lights so they see us!”  The engine stops. Pauses, and starts to turn back.  Wayne and I chuckle like 10 year olds at a fart contest.  I put on a straight face as the engine comes back and the driver pulls up by Wayne’s window.  “What the hell was that?” he asks.  “Sorry, I was bored” I explain.  The look on his face was classic.  He bends down Wayne’s Fisheye mirror and pulls off to turn back into position.  Wayne and I laugh so hard we cry.  I can hardly breath, and I’m pounding the mapbooks.  We pull it together, and I text communications for a status.  Shortly after we are placed in service by PD.  We are still chuckling as we get back to the house.  I crack me up.  Time for bed again.

This time, I even break into REM…..

0445-0528:  We get woken up to run to our second due to the north for difficulty breathing.  The patient is a little old lady who woke up and was scared.  She is friendly and lucid, but we check everything just in case.  Good BP, clear lungs, Dexi is okay, ECG is fine.  In short, pretty damn good for 85 or so.  She told me that she woke up nervous. I asked if she had a date that she was nervous about, and that got me a smile and a denial.  She has been a friend of our department for quite some time, as evidenced by a sticker on the window by her door of an old logo we had.  We mostly chat for a bit, and she decides everything is okay.  We have her sign a refusal, and tell her it’s good to see her, that she can call anytime.  Then we head back for the beds.

I tell Jon that we might be done now.  Too late for the drunks, too early for anyone to wake up dead.  I explain that pretty much our only issue is heart attacks.  Chest pains waking people up to call us.  As we climb into bed, a call goes out for another medic unit nearby…Chest Pains.  I smile and pull up the blankets.

0652-0703:  The sleep of the just was broken by a string of tones.  A fire call.  Well, that’s different, I didn’t think there WERE fires anymore.  (grin Matt)  Turns out I was right.  We respond off into the risen sun and stage.  It’s food on the stove, or smoking dryer or something generally not on fire yet.  We are placed in service and head off to WAWA.  It’s time for some Kenya AA.

The shift ended, we ask Jon how he liked it.  He’s enthused and tired, and may even come back.  I assure him that there is more where that came from.  We double check the unit, and pack up for the day.  I photocopy a log of our calls to write this from.  All in all, probably no lives saved, but a good dozen people helped.  Some bad, some not so much.  But, they called, we came, and even got a couple Thank You’s for the run.  We cursed, laughed, and told stories.  All in all, it felt good at the end.  We were tired but content, and we are all looking forward to next time.

Anatomy of a Butt-kicking Part 1

2006-05-22T23:10:00.000-05:00

Alright, as I promised earlier, (and I hear expected by several of those around me) I am finally getting some time to lay out a good solid busy day-in-the-life of a medic at DTX.  This Saturday had us staffed from 0844 until 0720am Sunday morning.  During that time, we got 16 runs.  While not a record setting day, it is certainly a full one.  That we had a rider with us, a lead EMT off a sister unit looking to “See what being on a medic is REALLY like” was just a case of perfect timing.  I don’t know if this will all fit as one post...but we shall see.

The story really starts the night before, at one of our other stations, with DTXMatt and I playing poker with seven others.  I had a weak night and went out somewhere in the middle.  Matt played well, but was up against one of the longest hot streaks of cards I have seen.  During that game, Matt shows us an online video that is funny as hell (Leroy Jenkins! -- link below).  We laugh and I promise to use it on duty.  As a result, I arrived at Station 12 about 0230 Saturday morning, and crashed out on a sofa in the main room of one of the trailers.  There were bunks available in the ‘medic bedroom’, but the basic crew on duty was in there, and I did not want to wake them.  As it turned out, they ran quite a bit.  I would not have disturbed them much, and I should have seen it as an omen.

Morning came early and I awoke to see the Engine boss on duty with his little boy on the sofa asleep.  Cute.  They played some as they awoke, and it was a good way to get going.  I got changed and washed quick, started coffee, had a breakfast bar (we have priorities and good thing too!) and went out to check the unit.  Our rider, Jon (not MedicJon) was there and helped by checking out the engine while I did the back.  Cat and Wayne showed up and jumped in getting ready.  A quick tag up on the plan of the day:  run calls and stay out of the bay as much as possible…it was being painted by the renovation crew that day.  That also meant parking outside too.  I had eaten, but the others had not, so breakfast was next in line, we pick a place to meet the engine for breakfast and we were ready to tell the county we were good to go.  The county must have sensed that because as we were doing the final nods-all-around that everything was good to go, the tones dropped for a first due “sickness” call.

0844 – 0940:  The second due career medic was dispatched, but we quickly radioed in that we were staffed and responding to the call.  As I had the MDT computer recall the dispatch, I see that we are starting off the day nasty…Pregnant female, lower abdominal pain and heavy vaginal bleeding.  Great.  Almost rather ‘start the day, with a D.O.A.’ (doo-dah, Doo-dah)  She was in her early 30’s, third pregnancy, with one child (G3, P1, A1 for those keeping score).  She was in obvious pain and certainly bleeding.  The call, though, was not terribly complex.  Her vitals were okay and we got her loaded up, started a line, connected her to the monitor and got rolling.  Cat got the honors of the visual inspection, being the resident female, and saw bleeding but (fortunately) nothing else.  A trauma pad was placed to help the bleeding and we head to the hospital.  A good first call for our rider, a default O2, IV, Monitor, transport call of the sort that fills a vast majority of our ‘ALS’ calls.  We drop off the patient, I write report and the team restocks and cleans up the unit.  I stop by the nurses station to see who is on, what Docs we have for the day and how full the ER is.  All critical intelligence to a medic.  The Docs on duty affect what orders we will and won’t get, and the nurses and techs, like sergeants in the military are the ones who really run things.  Piss them off, and you are in for a bad day.  We clear the hospital and it is time for breakfast.  Or not.  As we pull out of the parking lot, thoughts of breakfast are set aside by the chirping of the MDT.  I hear groans from the back as Cat and Jon realize we have another call.

0941-1043:  This one is for Chest Pains at the assisted living place across the street from the station.  This is a decent facility and a far cry from the Fossil Farm of previous posts.  We arrive to find a lady in her 80’s waiting for us with one of the nurses from the facility.  She’s really pale/pasty looking and generally has an “I’m sick” look.  The nurse gives me a stack of papers with her history, meds and such and tells me that she had heartburn all night, but really looks bad today.  Well Poo, I think, this lady could be 12 hrs into an MI if we are unlucky here.  She’s a diabetic and has a couple other problems too, but I can’t recall what now.  She gets oxygen right away, and tells me that she’s hurting lower mid-sternum and it is about a 6 or 7 out of 10 with 10 being the worst pain ever.  “We gotta run ACS protocol” I say to Cat and she nods.  (Acute Coronary Syndrome...basically, assume heart attack or similar until conclusively shown otherwise for those non-ems readers).  In the unit Cat goes for an IV.  The patient assures us that we wont get one and is so far correct.  Cat is in the vein, but it blows when she advances the cath.  We DO get a dexi on her and it is high, like 380 or so as I recall.  So, she needs fluids for the sugar and nitro for the ACS and both need an IV to happen.  I give Jon two baby aspirin to give to the patient, and I tell Cat, “ I know we told her we would not keep poking her, but if it’s all the same, I could really use a line here.”  She looking but not finding much, so I swing over to the other side of the patient to give a look-see.  About this time, the patient is rather seriously telling us that she can’t have aspirin.  I ask (again) about allergies and she says she is not allergic, but a doc told her not to have aspirin.  Something tells me she means it and I wave off the pills for her.  I get a flash on my little 22 gauge (a tiny little thing more often used on kids than adults, but meeting the requirement of ‘venous access’) and remembering Cat’s attempt, float the line in place.  The line is opened for fluids, and since I’m in her wrist and her veins are so fragile, I board her arm to keep it still.  She gets one nitro on the short ride to the hospital and we are off.  I give report, make the exchange we are doing the write a story, clean the unit dance again.  Jon comments that this one was pretty cool, by which I assume he likes watching me sweat getting a line quite a bit. Grin.

Breakfast and fresh coffee is secured from WAWA instead of the sit-down place we had in mind, but the coffee was good and the crew needed the food.

1132 – 1222:  Breakfast was done and we were contemplating getting comfortable when we get punched for a first-due injury, Man cut to arm or had with an electric saw.  Hmm, this one could be interesting.  We arrive at the house with the engine and are directed to the back yard by the LOL in residence (Little Old Lady in this case).  There we find a grown man in the fetal position holding a bloodied rag to his hand.  A quick check by Cat shows that he had cut the tip of his left index finger cleeeeean off.  It wasn’t much, only about to mid-nail, but then it wasn’t my finger, so I can say silly things like….it wasn’t much. It seems he was trimming the lady’s tree with electric trimmers and lost control. (ouch) Cat handles bandaging, I get history and other information and the engine crew, along with the engine boss from the previous night who came from up the street, look through the bushes for a finger top.  Steve (the boss) has the guys check with the thermal imager off the engine…it is a long shot, but a good idea.  They call off the search shortly after we load the patient.  The cut was about 15-20 min earlier, and it was a non-critical part, so a good faith effort was all that could be done.  The patient was calm, and even joked that he’d still be able to cook after all was done.  We assured him that he was still going to be very functional, and he seemed okay with that.  The ER Charge Nurse had us roll right through the ER and into minor care for stitches.  Well, not the massive shooting-caused trauma we hoped for, but it was something.

We did actually get a couple hours of quiet.  It was a tease.  We watched part of a movie called “Mean River” or some such, and generally took it easy.  A couple of firemen from out of state came by to take pictures of our apparatus, and we shared stories and comments for a bit.

1444 – 1534:  Fossil Farm.  Damn.  I was hoping that on a beautiful day like it was, sun out and a slight breeze, I would not have to go into that piss-smelling crap hole.  I knew it was a pipe-dream, but a man can dream right?  It turns out that Jon had never been there, only heard about it…which explains the sour look on his face when I turn to him as we get off the elevators and into the smell of urine and ask, “you smell something?”  A rhetorical question obviously.  We find ourselves an old guy in a wheelchair, with a lady that turns out to be his wife, and the nurse from the facility.  He fell the night before, and “was okay then” but now doesn’t seem to be able to talk.  He doesn’t have a facial droop, follows commands, and when asked, is able to put a nice even grip on my fingers with both hands.  He’s with it…but can’t speak well.  He mutters some, and sometimes you can gist what he’s saying but not much.  So much for “he’s fine”.  He’s on a fentanyl patch and was given vicodin earlier too.  His pupils are small and Cat and I are thinking Narcotic OD right away.  We search him quickly for a second patch, as often we find a couple on a patient, and that is too much.  We don’t find any but think we can find out quick with a little Narcan in the unit.  (Narcan reverses narcotics for a time…actually it blocks receptors..but whatever).  When we get in the unit, Cat starts taking off the guys shirt to make a more complete search for any extra patches.  The guy grins and caresses her cheek as she opens his shirt….He’s just fine mentally.  “Oh, you like getting undressed by a pretty lady huh?” she asks.  He laughs and smiles.  I chuckle and think, “You should see her in bunker pants” but I don’t share that one out loud.  We don’t find any more patches, and the narcan doesn’t make him any more able to talk.  We get to the hospital and the nurse is thinking Wernicke's Encephalopathy (stroke-like symptoms from thiamine deficiency) since the narcan didn’t work.  Most common in alcoholics, but not exclusively.  I’m getting ready to write report, and Cat is talking with the nurse when Jon rushes by and says, “A510 is came up on an auto accident at (intersection two lights from the hospital), 6 cars, one overturned, one entrapped.”  Now I just heard a medic from our west sent WAY south on a call, so I know ALS units are thin.  I have Jon tell Wayne we are leaving for the call and to get ready.  I find Cat and pull her from the nurse. And we are off.

1532 – 1740:   As we climb into the unit, the radio is starting to explode.  I hear the ambulance that found the wreck trying to give a vehicle count and initial assessment and doing okay but sounding very stressed.  Units are starting to head in that direction, and dispatch is getting out an initial assignment.  I try to mark up, “M512A is clear Potomac and….”  That is all that gets out..my portable is on and starts to feed back over the radio, blocking my transmission.  Stupid, stupid, stupid.  Disgusted , I shut off the portable and try to key up again.  The radio traffic is pretty busy, so I type a message to dispatch on the computer.  “M512a Clear Potomac, responding to Gideon MVA”.  “Put on your Vests!” I yell back to Cat and Jon.  Wayne is accelerating out of the parking lot and maybe a minute later we see the intersection ahead.

The entire intersection is debris, and the centerpiece is a car on its side, driver side down, with someone just sticking out of the driver’s window and a firemen leaning in to them.  “M512A on scene” I radio.  “M512a, are you on Gideon?”…”That’s affirmative” I reply and climb out.  There is one ambulance and one engine there on scene.  There are several clumps of people out of cars holding small wounds in a couple of places in the intersection and on medians.  I put Cat and Jon on triage duty, Wayne rushes to support the car that is wobbling some in the wind, to keep it from rocking onto the driver and firefighter, and I start looking for “command”.  I find the Incident Officer off the engine (the default command in this case) and offer to take care of all things medical.  He’s okay with that and I promise him a count of patients, and what units I’ll need ASAP.  I check with Wayne and he is good on holding the car.  (Now, he’s not holding the car up, it is rocking a few inches in the wind and threatening to rock the roof down on the head of the patient and the fireman that is leaning into the window to help her.  It is very much NOT SOP, but it is what needed to be done…and hey, he’s wearing his vest.)

(A brief aside:  we recently got new reflective vests that we are to wear in traffic.  They are more reflective than our old reflective vests…in fact, with one vest and a pen light, you can land a Boeing 777 in a rain storm, at night, during a lunar eclipse.  They are to keep us ‘safe’ in traffic.)

The lead off of the basic unit tells me I have one more ALS patient and four BLS patients.  I confirm with her a total of 6.  Two ALS (one in the car, and one somewhere else) and four BLS.  I translate that into needed units in my head quick.  I can take one ALS, two if I split Cat onto a Basic, but we are likely to fly the driver.  Okay, need one more medic for the ‘other guy’, and each basic can take two minor injuries so I need one more of them too.  Okay, cool…now where is command off to?  I walk over to the IO and tell him the count.  He’s good with getting more units and is on the radio doing just that when the BLS lead comes back and tells me that one has refused care and is “okay”.  I’m sure seeing the head of the driver sticking out from under a car made them thing that their scraped forearms was fine, but okay then.

Long story short(ish) we end up with lots of help, the Squad from our northern station comes to stabilize the car and get the patient out.  A couple people refuse care, and the other ALS patient turns out to be a basic run.  In the end we have three BLS patients and the driver of the flipped car.  I make the call to get a helicopter moving for her.  I have not made a full assessment, but I know the hospital is pretty full, we are sending at least 3 to them, she’s been tossed all over, and I’m told by a witness that the car flipped trunk over hood while spinning and every facet of the vehicle is smashed (Boot over bonnet with a pirouette as Wayne put it)  I take turns holding up the car and coordinating EMS efforts.  Cat triages and treats a couple people, then comes back to get with the driver.  Jon helps treat a few and I have him go hang two big IV bags for our patient, the driver.

The Squad frankly kicks ass and does an amazing job securing the vehicle on its side.  I am not trained in that work, but damn, by the time they were done (just a few minutes) I could have jumped up and down on this thing and it would not have moved.  The car was secured with more room between the roof and the ground than before, so the fireman and Cat were able to slide the patient down, through the driver’s window, and with help from Wayne and I, onto a backboard…all while holding C-spine.  I know the squad guys were disappointed at not getting a cut..but kudos to them for a job very well done.

We start moving fast thinking the chopper must be close, since it was called before the patient was out.  What we did not know was that the first chopper had an engine problem and a second one was coming.  We get the patient boarded, collared, exposed and loaded into the unit.  She’s remarkably unbroken, totally conscious, and saying that she really feels okay.  She’s worried about her kids, who are being checked by a basic unit, and not feeling all that bad…just a bump to her head.  I start to question the need to fly her, but I’m convinced she’s better off getting the full level 1 treatment even if it finds her okay.  We get the lines started, check her pupils, double check her movement in fingers and toes and do a second sweep.  We find nothing of interest, just a knot on her head and a pain in her left hip.

Then she asks us to stop her head from bleeding.  I check and it isn’t.  I tell her as much and she says she feels it.  Uh-oh.  “Okay ma’am, that’s why we need you checked out from the helicopter” I tell her.  Later she says something is in her nose…nothing is there.  Something is running down her throat…it is clear.  I’m convinced she’s cracked her noggin and is bleeding internally, but can’t prove it.  The helicopter eventually comes and Cat tells me that the patient is saying her left side “feels heavy”.  (I had stepped out to see what the hold up was…that’s when I heard about the failed chopper)  I’m feeling better about the fly-out decision, and when they get there, the flight crew adamantly agrees.  Trust your gut.  Always.  As busy as the ER was, I bet we saved her every bit of 60-90 min by getting her straight to the level 1 center.

We head back to the hospital and the unit is trashed again.  We have two reports to write since we left before filing the previous one, still have to replace the narcan from before, and the police are there from the auto accident with a couple quick questions.  The basic crew is already there and expresses great happiness that we flew to come help.  (that’s good for the ego too).  We told them anytime, that they had things under control, but sounded like they could use a hand, so we came to help them.  Cat does the accident report, I do the old guy’s report and Wayne and Jon clean and restock.  As I’m finishing my report, the basic crew comes in and asks if I will speak to the daughter’s and husband of the lady we flew.  They are being checked at this hospital and want to know what is up.  I go to Dad and explain that his wife was alert and feeling basically okay, but that I was very worried about the hit she took to her head.  Cat had found a serious hemotoma forming, and we are all feeling pretty sure she had a skull fracture…possibly a depressed one but we didn’t push to see.  He understood and was thankful for our caution….that felt good.  I then went into the room with the little girls about 9 and 5 I’d say and I told them that Mommy was feeling okay when I saw her, had a bump to her head and had to go to a special doctor to check her out.  I told them that mommy was asking about them and loved them very much and I knew the doctors at the other hospital would take good care of her.  In my head I’m thinking “Don’t lie to a kid….don’t traumatize them either….don’t say ‘Mommy will be okay’, cause if she isn’t….”  They seemed to calm some and smiled at me and when I asked if they had questions, the oldest wanted to make sure the car was gone…she didn’t want to see it when they left.  I assured her that it was, and that helped.  She was also worried that there was a movie they had to return in the car too.  That made me smile.  The little one said her shoes were in there still.  I lifted up the blanket and found two little bare feet.  I asked her if they were off BEFORE the accident (thinking…uh oh…if she was knocked out of her shoes..that is BAD.) and she said they were.  I pinched her toe and told her they were probably in the car still, but she might need new shoes.  She giggled and all was right in the world.  They seemed satisfied, the basic crew was happy and my job there was done.  Even the cop watching the girls gave me a smile and a nod on my way out of the room.  (Yea!  All I needed was a cape and a phone booth to change in…does NOT get any better than kicking ass and making the smile over it!)  With the double report, the feel-good duties, an extended clean up…we clear almost 2 hours after jumping the call.  It is almost 1800hrs and time for dinner…or so we think.

That will have to do it for tonight.  It’s midnight and I have a long day of meetings tomorrow and class tomorrow night.  I’ll finish up the night on Wednesday night I hope.  In the mean time, you have homework.  Watch this video.  It is a capture of some nerd-types playing an online game…and a commentary on blind action over too much talk.  It has a cult following, and is inspirational to us later in the night….(Hey Matt…told ya we’d use it on a call…)

Checking in

2006-05-22T07:04:00.000-05:00

Just a fast morning hello, and assurance that we are alive and well. I have been contacted by several people asking about a new post. Cat and I just got off a pretty busy Saturday duty and I am in the process of putting the day into a new post. I think it was a pretty good example of a full day at DTX. We went to the Fossil Farm a couple times, played in traffic lots, called in some air support, got us a nut job, were asked by the ER staff to stop showing up, and missed or delayed every meal of the day. In 23 staffed hours, we logged 16 runs. We had a rider with us who wanted to see what the running on Medic was really like. He saw.

I slept a lot yesterday, and did not get it all put together in time to post. I'm looking to finish tonight, subject to Capt's duties, and I'll try to post this evening. Thanks for the patience, and the support!

Chris

It's the people...

2006-05-06T23:58:00.000-05:00

While it seems that I am posting less often, it still amazes me the number of responses I get from various people based on the posts.  The post on life at the firehouse lead to some comments on here, several emails and even a couple phone calls.  More than one of them came from people who had either left the department, or are currently inactive.  That people read that post and felt a renewed commitment or a desire to return to running calls is touching.  A big thank YOU to those of you who commented, wrote or called. I have been struggling with deciding to write up the real story of why I run, how I joined etc, but the more I got the comments the more I realized that I forgot part of the big thing about being in, or at the firehouse….perhaps the biggest part, the people there.

See, much like running calls, one of the things about going into duty, particularly on a new or different crew, is you never know who you’ll meet.  I have met people from all walks of life on duty.  Sure, some, even many are firemen or medics by profession, but most have other ‘day jobs’ to pay the bills.  Now, this seems obvious at a volunteer house, but the impact of that is not so obvious at first.

Need some yard work done?  I once knew two different people at the firehouse who owned landscaping businesses.  Buying a home?  Realtors a-plenty, and Home Inspectors too.  Boat Issues?  Got that covered too.  Need how-to advise on damn near anything, pretty sure you can find someone who’s done that a few times to help.  Everything from baby-sitters to National security advice can be had at the firehouse.  I have to tell you, if I didn’t meet these people here, there is no doubt that I may not have ever met them.  And I’d be poorer for it.

To say that these people spend their time at the firehouse, or give time to help a community doesn’t quite touch it.  I know people who drive over 2 hours to get to the firehouse on duty night.  I know some who pay up to $300 per month in child care just to run calls (many people call that a car payment).  I know some who run two nights a week, fill in for others, work a day job, are trying to sell a house and will STILL work your bingo for you if you need it.  There are several guys who live at the firehouse and are available for calls four or more nights a week.  We have high schoolers and we have retirees.  I know people who have run marathons, and I know one who has been offered a job as a professional partier in Aruba.  (I was with him on that one, and I swear I would have never believed it.)  Speaking of which, if you ever have cruise questions, I know some experts on that too.

I have run calls with Soldiers, Coast Guardsmen, Airmen, Sailors, and Marines.  Highest rank I KNOW I have run with is Lt. Col.  I am probably one of a very few people alive who has told an active US Marine Lt. Col to grab my bags before he leaves.  I know a guy who when delayed indefinitely on the domestic leg of a returning international flight, was able to call one of our then Fire Captains and have his flight given priority service to get them home.  (The guy had the dubious duty to call over a flight attendant and say, “The pilot is going to get a phone call from control offering a round-about route….he should take it”.  Let me tell you, in a post-911 world…THAT gets you some looks).

I mentioned “that I know of” before.  You see, the people who do this, for all the bravado and BS we sling around the firehouse are generally somewhat modest, or reserved about life outside the house, or even other parts of the firehouse.  For example, I know one fireman who has been a medic of sorts in the past, and is welcome to work my patient’s airway anytime.  (For those of you not medics, that is a HIGH complement).  But he spends his time on suppression and actively denies any ALS skills.  Of course, he’s a salesman during the day and also steals cars for a living, so you can’t trust him.  Grin.  Okay, so he steals cars for Repo, so it’s all good.

I think at one call I looked around and realized that I was on scene with a policeman, a lawyer, a repo-man, a marine, an aluminum siding delivery man, a defense systems engineer, and a network security guy and a just-out-of-college student all at once.  Of course, we all had on “fire and rescue” uniforms.  It is times like that that you don’t feel all that far removed from the neighborhood bucket brigades and hearse drivers from years past.  Just one of the common threads I have seen between us.

I have heard people, often from those who make this their profession, say that this is a hobby for us, or that we are somehow less trained or able than others.  I understand where that comes from, but I resent it too.  I don’t know of a hobby around that has this sort of draw, or hold on people.  Many of our ranks do this as their paying job too.  I don’t know many people in other professions who work at their job all day, come home and do the same thing again for free.  The people I have met at the station love it, or came to love it if they didn’t when they got started.  As for training, many people here seem to absorb as much as they can as fast as they can, and in a way you don’t see on the job.  Speaking for myself, I’m personally kinda proud of the fact that I recertified my ALS certs for state and national registry in spring of last year, and before the year was out had my letter in hand stating that I had already exceeded the training hours needed for my next recert, two to three years away.

It seems that everyone I meet at the firehouse, particularly if they have been around for any time at all, actually might have a hard time telling you in words why they are there.  I think it is because they all just really want to help people, and be the ones that do the unusual, exciting things that not everyone can.  Of course, saying that sounds either cheesy or arrogant depending on how you phrase it, so you don’t say anything at all.

I had a conversation with a relatively new person to EMS the other day.  She could not ride at the time for a couple reasons, but had been recently.  It was fun to watch her agonize that she could not be on that next call out.  Even when you know it is likely no big deal, there is still something that makes you want to know what is on the other side of that response.  We have all felt that.  We have all had those first nights at the firehouse where you are almost afraid to sleep at night thinking you’ll miss a call, or too amped from anticipation to sleep.  I bet I didn’t sleep right at the house for a good year.    You get past that one.  I drop into full REM, drooling, snoring sleep now between calls.  I sleep fast and hard now, but then I’m old, so maybe it is just practice.  On the EMS side, the other really common thing  I see is the look on new leads faces.  You get your EMT card, go through training as a preceptee, and pass an oral board to become a lead in our department.  That means you can go out on your own unit and run calls.  (The process is the same to become a lead medic, just longer and more controlled in the precepting phase).  Usually, you are turned over right about the time you start to settle into precepting after class.  You think you kinda know what you are doing, and you are really glad to have that preceptor there to answer questions, or provide another set of eyes.  Then you get turned over, and BAM, you are in charge.  Your partner may be a non-EMT firefighter as a driver, the tones drop and your out the door and there is no net.  I remember my first call like that.  I got turned over at about 730pm, was leading that night with one other guy and my preceptor was GONE.  First call was an overturned truck on the highway and a 15 min extrication.  I was sweating it bad.  We all survived, even the patient.  As a Medic Lead, you break into a small sweat for about a year after turn over.  I don’t remember my first solo medic run though…isnt’ that odd?  I have to imagine the same is true for being a new Incident Officer (the lead on the fire side) on an Engine or Truck company for the first time.  We have all felt that, and lived through it and despite our various outside lives, we have so much in common this way.

I guess I’ve met almost every sort there is at the firehouse:  Geniuses and window-lickers, saints and assholes (Dennis Leary stuck in my head now), wizened vets and newbie kids, company owners and housewives.  I’ve seen people grow up, mature, grow old and even die while they were members  (Different people for each…I’m not THAT old).  I have celebrated weddings, births and graduations.  I comforted during divorces, unemployments and deaths.  And still, after it all, I’m struck with how very different we all are, and how very much the same.  And I really don’t think the experience would be at all the same without each and every one of them.  So it seems the firehouse is more than the calls and the activities, and the walls and the equipment, it’s more than the firemen and rescuers, it’s all the walks of life, points of view, experiences and goals of about 300 people who have found the one thing around that could possibly take such a diverse group of misfits and mold them into a common course.

Meanwhile, Back at the Ranch

2006-04-23T19:01:00.000-05:00

I have alluded from time to time about the family nature of life at the firehouse and the fact that we are currently living under renovation, but I haven’t yet really posted on those topics much. While fun, interesting, “Big” calls are great for stories, the environment of the station, the crews and general life back at the house are a critical part of the department. I think this is particularly true in a volunteer house because, let’s face it, we aren’t getting paid…it damn well better be fun.

Our department has three stations, and they each have a different personality as a rule. They have different lay-outs, different neighborhoods and different specialty pieces, that leads to each of them being unique, and while everyone seems to develop a special attachment to “their” station (usually the one they are assigned to first) we work hard at conveying that we are one department, and not three stations. That common camaraderie is doing well now and growing I think, and it is being done without having to mute the individual aspects of each station that make us unique.

As Captain, I get to all of the stations, and have an appreciation for each of them, but 12 is where I started, and it is “home” to me for the sake of running calls. I have run calls from all three; 2 is the administrative home for all of us, and I am often there attending meetings and doing paperwork, and was assigned for my ALS precepting to 14 for about a year.

The due is a fairly diverse one, with older homes to the north, with a large and growing immigrant population, far and away Hispanic, but also various African and Mid-eastern contributions that add language and cultural variations to the EMS mix. (Something not really taught well in class, but quickly learned in the streets). Gangs have a foothold and seem to be getting more active there, as evidenced by the increasing trauma volume we are seeing the last few years. The south end is full of new homes being built, and is bringing a higher-density suburban “McMansion” sprawl aspect to us. The Potomac River is to the east, and in the summer that becomes a city population of it’s own. We are seeing more and more calls from there, and our Boat capabilities are being used with growing frequency. To the west is more suburban sprawl, and a large outlet mall that brings in tourists and plenty of traffic. Second Due to the south is the Quantico area, and plenty of lower-income housing and transient population.

We have never hurt for call volume, and used to go head-to-head for highest volume in the county with Co. 11 on the west side of the county. Now, we have more support from 24hr career units to our south and west, so the volume has settled some, but is growing again. In a 24hr weekend crew, you can count on 10 calls, and a weeknight will bring 3-5 a night I’d say. (Last week we got 5 between 7pm and 230am…NOT good for sleep before work the next day). All of our stations are starting to see that level of calls with the growth of the area.

Our station is known as the “Animal House” and has a station patch with a black sheep wearing a “Delta-Tau-Chi” necklace in front of a house with a roof on fire. The patch is painted on a wall over the door from the firebay to the rest of the building, and the benches out front are painted with it, and the phrase “Knowledge is good” (you find the reference) and “None”. The “None” is a reference to the motto of the department to our west which is “Second to none”. Grin, inter-department rivalry is alive and well, but kept at the appropriate level. We, as a station and a department, have a reputation of being aggressive on both sides of the house (EMS and Fire) and frankly we actively work to instill that in our people. (See Matt’s posting for some insights..) On the fire side, our people attack very aggressively and have found that most fires are less dangerous if you put them out than they are if you pussy-foot them. On the EMS side, we stress good, rapid assessment, focused aggressive treatment and rapid transports. There are arguments for playing and fixing inside someone’s house and I’m not against it, but it is not generally our style for most calls.

The station itself is a pretty big one. We have five drive-through bays side-by-side, and an attached split-level building for housing and offices etc. It was built something like 12 years ago, and is currently being renovated. We are redoing the floor plan for the bunk rooms, and locker rooms, redoing the air handlers, adding on to the far side of the firebays for storage etc and putting in common office space with network connections and modern furniture. The kitchen/dining room is being redone to open that area up and all in all I’m really excited about the end results. The price for all of this is that we are currently living in two single-wide trailers in the back parking lot. One is set up as a big-ass bunk room with as many beds in it as we can fit. The other has two rooms with live-ins and the medic bedroom as well as the kitchen and TV room.

It is not at all uncommon to have families in with us on duty nights. Prior to moving into the trailers, we often had wives or members come in and cook meals, and in particular weekend cook-out and big breakfasts are the norm. Children of various ages are often playing in the bays, tossing footballs or pretending to run calls. Cat and I do not have kids ourselves (two dogs fill that bill), but we have 10-20 nieces and nephews at the firehouse. I have to admit, sometimes it is kinda nice to come back from whatever car wreck, heart attack or whatever and be greeted by playing and giggling children back at the house.

Out front on the ramp the guys have built a pair of really nice benches that they also painted with the patch and the sayings I mentioned earlier. Now that the weather is warming those benches will start getting more use. Often times, if the call volume lets us, we can sit there at dusk, watch the few cars going by, enjoying a sunset and chatting. Summer brings rapid, strong thunderstorms in the evening, and I don’t know how many of those I have watched blow in from the ramp. When the rain starts, the bay doors stay up and we move in to the front bumper of the pumper. As sure as watching the clouds coming in, we can hear the calls being dispatched from the west end of the county and moving closer with the storm. Alarms, water hazards and auto accidents seem to be the big ones in the storms.

The back of the house has the big gas grill, and weekends often mean burgers, steaks, chicken or hot dogs on the grill. Here it is really nice to have someone who is not on a unit to watch the grill….we have our priorities. Dinner is a classic important part of firehouse life and we have several good cooks, each with their own ‘thing’. Jon does a mean cheesesteak sub. Zark likes to try lots of different things, but is a bit of a breakfast specialist in my opinion…I miss his Saturday specials. DTXMatt loves the grill, and taught me a love for Montreal Steak seasoning on steaks. He once showed me to butter the steak lightly, cover it in seasoning, wrap it in foil and grill it. Okay, so it is an MI on a plate, but damn it is good. Often times, dinner planning starts right after breakfast so we can start getting a head count and buying the food. Weekend dinner head counts means the crew, some family members, the station live ins and usually one or two folks who ‘drop by’. You can’t beat a good firehouse dinner, lots of food and because of the bulk nature it is pretty cheap per head. We just divide the cost of the groceries by the number of eaters and there ya go. The food is always fresh too, purchased at the store only hours before.

After dinner on a cool spring or summer night means sitting around the big metal table in the bay and telling stories. It is those stories that inspired this site eventually. Poker and movies in the TV room are big draws too. The poker at 12 has kinda died down in the trailers…space is a bit tight, but Matt has picked up the tradition at 14 where he was reassigned this year, so there is a game to be had. In the winter we have been known to play hockey in the back parking lot in our turnout gear for warmth. There is a big hill that rises behind the house, it is GREAT for sledding….until you hit the parking lot at the bottom but if you do it right, you can slide right into the bay. Our station houses “The Maze” training facility for the county and weekends sometimes bring in the fire fighter 1 classes to train. That means the day’s entertainment is watching the new guys running laps around the station in full gear on air to see how the bottles drain.

Life at the house is painted in bold colors, and even trying to touch on all of the things that you learn to love is almost impossible here. There are pranks, girlfriend dramas, card games, training events, boat calls, food, tales, family and friends that fill the spaces between Heart attacks, car wrecks, sicknesses, asthma attacks, assaults, traumas and the occasional actual fire. There are stories and blogs behind them all, and they all go to answering the question I get most often from folks at work, or friends who find out that I was just up all night running calls for free and going to work the next morning. That question, “Why do it?” always makes me smile. It is because we love it, the calls, the excitement, and the family we gain. Of course, how do you explain all of that to someone new too? “A twisted sense of a good time” is my standing answer. We each have our own answers, but as those of you running elsewhere know, you almost never get that question from people who live it.

An Easter Thought

2006-04-16T19:18:00.000-05:00

It is Easter Sunday, and I have not yet done a post for this week. I will endeavor to put up a story in the next couple days, and I apologize for being occupied elsewhere this week. We got pounded all night Friday night at duty, mostly with the violent flu bug that has been striking people around here. So, I spent Saturday trying to recover, and not doing the things I had planned…like posting a blog. A friend who used to run with our department, and recently moved to an adjacent one to run with her new husband reminded me of my missing post tonight as I stopped by the station to say hello to my crews having Easter dinner. So, I will try to get two up this week if at all possible.

In the interim, as it is Easter a prayer is appropriate, and I will share one that I have (re)found recently. I have often said a quick, silent prayer before duty, even if it is just a “Dear God…don’t let me F it up tonight”. There are a few “EMS prayers” out there and they are good, but this one was written long before EMS, but it speaks to me and I think to our collective calling in EMS. It was written by St. Francis in the 13th Century, and I have thought of it often on the calls I have seen of late. It helps on nights when you are taking your 3rd or 4th “BS” flu run at 330am, and you have not seen any sleep.

Lord, make me an instrument of Thy peace;
where there is hatred, let me sow love;
where there is injury, pardon;
where there is doubt, faith;
where there is despair, hope;
where there is darkness, light;
and where there is sadness, joy.

O Divine Master,
grant that I may not so much seek to be consoled as to console;
to be understood, as to understand;
to be loved, as to love;
for it is in giving that we receive,
it is in pardoning that we are pardoned,
and it is in dying that we are born to eternal life.
Happy Easter to you all, be safe, have fun.

Chris

Check Pulse...

2006-04-08T12:51:00.000-05:00

Last weekend Cat and I saw each other for the first time all week Saturday in a PALS refresher class.  Welcome to my life.  I had been on travel most of the week for work, and Cat was working a 24 the day I got back.  The dogs didn’t bite me coming in the door, so that was a good sign.  We had duty on Sunday, and I was sure that going to PALS the day before was bad ju-ju.  The day started with a couple of kid-calls, but nothing too too bad.  Anyway, a part of the class goes over dealing with pediatric deaths, and how to tell the family etc.  There is a session that breaks out to talk about things that you may have done or seen that could have been taken wrong by a family member, and how to do it better.  That reminded me of a call I ran as an EMT years ago, but I’d rather share it here.

Now we all have our coping mechanisms, and the most common one that I have found among EMS providers is a morbid sense of humor.  Now, while very good at defusing a situation, we all know that you have to pick your timing carefully.  Family members really don’t like to hear a loved one referred to as “DRT” (Dead Right There).  That said, the right levity at the right time can help give a crew perspective and calm them down enough to get the job at hand done, and done right.

I was a fairly new lead EMT-Basic running with a very enthusiastic gentleman named Eddie who drove for me.  We got punched for a stoppage of breathing at that hole we call the fossil farm.  The engine from our station, and a medic were sent with us to round-out the complement.  Now, as I’ve said before, this place doesn’t seem to know much, but they know dead when they see it.  I’m sure we are going to have a code waiting for us when we get there, and Eddie gets us there pretty quick.  I am a newer EMT and I am pretty butt-puckered as we go.  My mind is swimming with what to do, and in what order when we get there.  I try to calm myself going in by mentally reminding myself that if this IS a code, he is already dead, and I can’t make that any worse.  We load up the gear on the cot and work our way past the collection of folks in the hall to the elevator and up to the room where the call is.

It seems that while the staff knows dead when they see it, it must take a while to figure out to call it in...The patient has clearly been down for a little while, maybe an hour as I recall, but the staff is doing half-assed CPR and saying things like, “We saw him go down”, “we were right here when…”  as they run out of the room.  Basically putting us in a position where we were going to have to work this no matter what.  This is a typical reaction here, and one that happens to this day.  As soon as I’m at the patient’s side I recognize that he is WAY past saving and I start to calm down considerably.  There is no life to save today.  The engine guys were in right behind us and there is more help than patient at first.  We bring the guy to the floor and start our routine.  While I know that are not going to make a save today, we are still looking to do things right.  Compressions are started, and the patient is bagged with Oxygen.  The patches from the AED are attached and we are in business.  We hit the “analyze” button and stand back, with baited breath, to see what it tells us.  Now, unless we are going to shock him with a lightning bolt, there is nothing that this little machine is going to do for him.  “No shock advised….Check Pulse” the lady in the box tells us.  Now, Eddie is standing by the door, and there are some fire guys in the hall.  Someone else is actually checking the pulse, and as usual the entire staff of this place has left the room.  The only people in the room came with us, or are dead on the floor.  Sensing the opportunity, I look back and make eye contact with Eddie and place two fingers on my own Carotid artery.  (Clearly we didn’t need to check this guy’s pulse, he’s asystolic and achieving room temperature, so she must have meant mine.)  I put on a concerned look for just a beat, and then beam Eddie my biggest smile and give him a thumb’s up and a nod.  “Got one” I say softly.

The intended goal here was a little bit of a smile and the perspective that we weren’t going to save him, and no need to keep our butts in a pucker.  Instead, Eddie lost it.  I mean, he busts out into a full-on eye-watering guffaw.  I guess breaking the stress hit him big time.  Well, out of sight in the hall is the rest of the engine crew.  They didn’t see what happened and all they know is that Eddie is laughing at the dead guy.  A life member of the department, and all around good-guy named Russ grabs Eddie and damn near throws him out of the room.  He gives Eddie a ration of Shit for the laughing, and pulls him into the hall.  I had turned back to the patient and was assisting the Medic with the code while that goes on.  I realize the misunderstanding, and damn near start up laughing myself.  It took a bit of will power to get that back under control and focus on the matter at hand.

The call proceeds normally from there, and as I recall, the medic got orders to cancel it from the ER Doc as soon as we hit the unit.  We take the patient to the hospital, drop him off and get the unit cleaned up again.  When we get back to the house, Russ wants to know what the hell happened on that scene.  At first I play dumb and deny everything.  Ultimately we had to explain what happened and let poor Eddie off the hook.

All in all, everything ended like it was going to no matter what, and I would love to tell you that I have since learned to never enjoy a private joke on the scene.  But too many people who know me read this and we’d have nothing but a steady stream of comments calling me a liar.

Either you're SWAT, or you're not

2006-03-30T22:34:00.000-05:00

Wow, amazing how fast two weeks can fly by.  Life has been really busy here.  Starting on a new assignment at work, working on my Masters in Systems Engineering, running calls, working of course, and fighting off a quick flu all seemed to team up on me.  Cat got her call out on here last week, and I’m glad to see the reactions to it.  We finally got to run together again this week, and the night didn’t disappoint us.  When you start in EMS, the idea of a SWAT standby sounds great.  Then you do a few and you know they mean hours of sitting around in the unit…an EMS stakeout.  But there are some redeeming points..

I showed up at the station after work already dog tired from a long couple of weeks.  In the back of my mind, I quietly hoped for a slow night, knowing that it was a slim chance of that.  The weather is warming at least, and I tried to keep things upbeat as we checked out the unit and got into the evening.  We ran out for dinner fast, and of course, that started the calls.  We ran a quick pair of auto accidents, the second one yielding a BLS hip ‘injury’ that we transported.  While at the ER, I see a favorite nurse of mine, we’ll call her ‘V’.  She takes no crap from anyone and used to work in Detroit.  I believe she was a street medic in a past life too.  We always exchange jabs when we see one another, her usual being to tell me to “Go home, you are nothing but trouble, and I have no time for your stuff tonight.”  That night I told her, “Hey, I’ve been good for weeks, but just for you…I’m bringing you one tonight, and they are going to be a mess…you watch, I got a special coming for you!”  I grin as I leave to go get that dinner.

Leaving the hospital I’m tired and didn’t verify that we were held clear of the hospital after that call and as a result, we were NOT dispatched on a “Stabbing in progress” in our next due as we should have been.  I radio to dispatch that we are, in fact, available to respond and they tell us to do so.  Of course, it sounds interesting so the medic originally dispatched claims to be closer and keeps rolling.  Okay, my bad, didn’t verify I was clear, and what the hell….dinner is waiting.  Over the radio, the call sounds serious, a 7 year old or so boy stabbed a bunch of times (31 was a count given by the engine later, most minor, 8 or so serious. My Lt on the Ambulance assigned tells me 13 good stab wounds) by an older guy who fled the scene.  They fly him out and I’m torn between missing a decent trauma and a nice hot calzone.  We settle into the trailer and have dinner. Cat has to work the next day, and trys to get some sleep.  Wayne is driving, and (bought dinner too!), Tess was not in that night, she was working.

About an hour later, I hear from one of the engine guys that communications has called and given a heads up that SWAT is active in that area…it seems the guy is back, and barricaded in the house.  It looks like they’ll want us for a stand-by, but not for a while.  Approximately 10pm, the call comes out for us to go stage for the PD at a school near by the address of that previous call….”time to go play with the SWAT team” I think, and start to the unit.  I climb in and start getting messages on the computer console:  “Come in quiet”, and “how long until you get there”.  I tell them just a couple minutes as Wayne parts the seas until we are close, and then we stop the lights and sirens and sneak in the rest of the way.

The parking lot of the school is starting to fill some, and I see the predicted car with maps and papers all over the trunk, surrounded by uniformed officers, suits, and an obvious SWAT commander. The CP.  The police are loose, and chatting, and several are on radios and phones.  Wayne sets us up out of the way, with easy access out, off to one side.  I hop out to see what’s up, and how we can help.  I’m assigned a POC, get an address for where the fun is, and tell them I’ll stay out of the way, mostly in my unit and do whatever I can to help.  In return, they promise information, access to the school for a bathroom and an interesting evening.  I’m introduced to a Police Captain who is settling in for the night, cigar in mouth.  He’s relaxed and friendly, glad to see us etc.  He confirms the department I’m with, and when I tell him he says, “Glad it’s you all.  Y’all always take good care of us on these things…coffee and such.”  I can take a hint, and get on the horn to the Rescue Chief to pass on the polite request for some refreshment help.  I later learn that police Captain and our Dept. Chief go way back, and the Capt and I share a joke.

“Lets see how this goes” was the response from the Rescue Chief, and we promise to get back in touch if it looks like we are going to be here a while.  I’m seeing more marked cars arriving, and the detectives are showing up….yeah, we’re camping for the night.  It’s only about 20 min later when another POC from the PD tells me that they are relocating people from the surrounding townhomes to the school, and they ask if we can get them some snacks and drinks.  Time to wake the Chief.  I call the Rescue Chief, (I can tell I woke him), and he agrees that we should talk to the Dept. Chief.  When he asks if I want him to do it, or do it myself, I volunteer.  The Dept. Chief moves fast and about 15 min later I hear that the Auxiliary is notified and moving with an ETA of 45 min.  The police are thrilled to hear it; even more so 20 min later when the Auxiliary members arrive and set up in the cafeteria of the school.  Wayne and I know a long night is coming, so you know some of that coffee made its way to our unit too.

In the mean time, Cat is curled up on the bench in the back trying to sleep.  She’s looking at 24 hrs starting at 0700 the next day, and knows this will take a while.  I’ve been given a new POC by PD, a former medic himself, who does a really great job at keep us informed.  Wayne and I settle into the front seats of the unit, tell stories, confirm the location of the address, drink coffee and wander around the unit killing time.  We learn from the POC visits every 15 min or so that the guy is the Uncle of the kid who got stabbed, and that he did it because the kid didn’t get off the computer.  He’s got a very violent history (no details) and is recently out of prison for something violent too.  He leans in to me and confides that he doesn’t think this is going to end calmly, and may well proceed rapidly due to the guy’s nature.  When he asks how we are at gunshot wounds, I perk an eyebrow.  Wayne assures him that he has the right crew for that.

About this time, a Television truck shows up.  Nice.  PD gets to them quick and tells them to stay out of the way, and seems to give them a contact as well.  I send a message to communications over the computer:  “The Lt didn’t tell me that I was going to be on TV…I would have done my hair”.  A dispatcher responds that the Lt didn’t think about the hair because he doesn’t have any.  That gets a laugh from Wayne and I in the cab of the unit.  The dispatcher and I kill some time sending text messages back and forth, joking mostly.  There aren’t many calls in the county so she’s probably bored, and I’m entering my third hour in an ambulance, so I know I am.  I tell her that we got coffee and snacks brought to the Command Post, but that in retrospect I was thinking that may not be the way to motivate the police to move faster.  She types back a laugh, and says she was a Police dispatcher for 7 years, and NOTHING makes this go faster.

About midnight (almost 2 hrs in) we get the five minute warning that they are going to gas the house.  My POC tells me that they will put a couple gas cans into the windows, wait a few minutes then add more.  Works for me.  It occurs to Wayne and I that if the guy goes down, it could be in the house and we don’t know for sure if PD will drag him out.  We take the opportunity to get a hold of our air masks, and double check our SCBA, the airpacks for our backs.  Wayne tells me that the gas does not affect him much and I tell him we ain’t going in until everyone is on air.  Our department equips us with full suppression gear, and that includes airpacks and masks, but we don’t need them much in EMS.  So, I review proper donning with Wayne, who also runs fire on another crew.  Okay, so now I CAN deal with it, but I really don’t WANT to.

A bit of time passes and the POC returns.  Something is up, they did gas the house, but are not going in yet…and the guy is not coming out. He says it “could be a while.” Great. I hope Cat is getting some sleep in the back, I know Wayne and I are feeling it.  The novelty of this sort of thing wears off fast.  You can tell everyone you know that these stand-bys are dull, but nobody ever believes you.  “So much for getting any sleep tonight” I think.  I think of the full days of potentially contentious meetings I have for my ‘real’ job starting at 0900, and hope I’ll be awake for them.  At least we are getting some information, and that makes all the difference.

Its about 2am when we get another five minute heads-up and I think more gas goes in.  We’d seen the K9 units going in earlier, so I know the dogs are around.  The POC comes over and says that they have one in custody, and asks for us to call for a Squad to come stage here so they can ventilate the unit.  I forward the request to communications, and shortly after, we get called to the scene for a patient.  (Finally, I think as we take our cue and join the party.)

We roll up the street and I’m surprised by the number of marked cars there are. I have to get out and lead Wayne around the scattered police cruisers in the crowded street.  I see the SWAT teams and the K9 officers walking away from the house as I approach.  I note that a couple of the guys look like they are in bomb outfits…interesting, wonder if that was the delay.  The townhouse is question is easy to identify, it’s the one with the guy laying in the yard handcuffed and surrounded by gentleman in police assault gear, automatic weapons and airmasks.

Our patient is a tall, laid out, bleeding from one hip and apparently unconscious.  One of the SWAT guys is tending to the leg wound.  He says a familiar “Hey there!” and is smiling behind a mask.  I say hello as I start to assess what I have here.  “Dogs get him?” I ask the group.  “Dogs woulda messed him up worse than that” one of the masks says.  They show me a small, shallow laceration and tell me that he must have done it to himself.  The bleeding is basically controlled, may need a stitch or two, but is imminently NOT life threatening.  The guy is unconscious and I ask if he was found that way.  Looking up, I see that the officer treating him, the one that said hello, is someone I know and I smile.  “Didn’t recognize you in the mask.” I tell him.  His sister is in our department, and was on the ambulance that responded to the stabbing.  They say he was looped, but conscious when they got to him, and dropped out like this as we were coming.  He’s breathing fine, and looks basically intact.  Wayne and Cat are coming with the cot and I start to get to work cutting away the guy’s clothes.  I’m feeling the first tingles from the gas the police used.  We are outside, but the “gas” is a very fine powder that gets on everything, and is all over this guy’s clothes.  He wearing layers:  Thermals, Sweats, shirt and so on, and they are all giving off more of the stuff.  I need to see if he has any other injuries, and I want these clothes away so they will stop adding to our problems.  As I get to work, I put down my left knee and pivot as I give him a quick head-to-toe.  This stretches my BDU pants, and I promptly rip them from the end of my zipped down and forward about eight inches or so.  Good thing I don’t run duty ‘commando’, or that could have been quite an issue.  As it was, I was feeling plenty ventilated and briefly (no pun) thought to myself how much I did NOT want CS powder in my crotch.  I give a sigh, comment that the rip is about par for the course, and get back to the task at hand.

We move quickly to the unit, away from the house, and the whiffs of gas rolling from the door.  We finish getting his clothes off, and we toss them out the unit to the police.  The vent fans are all running, and the windows are open.  An officer, our POC, climbs on to ride with us.  He saw the kid that our patient stabbed, and I think he’s determined to see this call to the end.  The patient is exposed, has dreadlocks to his waist which are also holding the gas, and really unconscious, only occasionally moving slightly as we work.  He is handcuffed behind him, and I use a cravat to tie the cuffs to the cot…just in case he wakes.  His room air oxygen saturation is only 93%, I’m thinking he sucked in plenty of the gas, and we get him on big oxygen fast.  His ECG is fast, but steady, and his B/P is fine.  I’m obviously not getting a history on him.  Cat gets the IV, as the police officer and I hold his arm.  He doesn’t even flinch at the needle.  His Sat comes up fast to 100%, lungs clear, and we find no trauma other than the small laceration.  Wayne gets us moving to the hospital, and we basically settle in for the ride.  As I’m calling in the report, I pull back one eyelid and Cat confirms that his pupils are pinpoint.  That is a classic and telling sign of narcotic overdose.

Normally, we give Narcan for narc overdoses, but the people often wake up fast, and pissed off.  They are known to fight us and a sudden bad hangover.  The last person who upset this guy was stabbed many times, and had at least a collapsed lung (I later heard), and being family and only 7 didn’t stop our patient.  If the narcotics were not actively killing him, and he was still breathing okay, I was not about to do anything to wake him in the slightest.  The trip was short and surprisingly uneventful, we basically just kept a very close eye on him.  His sats stayed good, and his respirations were fine the whole way, so there was very little to do.

We get to the ER, transfer him to their bed and give report.  The nurse looks at me like, “Another odd call from you?” and thanks me for the information.  The officer stays with him, and makes it clear that he is not leaving.  As I write the report, they give him the narcan, and when I’m done, I notice that he is stirring, and snorting some, but not entirely awake yet.  ‘V’ is there working on him and I take the time to rub it in.  “See, told you I got one for you!  That’ll teach you to talk your stuff to me.”  She gives me bilateral single finger salutes and says, “You see these, see them??  Yeah, go…See them?” Now Cat is right next to me as I just give ‘V’ the biggest two-dimpled grin I have, standing there with this huge hole in my crotch and a cool breeze on the family jewels.  I make no motion and just fire back, “You See these…see them…Yeah I got yours…see them?” She gives a puzzled look, and I see her glance down.  That’s it, the impossible happens.  The unflappable ‘V’ loses it.  She comes over laughing and rests her head on my shoulder. “YEAH, see how we roll?” I say.  “Oh, I’m sorry, it’s been one of THOSE nights huh?” she laughs. I have tears in my eyes, and not from the gas, as we turn and leave…yeah, it’s been one of those.  We head back for a shower and bed.  It’s about 3am, I’m exhausted, I’ve been gassed, and my pants are trashed.  Oh, I’m SO out of service, that other medic can have all the calls they want.

Checking in

2006-03-29T21:31:00.000-05:00

Hey all, I’m still alive and well, and almost done writing up a call we caught just this week. I’m stuck up north (Hello New Hampshire!) on travel for work, and have an early start so I have to stop for tonight, but I’ll get the call posted tomorrow. Besides, I like doing this better than studying for a midterm I have next week. The call was a SWAT assist call…hours of boredom followed by minutes of actual EMS. Of course, this is our crew, and Murphy’s law is always with us…nothing like hanging out on a call. Grin.

Marines Rock!

2006-03-22T12:31:00.000-05:00

There's a large Marine Corps base at the south end of the county we serve, so you can always find sharp looking guys with buzz cuts all over the place. The soldiers I've come in contact with on calls have been selfless, efficient, and very helpful to us. One time a motorcyclist got cut off by a pickup and ended up unconscious and pinned under the truck. Four Marines rushed over and, no lie, lifted the truck up and moved it off the motorcyclist so EMS could get in and help him. Another time I treated 2 Marines involved in a horrific auto accident who were more concerned about the other passenger in the car than they were with their own injuries. I have nothing but the highest respect for these soldiers who volunteer to give their time, energy and sometimes their life to defend this great nation and the freedoms we enjoy. Let me tell you about a recent call in which 2 Marines helped me to save a life.

Chris was sick this week so I’m running “on my own”, even our preceptee is working at her regular job tonight so it’s just me and Wayne. The problem with this situations has nothing to do with patient care (though it is more fun running calls together). The problem lies in the fact that every time – without fail – that I run without Chris I get some unbelievably complex, frustrating or otherwise pull-your-hair-out-of-your-head-and-scream type of call. Let me give you an example….

The call goes out for difficulty breathing at the Marine base south of us. The patient is reported to have a history of CHF (congestive heart failure) and came into the clinic on base with some mild difficulty breathing. Let me digress for a moment to explain this condition (if you already know all about CHF, skip the next paragraph).

Blood circulating through the body comes into the right side of the heart first, is pumped into the lungs to pick up oxygen, and then returns to the left side of the heart where it is pumped out to the rest of the body. (In order to pump blood all over the body, the muscle comprising the left side of the heart is noticeably thicker and stronger.) In patients with CHF, the left side of the heart is weakened and unable to pump adequately. Therefore since less blood is leaving the heart than is coming in, the blood gets backed up. Remember which organ was in line just before the left side of the heart? That’s right, the lungs. When the blood starts to back up, it starts filling all that nice wide open space in the lungs, producing pulmonary edema (fluid in the lungs). Unfortunately, lungs that are filled with fluid don’t work very well, that is unless you happen to be a fish. These patients are prescribed a diuretic medication to help pull the excess fluid out of the lungs and back into the bloodstream where it can be removed through increased urination. The scary part about patients with CHF is that when the heart fails, the lungs can fill with fluid VERY fast, like within 2-3 minutes a patient can go from breathing normally to completely full (this is called flash pulmonary edema). Also, because the lungs are full of fluid, not only is it very difficult to ventilate such patients, but they are often combative due to hypoxia making it even harder to treat them.

OK, back to the story. So we are told on the radio by the base ambulance crew that the patient is currently being treated by the clinic staff, but the ambulance will transport the patient to the front gate to meet us. This generally helps save time since our response is a long one just to the gate, and then we’d have to navigate through the base to the clinic after that; a task not so easily accomplished since we don’t have very good maps of the base roads. (The base only staffs BLS ambulances, and this patient needs ALS care which is why we’re going all the way there to pick him up.) Already I’m realizing how bad this guy can get in the time it will take us to get to him. Our response is definitely a wild one since it’s rush hour and both southbound lanes are stacked with traffic for miles. Wayne lays on the air horn as he steps on the gas and swings across into the northbound lanes. I have a death grip on the dashboard as we pass the long line of cars, dodging northbound vehicles who eventually realize we’re on THEIR side of the road and dive for the shoulder. After about a mile and a half of driving on the wrong side of the road we get to an intersection with clear road southbound ahead. “Nicely done”, I comment as Wayne slides back across onto the southbound side of the road; he grins and gives the air horn another blast as we continue on our way.

Upon arriving at the front gates of the base we drive past all the nice men with the automatic rifles, only to find no ambulance waiting with our patient. We get on the radio and ask what’s up, the ambulance crew states that they are packaging the patient in their unit on the front ramp of their station and could we come to them. Great. Wayne says he knows the way to the station, so I hop in the back to get an IV line set up and the med box out while we drive through the base. We pull up and I hop out to see what we’ve got. “He’s getting bad”, one of the guys tells me about the time I lay eyes on our patient. This guy was way past “bad”. Our patient was a large (300+ pound) man sitting bolt upright on the edge of the stretcher, eyes wide, gasping for air. He wouldn’t respond to any questions, wouldn’t even nod or shake his head, he just kept staring straight ahead as he struggled to get air. Now is when I shift gears. I’m getting information from the ambulance crew and visually assessing the patient at the same time. I’m hearing things like “His O2 sat is in the 60’s” and “He’s supposed to be taking Lasix (a diuretic medication) but he stopped taking it a while ago”; and I’m seeing things like a nasal cannula that is supplying this suffocating patient with a puny few liters of oxygen (this was done by the clinic staff, not the ambulance crew I soon discover). I ask one of the EMT’s to switch the patient to a mask and crank it up to 15 liters while we get the guy moved onto our stretcher. His wife is no help, she doesn’t seem to know anything other than he has CHF and stopped taking his Lasix. She doesn’t know when he stopped, how much he had been taking or if he took any other meds or had any allergies or other medical conditions. The station officer asks if I need any assistance during the transport, ummm, duh! Two Marines from the ambulance jump on and I tell Wayne to respond to the hospital and to “Get me there yesterday”. No time to waste on scene, we’ve got a long response to get everything done.

Meanwhile the patient has remained in the same state, staring straight ahead, not responding and gasping for air. A quick listen tells me that his lungs are almost completely filled, and his breathing is getting shallower due to fatigue – a sign the patient is deteriorating. A quick call to Med Control gets me orders for 80mg of Lasix and 2mg of Morphine which I can repeat as needed. At least the clinic staff got an IV started. Or not. I attached the syringe of Lasix to the IV line and try to push it. Nothing. Check the line, make sure the tubing isn’t crimped, etc. Someone had wisely slowed the fluids down (after all the last thing you want to do is give this patient’s body MORE fluid to deal with), but they had inadvertently shut the line down completely. No biggie, open it up, now it should be running. I glance at the bag, no drips. A brief squeeze of the bag doesn’t even get things going. “SON OF A B@$%*!!” I say out loud, “the line’s clotted off.” It’s then that I find out that one of the guys from the base ambulance is a paramedic. I hand him the IV box and tell him to find another vein, a challenging task on a large, dark-skinned person who is starved for air and therefore uncooperative. Meanwhile I got the monitor on him and set a BVM on the seat beside me; I had a feeling we might be needing it. He was tachycardic – no surprise there – but the rhythm was otherwise normal sinus. Pulse was about 124, blood pressure around 210/130, and his O2 sat was hovering in the low 80’s with 100% oxygen flowing in the mask. (Still a bad number but at least it’s better than the 60’s he had on that cannula.)

“Got it”, the medic said as he threaded the catheter into a virtually invisible vein on the patient’s hand. Nice work, let’s get some drugs on board FINALLY. I start to push the Lasix nice and slow, about half goes in before the skin around the IV site starts to balloon out meaning the vein blew. You’ve got to be sh%##&*g me. Murphy, get the hell out of my unit, I’m trying to save this guy’s bacon! By this point my patient is getting noticeably worse, now he has that “I’m-going-to-crash-on-you-at-any-moment” look as his breathing starts to slow down. We both quickly start looking for another IV site while the second Marine gets out an oral airway. Unfortunately the patient is now tense and his jaw is hopelessly clenched shut. Somehow another IV was found, and this one didn’t fail – third time was the charm on this one. We got the Lasix and 2 doses of Morphine in about the time the patient’s breathing gets too slow and we have to start bagging him. OK, time to get the intubation kit out. We can’t get his mouth open to tube him, he’s still clenched. Now is when I wish we had the same protocols as where I work, this patient is a prime candidate for RSI (rapid sequence intubation – a procedure using sedatives and paralytics to facilitate endotracheal intubation of a still conscious, still breathing patient). I have an idea, but there’s little to no chance the doc at med control will go for it. But we’re still several minutes out and the patient is getting critical, so I call med control a second time and ask to give some Versed to relax the patient so we can get a tube in. Oh, my God. The doc gave me the orders. I’m so shocked that I almost drop the Narc bag. I give the Versed and we try to intubate again. No luck. Give the med a minute to work, try again. Nope. Man this guy is really a fighter! He’s still breathing on his own somehow, though barely, and is still holding onto enough consciousness to keep that jaw firmly shut. Oh well, the BVM still works.

Once in the ED, I give a detailed report to the nurse and MD I spoke to on the phone. They give him another dose of Versed but he remains clenched. (OK, now I don’t feel so bad for not getting the tube.) The doc eventually ends up nasally intubating him, a skill we aren’t allowed to do in the field. Before we leave our patient was successfully intubated and stable but sedated.

I step out to catch my breath and write a report. The back of my unit is TRASHED. I tell Wayne to try and get all the trash out, and I’ll help him restock after I finish the report. The two Marines that rode with me seemed happy to have been part of a “good” call. Especially the paramedic. It’s got to be tough having advanced training but working for an agency that only has BLS capability; he seemed pleased to have been able to out his skills to use. I was certainly pleased to have both of them with me. There is absolutely no way I could have run that call without their help. So wherever you guys are, OOOO-RAH to you!!

Instant Karma?

2006-03-09T19:56:00.000-05:00

Okay, so I posted the below story about my beloved wife handing me..well you read it. Anyway, I'm not usually a "Put a thought into the universe..and it will manifest and come back to you" sort of guy. That said, a quick update. Cat and I have duty tonight, right now in fact, but I am home not feeling well, so Cat is there with Wayne (Tess has class tonight, so she's not there yet). So, instead of our massive four man crew, it's just the two of them.

I just got a call and was informed that my life is in danger. It seems that Cat just got sent down to Quantico (hoo rah) to pick up a Congestive Heart Failure patient from the clinic. That's about 3rd due south of us, and a pretty good run. In her words to me: "When I get home I'm wringing your neck. You send me here, and that CHFer crashes on me. They got no veins, so I get the IV on the 4th try. I have to tube them, I pushed Lasix, Morphine AND Versed....you are SO dead." I managed not to laugh out loud. A bit of Captain came out and I asked if she made sure to follow our Protocols, which are WAY too tight, and not her's from work. "Yeah, Had to call twice to get more med orders, but I got them all." Apparently, she talked to the new doc at the ER...a lady I do not know. I told her to tell the doc that if she keeps letting us be aggressive, I'll buy her dinner. More to come...well for ME for sure, I'll make sure to update.

Guess we are even on that bucket....

Can't say Cat never gave me anything.

2006-03-09T01:09:00.000-05:00

When I was a ride-along, not even a member of the department yet, I was lied to.  Well, perhaps mislead is a better word for it.  I rode with MedicJon, and about every call was a no kidding ALS emergency.  I mean, I had two respiratory arrests in a single shift with him.  We had heart attacks, serious overdoses and auto accidents.  It was intense, it was life saving and it was COOL and I was hooked.  That was over seven years ago.  Since then, I’ve learned a lot of things.  I’ve learned how to start IV’s, how to intubate, what drugs to push when.  I’ve learned that KED and slow are not synonyms, how to use a scoop stretcher, and that ADC puts errors into mapbooks.  I’ve also learned some cynicism; Sunlight causes roofs to burn (nod to DTXMatt12 for that one), all fires go out and all bleeding stops…eventually.  And sure as death and taxes, I learned that it had to be a cosmic conspiracy that kept me from seeing any of the ‘regular’, bread-and-butter calls during my ride alongs.  So, when Cat came to me and said she had a ride along for us this past weekend duty, I just hoped that he’d get a more representative sample of what EMS is really like.  (Okay, I hoped he’d be a ‘white cloud’ and scare off all the calls, but I knew better than that…not in our due.)

We spent most of the afternoon hanging out in “Trailer 1”, the trailer with the TV room in it watching bad movies and telling stories for the ride along.  He was the son of Cat’s hairdresser, and his mom said that he was a ‘good kid’, interested in EMS, and ‘looking for some direction’.  He found the right place, Lord knows our house has been a home for wayward boys before.  He seemed a good enough kid, a bit amped about being at the firehouse, but hey, that’s normal.  A couple hours of TV hadn’t damped that in him when the call went out for us to assist a second due engine from the neighboring department on a “CO Alarm Sounding.”

Hmm, we don’t go on those normally, so there must be someone feeling funny in the house, I figure as we walk to the unit.  Not exactly exciting on my end, but the rider is psyched.  The crew was Me, Cat, the rider and my ALS preceptee Tess.  Wayne was off for a bit, wooing his woman I believe.  Cat fills in the driving role and we head off to the call.  The extra info on the call is that everyone is out of the house, but someone is “feeling ill”.  I anticipated the feeling ill, but the ‘everyone’ perked my ears.  I type out a quick message on the MDC to the dispatchers, “Do we know how many patients there are?”  The MDC is nice, I can stay off the radio, but still chat with the dispatchers, or other units.  I’m a text messager from WAY back so that feels normal to me.  (Started texting on Ytalk on an RS6000 in college…NERD!)  One dispatcher responds that there is one patient, another chimes in that they do not have a patient count at this time.  Okay, no biggie, but different answers gets a cocked eyebrow again.

We arrive on scene and I see that the engine is already there.  The house is a typical split-level for the area, and there is a gas company truck out front.  The engine officer seems to be talking to the patient, a Hispanic male, next to a van parked in the road.  As I walk over the engine officer comes to me to give me the low-down.  He’s an unending string of bad news.  His report goes something like, “Hey, this guy says they’ve been feeling bad all week..” THEY?  Oh, him and the van full of kids…four of them, smallest in a car seat…great.  “…and yesterday they went to the doc and were told they had a stomach virus, so they came home.  Today, he thought he smelled gas, so they called the gas company.  The gas guy got a CO reading of 200 parts per million at the front door.”  Holy Shit.  A CO reading of 35 ppm is I-gotta-fix-that bad.  “…When we got here, we got a reading of 200 too.”

If you know why Carbon Monoxide is bad, skip this part.  If you don’t the easy version is this:  Hemoglobin in your blood carries oxygen to your body it can do what it does.  There are receptors on the hemoglobin just for this.  Carbon Monoxide, CO, once inhaled attaches itself to those same receptors, but does it MUCH ‘better’ than oxygen does.  So, as you get more and more CO in your blood, all the slots for oxygen get used up and your blood can’t carry the O2 it is supposed to.  So, your tissue ‘suffocates’ for lack of oxygen.  It can cause vomiting, heart attacks and irregular rhythms, and brain swelling. That’s bad (Yeah, that is a bit over-simplified, but it works for here.)  You treat it by bombing your system with O2 until the CO gets pushed off…kinda.

As I’m hearing this, the patient is walking off, that’s never good.  I start over to see where the heck he’s going when he bends over by his car…oh.  He’s puking again. Wonderful.  The engine officer also tells me that he doesn’t speak English either, so that’s a bonus challenge for us.  Fortunately, Tess is a native Spanish speaker, so she gets translation duties.  She starts talking to the guy, while I look in on the kids.  They all look a bit like sick kids, but none of them are in distress right now.  I give a call for the oxygen and instruct Cat and Tess that everyone gets O2 as quick as we can get it going. The kids all tell Tess that they have upset tummies and headaches, but nobody has thrown up.  They are answering appropriately, and behaving normally, so that is a plus.  I ask if they are all the guy’s, and how old are they, and I’m told that two are his, and the ages run from 11 yrs to 11 months.

So, I have five patients, and they ALL need to be seen at the hospital.  Some or all of them may need to go to a hyperbaric chamber for treatment, but I can’t tell which ones from the field, and the nearest one is a helicopter ride.  I am NOT flying 5 people out of here, if only because I’m not calling in that much air support.  (Interesting mental image though…I’d have a bigger air force than most countries).  The idea is to get them oxygen, get them to the ER, let them do the blood work and sort out who needs what.  My limiting resource, besides the fact that we aren’t supposed to transport that many people, is the number of oxygen regulators I have.  We are going to need help, but everyone is stable for now, so I tell the engine officer to get me a basic unit to help transport.  None are available nearby, so I get a Medic from the local department.  Even better I think.  I ask which kids belong to the guy here, and he points to one boy and one girl.  “Where’s mom and dad for these others?” I have Tess ask.  I hear that they are ‘coming’, and only a few minutes away…oh, and one of them feels bad.  Of course.  I give the ER a quick call and warn them that I got at LEAST 5 coming, one adult, possibly two, along with four kids all exposed to really high levels of CO…more to follow.  The ER thanks me for the warning, and I’m sure starts getting ready.

“Let’s split by family.  Take him to our unit, and we’ll take him and his kids, the other unit can take the others.”  This way the minors are with their parents for treatment permission etc.  There are built-in regulators in the unit, as well as the big O2 tank, so between that, my portable tank and one from the engine, I can mask all but one right away.  Dad’s puking, he gets one.  The baby is a baby, she gets one.  The boy and girl go with Dad to the unit with Cat, and they buddy breath a mask.  The rider follows them and gives Cat a hand.  Tess and I give the littlest one blow by oxygen and take care of the last child.

In fairly short order, the other medic arrives and I think that we are doing good.  Then the crew walks up empty handed and I go talk to the medic to get her up to speed.   I’ve seen her several times, and have always been fairly impressed.  Frankly, I must have caught her off guard, or on an off day, because as I explain what’s up and what the plan is, I get nothing but a blank look.  I finish the report and she just stands and looks at me, then around at the scene and back at me.  Period.  So, I tell her again.  And not much seems to click.  She asks about the kids, and I tell her once again.  The one family (Dad, boy, girl) are in my unit, and going with me, the other family (Baby and boy) are going with her, parents should be here ANY second….this time it seems to click and she heads over to see her patient.  She also asks her crew to get their O2 so we can get ours back and get moving.  While she talks with Tess about the kids, I check in with Cat on the unit.  She’s busy but holding her own, getting history and vitals as best she can on all three, with the help of the rider.  The guy is puking still, but into a bucket now.  I hate pukers.  She tells me that we should roll sooner than later, and points to the reading on the on board oxygen tank.  There is plenty of pressure, but with multiple lines running, I can see it dropping as we talk. There’s a first.  She says they are all stable, and Dad’s the worst…no kidding.

I get back to the van, and the other Mom and Dad are arriving.  And of course, Mom is very upset.  Now, she’d just left there, but something about the ambulances there really got to her.  I start trying to extract Tess to the unit so we can move, and check in on the other medic.  She’s in the groove now, and things are moving finally.  I feel like I’ve been on scene forever, and my mental clock has long since sounded.  I hear the second dad saying he’s feeling bad, so that makes three for the other crew too.  I double check that the other medic is okay, get a yes (She has a translator too) and get back to the unit.

Inside, I do a quick check on “my three” and see things are about the same.  We get a quick set of vitals all around, start paperwork on each of them, monitor dad, and I believe dad got a line too.  (I didn’t do it, one of the ladies did).  I ask Cat if she’s ready to drive to the hospital, that I’m good with the folks back here and she says “yeah” but has one last present.  “If I take off with this like this, it’s going to splash all over.”  “This” is the open bucket of vomit she’s holding.  Nice.  Yeah, it’s basically a plastic bucket like you might get cheap ice cream in, and it’s about 80% full of this dude’s puke.  It’s yellow, warm and it smells bad, and now it’s all mine.  Can’t say Cat never gave me anything.  Cat, quite reasonably, suggests I dump it, but I’m uneasy about opening up the door to the unit and chucking out a bucket o’ chum in front of all the neighbors, and while he fertilized his own law with great vigor before he got into the unit, I don’t think I can toss his biohazard myself.  On the other hand, I am NOT trying to balance this all the way to the ER without spilling it.  One more challenge.  (And they don’t advertise this stuff).

I look around and see the bucket for the onboard suction system.  “Give me that” I say.  It has a top, and there are caps for the suction holes, so I can seal it up.  The rider grabs it for me just as I get a nice, big, open mouthed tasty whiff of this puke and start to gag.  I motion to Cat to head up front, and that I’ll take care of this.  I’ve never blown chunks in my own unit, and I’m not starting today.  So, with all the care of a hazmat technician, and while fighting off repeated gags, I pour the stuff into the new bucket and get it sealed.  Then I turn, hand it to the rider and tell him to put it on the counter, but make sure it won’t spill.  (Welcome to EMS buddy! No glamour today).

On the way, I call in a report for each patient and explain that more are coming on a second uint.  After I hang up I hear that the engine crew has done a reading from the kid’s room: 1200 ppm, six times as bad as we thought.  We get to the ER quickly, and they are waiting for us.  They ask who’s the worst and I tell them Dad is.  He gets taken to a “Big room” for fastest evaluation, and Cat goes with him to give report.  I take the two kids to another room, with two nurses close behind.  It takes a while to get everything sorted out in the ER, and explain who was with whom in terms of parents etc.  It turns out that putting one family on one unit, and the other on the other really helped minimize confusion.  In relatively short order, everyone has their own nurse and is getting oxygen from the ER.

In the report room, our rider is full of good questions and we are explaining carbon monoxide and things he saw on the call.  We basically just gave oxygen and monitored people, no biggie but for the number of patients, but the rider is just as stoked as if we had shocked them back to live just for him.  He even got to be a part in disposing of the vomit…lucky him.  While I write reports, I hear him asking Cat how he can join up and when the meeting is.  I guess he got hooked too.  We’ll see.  At any rate, he can’t say he wasn’t warned.  I didn’t falsely advertise to him.  And I’ll be a bit more careful the next time Cat wants to hand me something on a call.

** UPDATE **
For a related, and extremely humorous look at another CO related call we ran, and perhaps why the delayed reaction on the part of the other medic, do yourself a favor and check out Matt's Wonderful World of Woodbridge. I promise you’ll get a laugh.

Where does THIS plug go?

2006-03-01T22:46:00.000-05:00

It has been really busy since the last post, personally starting a Master’s program, and at the station as well.  The department ran one of those truly difficult calls that you know is out there somewhere.  I was only peripherally involved in the call itself, as I was busy on a taxi run when the call went out.  I’m going to write up the call, and my understanding of the great job our entire department really did on it…but not tonight.  CD’s comment on the last posting (and by the way, I’m choosing to assume that the scary part of the post was the Doc not believing us and sitting the guy up again) reminded me of another call, one that abruptly ended upon arrival at the ER.

In our first due, there is a place we all know as The Fossil Farm.  This place is the poster child for every bad story you’ve ever seen under the title “Nursing Home”.   This place makes you want to die young as opposed to risk going there.  I have to follow it with the fact that it IS better than it has been in the past, thanks to law suits and state interventions I understand, but it smells of urine and Funk, the staff is minimally trained, and on the whole doesn’t seem to give a rip about the people inside it.  The patients are generally in pretty bad shape, with med lists and previous conditions as long as your arm, and don’t have the insurance to go somewhere else.  You can see them most days sitting in wheelchairs at odd angles in the hall staring at you as you pass with your cot and gear.  We all know the place, and we all know it well.  So well that we all start to groan as soon as we hear the box 12-01 on the dispatch.  There are few things they do well, but recognizing dead is one of them.  (Okay, sometimes it takes an hour or two, but that is another blog).

Anyway, when the call goes out for a “Stoppage of breathing” at this place, and we all head over knowing two things: One, someone is dead and two, they probably stink.  The response is a short one, and Cat loaded the cot with all the bags, the lifepak and the drug box as we roll.  We arrive just ahead of the engine, and start to glove up as we ride the elevator to the ‘second’ floor.  (The main entrance to this place is on the lowest floor, but there is a hill to one side, and there is a door from the ‘second’ floor out to the side parking lot at the end of the hall…this comes into play later.)  We exit on the second floor, and turn left towards the dispatched room number.  There is some staff standing around outside a door down the hall.  “No need to be in doing anything, just look from the hall” I think as we head that way.  There were also a few people around who were not staff, possibly family, which struck me as odd.

Of course odd is relative, pun intended, and when I turned to enter the room, the sight made me forget about the strange non-staff in the hall.  On the floor of the room is a large, apparently dead, man who is on the receiving end of some spirited CPR compressions.  That’s a real plus all things considered, but while he is laying on a board, presumably to give a solid base for compressions and to move him to the floor from the bed, it is laying across him, not along him.  Oh, his head is UNDER the bed, and compressions are being given by a (normally) slight lady who looks a full 40 weeks pregnant while a fairly built guy is struggling with a nonrebreather mask and oxygen tank….maybe they were just ahead of the curve on the “compressions only” CPR trend.

A LOT of things went through my head here…none of them complementary.  The reader’s digest version is something like, “Well, they are doing compressions at least….Holy Cow is she pregnant…If she goes into labor, I’m quitting…Where’s the dude’s head…How did they get his head under THERE?...So much for an airway…Nice guy – lets HER do compression while he tries to put an oxygen mask on a guy who isn’t breathing….Well, let’s do this.”

Orders get issued pretty quick and we go to work.  We slide the patient out from under the bed, and Cat gets down on the floor to drop a tube into his airway.  The compression job is taken off the soon-to-be-mom’s hands, and I get the lifepak connected quickly to take a look at what we have.  Cat gets the tube in the first pass and now we can breathe for him.  Compressions are paused and the ECG shows an asystolic ‘rhythm’, but also a couple agonal ‘beats’.  If you’ve run for a while, you know the funny looking, wide, ugly wiggles that are the final throes of a heart that I’m talking about.  Well, thank God for combi-pads on the lifepaks, because we were able to get pacing started really quickly.

Protocols say to do something silly like start with low milliamps and work your way up in intervals until you achieve mechanical capture and then increase it by 10% at a rate of 80 beats per min etc, etc, etc.  Well, technically that’s what I did.  It just looked to the untrained observer like I looked at the 320lbs or so dead guy, hit pace and spun the dial until it stopped.  Hey, I hit every increment!  As Bob Page would say, “Set it and forget it”.    The patient is moving a bit with each beat, and the monitor shows electrical capture.  Cool.  “Hey, do we have a pulse with that?” I ask.  Cat and I check are checking for a pulse, but it is hard to tell at the carotid because of the way the guy moves with each beat.  We check further down the arm and find a faint, but palpable pulse.  He’s still not breathing, but hey, we can do that for him.

I used to call pacing a patient, “Summoning the invisible elf”.  When you do it, the patient twitches at the chest as the pads deliver smallish shocks to the patient, causing the heart to beat.  If you stand back and look at the patient, they look like there is some little invisible elf kicking them in the ribs about 80 times a minute.

Well, woo-hoo, check this out, he’s not out of the woods at all, but hey, we’ve been here just a few minutes and we have gone from dead under the bed to a pulse, albeit thanks to our pacing, and that is more than you get most times by far.  The guy is moved to our backboard and cot and we start to head for the unit.  The fire guys have moved the unit around to the side of the building, so we can use the exit at the end of the hall and don’t have to go into the elevator again.  Nice thinking on their part.

An IV is started in the unit and we go for some vitals.  There was a good flash in the chamber when we got the line, a good sign for a blood pressure, but not conclusive.  We have him by a thread, and I really, really, really don’t want to lose that.  His eyes looked bad, in the I-was-just-dead way, and we noted that his nose started to bleed.  “Hey, he’s bleeding!” I think, and probably for the first time that it was good news.  Bleeding from the nose in this case means not just a pulse, but a pressure.  Cool.  Now yes, gravity can do that too, but he was flat on the floor before and not bleeding, and he was on the cot, somewhat less flat, and blood does NOT flow uphill.  As we take off for the short response to the hospital, maybe two miles away, the BP machine beeps with the news….90/30 or so, not much, but I’ll take it.

The call goes out to the hospital to say we are coming, and preliminary report is given.  At the ER, I’m pretty much floating out of the unit.  This isn’t a save, and it probably results in no brain activity at best, but I’ve done my part in this one, and we are “Not Dead”.  Not Dead is good on a code, and it happens rarely enough, so it’s good enough for now.  We get into the waiting cardiac/trauma bay where the code team awaits.  They quickly hop into action as we walk in, and I start spouting a report.  The IV bag is on the guy’s chest, and the tube has blood in it, gravity does that too, but a pulse helps.  I see them setting up their machines, and the Doc comes over to inspect things.

I’m telling him that we got a BP en route, pulses to match the pacing and mechanical respirations, and wondering “What the HELL is that whining, buzzing, ringing noise?”  I look back at the LifePak and am greeted with three parallel, horizontal dashed lines, and a flashing indicator telling me to connect leads.  “What the…”  I scan the patient, and my pads and leads are still on.  Then I see that the wires from the pads end at the connector, and the connector is loose on the cot…Someone disconnected my pacer.  “You have GOT to be kidding me!” I think so loud I almost yell it.  “No pulse” says a nurse next to Cat.  “The Patient has no pulse…in PEA on arrival” I hear the Doctor say to the report taker.  “LIKE HELL!” I think…I’m livid.  (To those now lost, the doctor just said that the patient never had a pulse at the hospital, that I was shocking him, but that it was not causing the heart to beat.  Pulseless Electrical Activity.  It also means he’s saying that I just ran an entire code without doing CPR on someone with no pulse.  My ass I did!)  I hold up the disconnected lead from the paddles towards the Doc, “No shit…Y’all pulled the pads!”  I don’t recall his response, but it didn’t matter.  I go to the nurse taking report and make sure she has all the background on the call and storm out to the report room.

There, for the first time in my life, I actually throw things.  Just pens, sure, but I’m as pissed off as I’ve ever been.  I’m pacing, cannot sit down, and sure can’t write the report.  Cat and Wayne gathered our stuff and were headed back to the unit.  Now, I wasn’t about to let the report stand saying that there was no pulse on arrival.  They boned this one and I was not rolling over.  I stick my head into the curtain, and see that they did not regain capture, and that the code is going poorly.  Frankly, a lot of this time is a bit of a rage-filled blur.

I must have been visibly pissed off, because Doctor Dave, universally liked and respected by everyone I know came over to talk.  “What’s up?” he asked.  I told him what I had, that I got a measured B/P, two providers felt a pulse, and we had active bleeding.  Before I get to the end, he puts his hand on my shoulder, looks me in the eye and says, “We disconnected your pacer didn’t we?”  And THAT is why he is liked and respected.  “Yeah, and the doc said we came in here in PEA, and no compressions.  That’s crap, and I’m pissed.”  He talks me down and assures me that he’ll be talking to the doctor and the team.  I feel better, and I trust him to follow up on that.  Of course, my report is both accurate and complete, and clearly states that we had capture, a blood pressure, and the pacer was disconnected upon arrival.

I get back to the station, still fuming a bit and the guys ask me how it turned out.  The patient died and I explain what happened.  They empathize and have a story of their own to share.  You see, among the many patient care issues at the Fossil Farm, the staff had been repeated told that they had a serious fire hazard.  The door we left from, the one on the second floor, for years had opened inward, not outward.  This is bad.  If that place burns, heaven forbid, then when people rush the door, it would not open, they’d have to pull it into themselves to get out...that’s not code, and they have been told to change it many times.  It seems that my fire crew, ornery and helpful bunch that they are went to open those doors for us while we worked, and found that they couldn’t push them open.  Well, not ones to be stopped by mere hinge structures, they pushed on the doors until they DID open outward.  I’m sure that did nothing good to the hinges.  They told the staff that they’d have to look at having that fixed, but make sure the next time they came that it still opened outward.  I love those guys.

Well, a good chuckle was had by all, and my anger away quickly.  Nothing makes you get over a bad one like the guys back at the house.  I love this place.

The Human Lightswitch

2006-02-18T14:04:00.000-05:00

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.

DTXMatt12 comes out

2006-02-17T09:51:00.000-05:00

Well it has happened again, someone else I have known for years, and have very high respect for, has started his own blog. DTXMatt12 has posted his own humorous comments, and even an article here, and now has decided to go out on his own as well. His first postings hint of life at our beloved firehouse, and the fraternal nature of those of us who live and run there. You cannot understand a firehouse without understanding the heritage and traditions of the building and people there with you, and before you. It is an aspect of life there that I have not yet addressed here due to the popularity of run stories. I recommend his site, he is an endless source of great tales still told to our new members as a right of passage into our tight little family. He is at http://www.dtxmatt12.blogspot.com/ and I will add him along with S. and MedicJon on the instigated blog lists tonight. I am looking forward to reading him, and I hope he continues to participate here as well.

As for myself, I’m looking to curl up with the laptop and get a story up on here either tonight or tomorrow. I’m working on a call from years ago on a guy who was suffering from “Human Lightswitch Syndrome”. See ya there.

That dead lady gave me the finger

2006-02-12T22:06:00.000-05:00

Alright, you won’t often hear a Medic (capital M) admit it, but there are times you look back and maybe doubt your past decisions.  Call it reviewing, re-evaluating, whatever you want, but the bottom line is you are scratching the quiet itch of doubt.  Now, if you honest with yourself, you find things to do better next time, or learn something new.  And if you’ve been doing it a while, and learned from your past, more often than not you can reaffirm your actions and stick to your guns.  Almost nothing puts you through that mental review process more frequently than a call that ends in a code.  And sometimes, the Reaper is just yanking your chain.

The engine crew was already on a run when the call came in for a Stoppage of Breathing at the assisted living place across the street from the station.  As result, we got a BLS ambulance and engine from our second due sent with us for help.  The extra information says that it is a 93 year old female patient, call placed by the staff who found her.  We did not get the usual “CPR instructions are being given”, but there are nurses there, so that may not mean anything.  Oh, and the call is on the top floor, but you knew that already too.

Jen was with Cat, Kelly and I, and was, at the time, in the midst of an epic run of codes.  By epic run, I mean something like 7-9 of them in a three month period.  She had her own entry in the CDC’s Morbidity and Mortality report.  This is the same stretch that had the guy on the bike hit by the car. Anyway, getting a code with her at the time was anything but surprising.

We do the usual “toss everything on the cot, and haul it up to the room” routine and get upstairs pretty quick.  As we head down the hall to the room, we see two of the staffers waiting for us.  Of note, they are in the hall, not in the room…guess there is no CPR going on here.  A bit of an exasperated sigh, and we are past them into the room.  On the bed is a 93 year old lady, looking for all the world like anyone’s grandmother, but dead.  She’s flat on her back, eyes open, mouth gaping, and clearly not breathing.  She’s been down a while and I can see that her pupils are glazing over as I do the mandatory pulse check.  “So, you just found her like this?” I ask the staff.  They tell me yes, it was on a check, but they just saw her, “not long ago.”  Of course.  It always seems that whenever we get a code at a nursing home, or assisted living place, the patient was always “Just seen”.  Sometimes it is clearly a lie, like the time we took a guy out in full rigor, this is not that obvious but more likely they just didn’t realize how much time had passed.  I have Cat setup the LifePak to document the findings, knowing she’ll be asystolic even before everything is on.  I’m looking to call this here and now, but not long prior to this, a medic in an area north of us called a DOA, only to have the overdose patient later wake up and make a full recovery.  Her butt was in a sling, and that case is still pending.  As a result, EVERYONE gets an ECG, and we document it all.

I’m on my cell phone even as Cat grabs the LifePac and hitting my speed dial to the Doc at the hospital.  The doc answers quickly, and it is a doc I know, but is middle of the pack as in reputation amongst the Medics.  I explain what I have, an unknown, but reportedly “not more than 30 min” down-time, no CPR in progress on arrival, milky pupils etc.  Our protocols say I can only call it with lividity, rigor, or “injuries incompatible with life.”   She doesn’t have obvious lividity etc yet, so I have to call.  The lifepak is on as we are talking, and no surprise, she’s textbook asystolic.  “What interventions have you performed?” is the question I get over the phone.  I explained we have done nothing ALS, that the call is to not work the code.  He explains that he ‘can’t have you stop if you have not done it yet’.  “Okay doc, copy, work the code…” Cat gives me the you-must-be-shitting-me look “we’ve got a lot to do, will call when we are on the way.”  I think the doc heard the tone in my voice and he started to say, “You don’t have to work it all the way, just call when you’ve done things.”  Okay, now THAT is confusing.

A brief interjection here.  I am NOT in the habit of not working codes.  I’m considered fairly aggressive on the street, and I’m not going to use age, status, or medical condition (outside of being dead) to determine working a code or not.  Hell, my only two walk-out-of-the-hospital saves that I know of are a drug dealer (see S.’s blog) and a terminal cancer patient.  I’ll run the code with about no chance at all, just in case the big man upstairs wants someone back.  But, this lady is D-E-D Dead, and there is nothing else to be done about it.  I know of only one medic that can get this lady back, and last I heard he gave the slip to a couple of Roman Centurions about 2000 years ago.  This was just one of those cases where I was not going to go around protocol and say I saw something I didn’t (rigor etc) just to avoid the call.

Okay, so, we are working it.  It’s a training run, but if we are going to do this, it will be done right and by the numbers.  The engine and the basic come in to see us pumping chest and getting the BVM to the O2.  I had gotten past the unique pleasure of cracking the lady’s ribs with the first few compressions and started to hand compressions off to Jen and Kelly.  The basic unit lead was in EMT-I class, so with her, Kelly out of I class, Cat and I, we had silly ALS help.  The staff of the place wasn’t much help and was struggling to get paperwork in order for us.  Typical too.  I make the call to run the code BLS to the unit, and we are moving that way fast.  There is good compliance with the BVM, and we had her on the cot before the other unit got there.  The patient and the folks doing CPR head to the elevators, and I follow on another one.  There is limited room, and we could not all get in at once.  The team is solid, and I’m not adding anything to that point.

We transition smoothly to the unit and get setup fast.  Everyone is kinda got that amped-up code groove going and I take a moment to calm everyone.  “Okay, everyone understands how this one is going to end right?”  I get nods from Cat and Kelly, and a little confusion from the rest.  “She’s dead, and nothing we do here is going to change that.  Let’s do this right, get everything done, and don’t poke each other…okay?”  I can feel the back of the unit calm and everyone gets going.  I have the intubation kit out and work with the lead from the basic to get going there.  Kelly offers to get the IV, not a trivial deal on the arm of a person with no blood pressure, and I tell her to give it a shot.  It’s good experience, and she’s pretty good with a needle.  If she doesn’t get it in the time it takes me to get the tube, I’ll have Cat try or I’ll just go for the EJ (IV access in the neck veins) from up here at the head.  Cat gets Kelly going and after the basic ventilates, I take a quick look into the trach of the patient.  Yeah, she’s been down a bit.  I see right away that there is none of the usual ‘goop’ you find in there.  She hasn’t vomited, she isn’t full of mucus etc and all in all, a very clean airway.  (okay, if you aren’t a medic, you may no know that that is a compliment.)  I know I have an EMT-I student next to me, and this is a good a shot at experience as she’s going to get.  (I can’t let her get the tube by protocol, no students get field intubations until after certification etc…kinda stinks, but thems the rules.)  So, I lean back and motion with my head for her to take a look.  She leans over fast and sees her first human airway.  “Cool, not like the dummy” she says.  “okay, so this is not a total waste” I think to myself.  Jen is on my other side, and giving me the raised eyebrows, so she gets a quick peek too.  I have the tube all set to go and pass it quickly, seeing it going through the vocal cords and into place.  I’m well under my 30 seconds for the intubation, so I have the student look in to see what that looks like too.  “Tube placement visualized by two providers” I think to myself and grin.  My documentation will show that this part was nailed.  I hear that Kelly hit the line, and Cat is pushing the first round of meds.  Compressions are going smoothly, and I listen to confirm placement of the tube I already know to be in place.  The Capnography is flat, but then, she’s dead so I have great ventilations, and no respirations.  (Air in and out of the lungs fine, but she’s been down to long for her body to exchange the O2 and CO2 in her blood).  You get that same effect when you intubate a tree.

Alright, wow, smooth code I’m thinking.  Everything went great, worked the first time, and everyone knew what to do. Nice, smooth.  As much as I abhor a Custer-Fluck, I do admire a group just doing what needs to be done.  The student goes up front to drive and the hospital is only about a mile and a half or so away.  (Which is why we weren’t already rolling).  Quick checklist in my head:  Airway check, compressions check, IV in, drugs in, oh yeah monitor….still asystolic and textbook flat.  Time to call the doc.  “Hey doc, Okay, CPR in progress, asystolic at the start, Tube in, IV in, one round Epi, one round atropine, still asystolic. Pt eyes continue foggy, request permission to call it.”  He asks me how long it has been.  I check my pager…holy cow, I was Dispatched 20 min ago.  “20 min” I tell the doc, and he says to call it.  I give the wave-off to the team in the back of the unit.  “okay, 2 min out” to the doc. Hang up and yell up to the driver so we can just drive, no need for the lights.  (We were still in the parking lot)  Now that means that 20 min ago I was watching TV.  We got the call, got across the street, up the elevator, to the room, talked to the doc, talked to the staff, ran the CPR, got down the stairs, to the unit, ET, IV, drugs and another call, in 20 min.  That’s silly quick and just another case of the mantra: Smooth is fast.  Doing something right the first time, under stress, even though you think you are going slower to be careful, is actually much faster than rushing and messing up.  I’ve noticed our EMTs picking that up, and it’s fun to watch.  Again, a good team is everything.

We get to the hospital and wait in the bay for the doc to come out and declare the death.  It takes a while, something like 15 minutes, the ER was busy and it took him a while to come out.  Some time during this, the Rescue Chief comes by to see how things went.  He finally comes out, listens to her chest, sees our leads and declares death.  We go into the ER and I work with the Charge Nurse to get someone to the morgue so we can take the body around.  This takes about another 10 minutes to arrange, but finally we can drive around, “downstairs”.  The Chief gives the wave and starts to leave.

The morgue entrance is in a parking garage type structure that is under construction, so it takes a bit to maneuver the medic unit to the door.  We get the lady transferred onto the pan, after moving another resident and get started to leave.  I’m helping back the unit up around some obstacles when one of the ER staffers comes running out, eyes WIDE open and gesturing madly.  “Your patient is MOVING” he all but yells.  Aw, hell.  Visions of the medic north of us in my head, and grateful for all of my ECG tracings, I stop Cat from backing the unit.  I grab the LifePak from the unit and call back the Chief on my Nextel.  He comes screaming back into the garage in his buggy in a flash.  Me, Cat, Jen and the Chief head for the door to the morgue.  Inside, there is a patient rep, a nurse is just running in, and the patient on a table.  I rush in to see what’s up.  The rep is pointing and agape, not a good sign.  “Don’t touch her” I get from the Chief “that is the Hospital’s patient, not ours”.  Good, clear headed thinking on his part, and he’s exactly right.  We’d handed off care, and the ER doc examined the patient and declared death…this is not my patient.  About that time the doc is walking in.  “She’s moving her finger” the rep says and we all stop and stare.  Sure enough, she’s moving.  Her index finger is moving off and on, kind of a “Come here” move.  “You HAVE to be kidding me” I think as she does it again.  The doc is in now, and listens to her chest.  We are all silent as he leans in, and the finger twitches once more.  “It’s okay, just a reflex from the drugs” he says.  Well, that makes sense, and I’ve heard of such things, but never seen it.  It seems that the Epinephrine, given to help stimulate the heart muscle was causing twitches in her finger.  Let me tell you, hearing it is one thing, but seeing a lady who has been dead for at least an hour or so give you the “come here” will cause you to suck the underwear right up your butt, and I’m not too big a man to admit it.  I’ll know it if I see it again, and I damn well better not see it again too. Grin.

We pack up and go to write the report, and I un-pucker my backside.  I document he heck out of this one though, and have plenty of tracings to show the call.  We clean up and chuckle, knowing that we took a plain old code, and a practice run at that, and turned it into ‘one of those calls’.  To this day, I wish I’d just let her stay in bed, and none of this would have happened.

Maybe it was the one-armed man

2006-02-02T21:50:00.000-05:00

I have a confession to make.  Sometimes I have been guilty of mocking a dispatch.  Now, I know they are often just passing on what the person on the line is saying, and that person is the member of the public.  And as the little old ladies here would say, “Bless their heart”, we all know we can’t trust the public’s description to in anyway match reality when it comes to our emergencies.  So, a couple weeks ago, when Cat, Wayne and I get dispatched early in the night for a “Possible injury from a fall”, I admit I asked allowed of Wayne, “Well, did he, or did he not fall down?”  As it turns out, the dispatcher was correct.

The call was for our second due, and the MDT (our onboard computer) passed an update that Police were on the scene, and that the patient is disoriented, and saying someone attacked him.  “What does this have to do with a fall?”  I’m thinking as Wayne accelerates north, negotiating the moderate traffic.  The address is an apartment building in a part of town that has seen better days.  The apartments are known for a fine history of fires, and having multiple families per unit more recently.  We often get sent there for assaults, and unconscious calls that end up being cases of lots of alcohol, very little sense.  The first due engine gets there just ahead of us, and as we pull up, I see that there are one or two police cars waiting and the Rescue Chief has come along as well.  Yeah, just another call on Bayside.

We trot up the stairs (again, it’s always upstairs) to the apartment.  Again, easy to see which one we are headed for, the door is open, there is plenty of people in the first room, and a Police officer at the door.  We get to the door, and I ask, “Where are we headed?”  I should have known the answer before I got it, “In the back room”.  Of course.  As I make my way through the apartment, I can’t help but notice that there are about 15-20 people in the front room, kitchen, hallway and bathroom.  Now normally, this would be a mix of all ages, and represent a couple of families.  In this case, they are all between the ages of 18 and 30, mostly male, and all in pretty good physical shape.  There are about three Police on the scene, and the further I walk back to the room, the more of these guys that are between my crew and the door.  That is not necessarily bad, but it is never good.  The engine crew seemed to be noticing it too, and they kinda spread out in a line from the front door to the back room.  There, I find the patient, face down on the floor, handcuffed and being held down by a female officer, who is kneeling on his back.  He looks confused, and while dressed, is a bit wet.  I notice that while she is on his back, she’s scanning the room as we enter….SOMETHING went down here.

Her words to me are something along the lines of:  “I’m not sure what is wrong with him.  He says someone attacked him in the shower, but he’s all confused and not answering questions.  They,” motion to the door and the people beyond, “were fighting with him when we got here.  They say he came out crazy and was fighting all of them.”  The patient has his head lifted up and is looking about, and muttering something, but it is unintelligible.  The room is dark, lit only by the light from the attached bathroom, but I don’t see any real obvious clues.  But, I have one guy in police restraint, no obvious trauma, conscious but confused, looking around slowly…kinda like, “Hey, look…people.” And he was taking on a group from the other room.  Now, I know with family etc, they were probably taking it easy, but that group looked like a sports team, and I didn’t give my crew, plus the cops, plus the engine guys much better than a 60/40 edge if things went bad in here.  So, this thin guy must have been pretty ramped up.  (Any of this sound familiar, because it LOOKED familiar).

Well, I got a string of guys from me to the exit, and the Rescue Chief is in the doorway to the room.  I know he’s thinking what I am, and has placed himself in a security position.  I stifled the urge to say to him, “Holy Shit Custer, look at all them Indians.”  I’m sure he’d have slowed down a rush long enough for us to do something before he got run over, and I’m glad he did that.  So, while the group is kinda anxious and walking around nervously, we are as good as we are getting, and I can’t hold past experiences against them…even past experience in this neighborhood.  I ask the patent a few questions, and basically get no answers, but he seems to be intent on conveying that he was showering, and “some dude attacked me”.  Eventually, we get out that this ‘dude’ reached in while he was showering, grabbed his ankles or legs and pulled him down.  (A-ha! A fall, now I get it.)  His girlfriend, nearby, tells me that she was in the other room, there was nobody in the bedroom but the patient, and nobody went in until he came out of the shower, “all crazy”.  Maybe it was the one-armed man, I think to myself.  His vitals come back okay, nothing out of the ordinary.  Pulse was up a bit I believe, but that makes sense here.  He’s not diabetic, not on any medications.  I check his pupils and they DO seem a bit small, not really pinpoint, but too small.  I’m thinking drugs, and so is Cat.  “Any chance he took something?”  I ask his girlfriend.  Now we are in front of the cops and everyone, so the “no, no” answer is neither surprising, nor necessarily accurate.  But, one has to ask.

Okay, let’s roll.  I’m thinking we’ll be trying the Narcan, a narcotic antagonist, to see if that doesn’t bring this guy back, but it’s a bit of a stretch.  The idea of un-cuffing him is never even discussed, so he’s going out like he is.  I have the engine crew get our Reeves from the unit.  I don’t know if I’ve described that here or not, but basically, it is a series of small strips of wood, about six feet long that are have been laid out side by side and wrapped in a plastic wrapping with handles.  The result is a very portable litter that is rigid from head to toe, but can be rolled up, or wrapped around someone.  We use it all the time.  Now, I’m thinking he should go out on his back, face up, so I can keep his airway clear as we go down the stairs.  The Chief opines that we need to take him face down so he’s not on top of his cuffed wrists.  I’m not so sure I like that, and I express some concern about positional asphyxia etc.  He points out that his legs are not bound, and that is a big part of the positional asphyxia thing.  Okay, I’m more interested in moving than arguing, and if he has issues when we get going, I have plenty of people to deal with that too.  Face down it is.  I had already made the call on the possible backboard issue – He was unclear on his falling or not in the shower, there is no sign of trauma, no pain or tenderness when I press on his neck/back, AND he has been wrestling his entire family since then.  Boarding would mean uncuffing, and we are not doing that if we didn’t have to.

We roll him onto the Reeve’s and get ready to carry him out.  As we exit the room and start down the hallway, the Chief gets a better look at the patient and the situation.  “Hey Chris, I think you’re right, he should be on his back.”  Now, we’ve discussed this moment between ourselves since then, so, while he may well be a reader, I feel confident when I say the thought, “Gee, that’s great timing on that one Chief.  Thanks for the help.”  (During the later conversation, he clarified that his concern was over stressing the wrists of the patient, and putting his torso’s weight on them.  As it turns out, the patient was kinda loose in the cuffs and able to move his wrists to his side…as we’d see in the unit.)
Now, I’m moving, carrying the patient, and we are NOT stopping again until there is an issue or we are at the cot.

The engine company has the cot waiting outside the door of the building, and when we get there, we open the Reeve’s and flip the patient over, careful to bring his arms to one side to help his wrists.  We load to the unit, and have an officer come with us.  They are okay with that in light of the struggle they had before our arrival, but to be honest that was only a minor concern.  We still didn’t know for sure what the deal was, and while he seemed stable now, if something happened, we’d need the cuffs off fast, and that is not something we can do.  Also, considering everything, I’m okay with an officer there to observe the fact that we take care not to harm the guy.  We get vitals, and Cat does a nice job getting the IV going in spite of the odd positioning on his arms.  The patient is starting to talk more now, and is making more and more sense as he does.  He’s calming and generally becoming “OK”.  I decide against the Narcan at this point.  While this may be a narcotic deal, it doesn’t feel like it, his behavior doesn’t dictate it, and even his pupils are looking okay in the light of the unit.  While Narcan is often considered one of those drugs that, “It doesn’t hurt ‘em to try”, I also was taught to remember that all medicines are poisons, but that they have really beneficial effects, so we use them.  I’m still thinking drugs are a possibility, but his behavior is more PCP or hallucinogen than narcotic.

His ECG is good, no ectopy, not tachy or anything.  He’s oxygenating well, and starting to hold a conversation with the police officer.  I try not to interrupt too much, the cop is asking good questions, and I’m more watching his level of response than anything else.  He is concerned about the cuffs, and the cop tells him that they can come off at the hospital.  We basically monitor him on the way, and don’t do much else.

Arriving at the hospital, we get him transferred quickly, and the officer loosens the cuffs after a clear explanation of the consequences of acting out once they are off.  I give report to the nurse, and she gives me a quizzical look.  He may or may not have fallen in the shower, he says he was attacked, but everyone says that is not possible.  He was certainly not responding well on scene, but recovered quickly in the unit.  He was battling his whole family, but is now calm and cooperative.  His vitals are good, and everything is stable.  I’ve got a line, cause that is what we do, and here you go, best of luck, gotta go, see you with the next one.

In the report room, we compare guesses and notes.  Drugs, always a popular choice, but wow, that wore off kinda fast with no intervention, and they say he didn’t have any there.  That could be a fabrication, or perhaps it was a flashback.  Seizure of some sort, postictal when we got there, awake now, but that does not quite fit either.  Low sugar, no diabetes, and the number was okay.  Actually fell in the shower?  Possible, but that does not explain the rest.  Actually attacked?  Possible, but again why the incoherence?  Psych issue, again, a popular choice always, but who knows.  Was it an act in the house, looking to get out for whatever reason, domestic issue etc, and then the ‘wake up’ was just dropping the act now that he was out?  Again, fits well, but we don’t know.

These calls are always interesting, and frustrating at the same time.  We never did get a diagnosis from the hospital, as usual, and will never know for sure.  No matter what the cause, it does make you appreciate the complexity of humans and the things, internal and external, that affect them.  That’s something they don’t cover in class though, the “Gee, I dunno, he’s sick and I brought him here” calls that make up a fair bit of our practice.  Or, maybe I missed that day.

Car 512, Where are you?

2006-01-31T21:09:00.000-05:00

Sorry for missing a week on my posting, life has been a bit hectic. Cat and I have been overhauling the house in preparation for our annual Mardi Gras Party on the 11th, she’s been studying for her registry upgrade test, and preparing for hand surgery tomorrow. I’ve been out of town some, up in New Hampshire for work. As a result I’ve slacked off here. I will get a post up here on Thursday afternoon/evening as I will be off and spending the day holding sparkly things in front of a highly medicated MedicCat. I hope this means my email box will not be shelled with the “HEY, Where’s your Post?” emails for a day. Grin. Thanks guys for keeping me focused here. For those of you in the DC area: “Sorry for the clip show, have no fear; we’ve got stories for years...”

Signal 14

2006-01-22T00:54:00.000-05:00

Fortunately, it does not happen often, but in our system we have a radio code known as a “Signal 14”.  For those of you more familiar with the Police side of things, this is our version of “Signal 13”, or 10-13 code.  Where Signal 13 is the call for Officer in Distress, Signal 14 means that Fire or Rescue personnel are in trouble.  And like an Officer in Distress call, a Signal 14 brings absolutely everyone.  It is reassuring to see, but it is not something you want to use lightly, and if you can, you want to avoid seeing it displayed.  I’ve only said those words once over the air, and we were deep in it when I did.

The call was several years ago, and I was running as a BLS preceptor at the time.  The crew I was with that night consisted of my preceptee Nancy, a then-new EMT, Rob W also an EMT and Rob L a firefighter who was driving so I could precept Nancy.  Now, Nancy is a nice girl, and decent EMT who stands about 5 foot nothing and has a slight build.  She was pretty close to turned over, but was having some confidence issues, and was getting some more street time to work that out.  Rob W is an all around good guy, and family man.  He had more angst over doing the right thing all the time than anyone I’ve ever known.  While of medium stature, he was also a Marine Corps reservist, where he held the rank of Major.  (He later became a Lt. Col, a statement of his character.)  That’s the thing about interacting with a volunteer organization; you never know what the person you are talking to does in “real life”.  Rob L is a career fireman as well as a volunteer, and in pretty good shape himself.  All of these come into play, and in retrospect, we had a pretty good combination that night.  Ironic, since we did not usually run as a crew.

Early in the night, we get a call to assist a career medic in the area south of us for a possible overdose.  En route we hear that the patient has taken PCP, and the family is worried.  At that point, I had never run a PCP patient, but had heard plenty of stories about the amped-up, super strong, raging wild patent tearing up houses, and taking on teams of Police.  My dad was a cop for over 20 years and one of his best stories is of a guy on PCP.  So, this is what is running through my head as we head down for the call.

The career unit was there well ahead of us, and we grab our bags and head into the house.  Inside, we see the medic crew talking to the patient, who is seated on the sofa and is clearly high.  Like I said, this was the first time I’d seen this before, and for those who haven’t seen it, it is really not like you might expect from the stories.  The PCP patients that I have seen seem to be running in super slow motion, and they like sparkly things.  For example, I once saw a guy who had wrecked his van while on PCP come out to face the three or four police cars that had arrived when we did.  He came out, and slowly stared from one car’s lights to the next with this look of wonder on his face.  (He then SLOWLY took this silly martial arts stance out of a movie and was sacked by about four cops who, unfortunately for this guy, moved at full speed.)  This guy was behaving exactly like that.  He was answering simple questions, but only after you were sure he didn’t hear you.  I also noticed that he liked to look towards movement.  The family was very concerned, and knew it was PCP because “this is how he acted last time he was on PCP.”  Now, I’m trying not to chuckle, and I’m trying REALLY hard not to mess with the guy by rolling a new quarter on the floor or something, but in the back of my mind I know we should be glad he’s calm and try not to stir him up.
The medic that day was running with a crew of two, one of whom I know had been a cop before becoming a career medic.  We had good rapport and the assessment went smoothly.  As I recall, the guy was basically okay, or at least had vitals that you’d expect for PCP.  We decide to walk him to the medic unit, and the guys ask us if we can spare someone for manpower, just in case.  I was all for that, and while Nancy was precepting, and could have used the experience, I sent Rob W, the Marine.  They weren’t planning to do much but get to the hospital as I recall, so things were pretty low key.  The patient’s family was going to follow the unit to the hospital, and everyone was going without lights and sirens…no need to get the patient fired up over something.

Now because of the way we approached the house, we had to go down a street to turn around, while the medic unit had a straight shot out to towards the hospital.  As a result, while we were following them to the hospital, they got a considerable jump on us, and were out of sight ahead of us on the way.  Rob L, Nancy and I were joking in the unit about the reaction of the patient, and comparing notes on other calls when we hear the medic unit call out over the radio.  They are calling dispatch asking them to send a Police officer to assist.  They have pulled over at an intersection a couple miles up the road, and the patient is unruly in the back.  Now, I’m sitting in the back of the unit, letting Nancy lead from the front, but that was enough for me to assert control.  “Rob, get there, light them up!”  Rob did not need to be told twice, and in all truth was already moving when I said it.  The lights come on, the siren wails and feel the unit accelerating hard.  Our guy is in the back there, and it’s only him and the one medic.  It didn’t take long to get there at all.

Pulling up I see the medic unit pulled to the side of the road, the back doors are open and there is another car pulled in behind it.  Inside, there are a lot of people, none of whom are the Police.  Running to the unit, I see that the family had been following right behind, and the patient’s mother and two brother’s had hopped out to ‘help’.  Mom was outside behind the unit wailing.  Inside, Rob W, the medic, the patient and the two brothers were all in ball trying to restrain the patient to the cot.  It looked like the family was helping the medic, and as we entered, I saw that was the case.  I told Nancy to go up front.  She was pretty small, and I didn’t want to have to keep track of her in any melee.  Frankly, there wasn’t much she could do but get bounced from wall to wall in the back, so, I wanted her safe.

Now, the struggle in the back was pretty unusual.  There wasn’t any swinging or punching exactly, but there was this slow motion wrestling.  Apparently the patient had tried to get up and exit the unit while they were headed up the road.  This would have been bad for the patient, and we lose points for letting a patient wander in traffic at all, never mind doing the 40 mph exit from the back of a moving unit.  The goal here was to get the patient secured back in the cot.  Well, he was fighting this with persistent, but slow resistance.  So, while we were moving much faster than him, he was exhibiting the incredible strength that I’d heard of before.  At one point I had myself and another guy losing a battle against a single arm on him and we had both position and leverage in our favor.  The guy just slowly pushed us back and off the cot.  Of course we just let go, repositioned and started over because he was in PCP slow-mo.
So, now that both crews, minus Nancy are in the back, and a PD unit is coming, we start telling the family, “we got it, please go back to your car. Thanks for the help” etc.  We don’t want one of them getting hurt accidentally and adding patients to the situation.  This is all well and good, but then the family members decide that things are going badly.  Specifically, mom starts up with “Don’t let them hurt him.”  I hear this and can already see where this is headed.  At this point, I have to paint in one more fact that was not relevant from my point of view until exactly this moment.  The patient and family all happened to be black, and of course, as fate would have it, both my crew and the medic crew were all white.  That fact didn’t even occur to me until one of the brothers made a comment to that effect.  I don’t recall exactly what he said, but it was not helpful or complimentary.

I call back to mom that we are NOT hurting the patient, just trying to keep him in the cot so he won’t walk into traffic.  Well, that didn’t seem to be a convincing argument, because now the brothers start trying to pull us back off the patient.  So, when the Police Officer arrives, he has mom outside inciting things from outside the back of the unit, and one patient, two brothers, two medics, two EMTs and a firefighter wrestling inside.  It was Real Cozy in the back there for a bit.  Amazingly, it STILL had not come to blows, just pulling and pushing trying to gain control.  There was plenty of yelling going on too.

The officer quickly gets involved, and gets the two brothers out of the unit by explaining that they can stay and go to jail, or get out.  He closes the doors behind him and it’s just us and the patient.  The patient has managed to get from the cot to the bench seat and the cop and the medics are trying to gain control of him there.  The good thing is that since he is against the wall of the unit, and the bench, things are a bit more controlled.  I’m actually standing away from the action, but inside the unit on the opposite side of the cot towards the back.  Frankly, the patient was covered and there was little I could do to help outside occasionally helping with an arm here or there.  I’m a bit worried about the family outside though.  I can’t see them well now that the doors are close, and through the back window, I see them moving around in their car.  That could be bad, so I’m trying to keep watch in that direction too.  When the car door opens, the interior light comes on, and I see someone getting out of the passenger seat and headed for the unit.  I call out a warning and try to see who is coming and where they are headed, but I can’t tell.  I don’t think anyone heard me over the struggle, or if they did, there was little they could do.  They are getting the upper hand on the patient finally, the cop and the Police trained medic getting him into some holds to keep control, but aren’t quite there yet.

The side door to the unit flies open suddenly.  Standing in the doorway is one of the brothers and he’s clearly pissed.  I start moving in that direction as he reaches in, and around the cop, who is bent over the patient.  To this day I clearly remember what happened next.  The brother’s hand comes in and around the cop’s hip…right to his gun.  He latches on and starts to pull.  The cop pushes down once on the patient, grabs a hold on the brother’s hand, spins and basically dives out the door into the dark down the ditch on the side of the road.  Now things have slowed down for me. I spin around and reach for the radio.  I don’t know who got that gun, but if it is not the cop, we are in a world of hurt.  There are six people in an ambulance and SOMEONE outside the open door has a gun.  Fish in a barrel does not quite summarize how screwed we may be at that moment.

Grabbing the radio, I say those magic words. “Medic 52, Ambulance 12-8 are Signal 14, repeat Signal 14, gun involved.”  As I’m talking, Rob W has converted from EMT to Marine and thrown himself out the back door and to the aid of the police officer.  I hear the medics saying they can at least contain the patient finally and are yelling to help the cop.  The other brother comes from the car, and I believe is being met by Rob L outside.  Now I’m desperate to know that the call has been heard and that the cavalry is coming.  I know that ultimately the arrival (or not) of the rest of the police is going to be the difference here.  I can’t hear the radio at all over all the yelling and I go out the side of the unit and up to the cab.  I’m pretty focused on making sure help is coming, and only peripherally notice the wrestling that is going on in the ditch.

I try to open the passenger door and it won’t budge.  Nancy has locked herself in, and is now so freaked that she can’t work the lock.  I yell to the window, “Did they HEAR me?” “What?” is her response.  Okay, when this is over, I’m going to kill her.   “Did the call get out, did they say they are coming?”  She looks sheet-white and says, “I don’t know, they said, ‘All units hold your traffic.’.”  Excellent!  By protocol, when someone calls Signal 14, they seize the channel, and everyone else is ordered to maintain radio silence until the signal is lifted.  If they issued that order, they got the call.  We are only about 2 miles from the Police Station, and I already hear sirens.

Looking to the ditch, I see the first brother on the ground, holding his face and being held by someone (I can remember who was who now.)  The cop was in the process of Pepper Spraying the other as I recall.  Inside, the medics have the patient pinned.  As I see the blue lights of the first unit coming from the next hill, I rush over to cut off mom, who is racing around the car to jump on the back of the police officer.  “Ma’am, go BACK to your car.”  I yell as I square in her way.  She’s yelling about hurting her sons and at that point I get angry for the first time in the call.  I tell her that her son’s are in trouble only because she didn’t shut up and go to her car when she was told to before.  Now, that may not have been the textbook answer, but at this point the text was out the window.  The first unit comes on scene and the cops quickly secure the brothers in the ditch.  Other units follow quickly, on the order of ten or so and the situation resolves as fast as it escalated.  At some point Nancy figures out how to work a door and gets out to help.

In the end, the brother’s we treat the brothers on the scene for Pepper Spray and release them to the cops who bestow them with chrome bracelets, room, board and a court date for assaulting a police officer.  The patient is secured to the cot and taken by the medic to the hospital with police on board.  Mom barely escapes getting locked up herself when she starts yelling at the cops.  I’m mildly amused when I hear the officer explaining that it was most likely her stirring things up that got her son’s arrested.  After that call, we go out of service, and fill out individual police reports back at the station.  We all carefully write what we know, and don’t compare notes while we do it.

A couple months later we all get the news we knew was coming.  We get our subpoenas for the court date.  It seems the brother who grabbed for the gun had been under house arrest (you know, tracking anklet etc) at the time of this call.  It seems that a few months prior to our little party he had assaulted a Police Officer.  So, he was fighting the second conviction saying he was “Acting in defense of another” namely the patient.  It was a short court date.  I did have to testify, and the defense attorney asked something like, “Isn’t it possible that the defendant intended just to get the officer off of his brother and just happened to grab the gun?”  Now, I paused, thinking the prosecutor would object to my being asked what the guy was thinking, but he was taking a note and didn’t jump in.   So I thought briefly about offering that he might have intended to get a ham sandwich out of the cop’s pocket for all I knew, but answered along the lines of, “I don’t know what he intended, I’m not Ms. Cleo, but I know he grabbed the handle of the officer’s weapon, held on, and pulled him from the ambulance with it.”  At which point he winced and basically gave up on that line.  The others there were not all called in and things closed up quickly.  It did not go well for the brother.

Months later I learned that things had been pretty close outside the unit.  According to the story, later verified by a bashful Rob W, when Rob left out the back of the unit, he found the officer and the brother locked arm in arm in the ditch.  They were struggling over the gun, still in the holster and the final possession of the weapon was not clear.  Rob, reverting to Marine, dove into the fray from the top of the ditch and landed between the cop and the brother.  On his way down, he brought his forearm across the bridge of the brother’s nose breaking it rather cleanly according to reports.  This seemed to have been the decisive act, as he let go of the gun handle and covered his face, allowing the officer to gain the upper hand and move to secure him and the other brother, then arriving from the car.  By all accounts, up until that moment, the fish in the barrel outcome was still very much a possibility.  Needless to say, Rob is always welcome on my unit, and his first beer is on me any time he wants to get out socially.  That’s the thing about a volunteer organization, you never know what that EMT does in “real” life.