BACK in the Saddle

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

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

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!

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

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

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

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.