Adventures in Emergency Medicine

This post covers multiple calls/cases from this past weekend. It will get long I'm sure.
Sat. I ran w/MedicJon. The interesting activity around the county during the AM hours was from the Marine Corps base in our area. The OCS Class had just started up and they had 10 guys fall out from heat emergencies before shutting it down. One guy had a core temp of 108F. When asked why he didn't say something, he said "We're Marines. We don't do that." Bloody hell! I've always said that a high level of testosterone poisoning is required to be a Marine. The worst-off Marine had a core temp of 110F and was having seizures, totally unconscious. I'm glad I didn't have to take care of any of those poor guys.
Our first call was for the "Oh boy!" lady. She was in the very back room in her filthy, disgusting house w/her fat slob piece of shit son and her sweet but equally neglectful husband. She had been discharged from the hospital just 10 days before on O2 and steroids. I call her the "Oh boy!" lady because that is ALL she would say. She wouldn't even look at us. From the looks of her, she had not showered since her hospital stay. She still had tape residue on her arm from the IV. She had what appeared to be 10 days worth of dried mucous around her mouth, leaving me to wonder aloud if carbon dating could be performed on sputum. Her t-shirt was stained and torn, and her saggy boobs were enough so that her nipples kept poking out the bottom over the top of her sweatpants. She was fat, too. Her family said she was short of breath. She did have a slight, audible expiratory wheeze and was in mild-to-moderate resp. distress. She was also febrile. We gave her a neb, started an IV, EKG, O2, EtCO2, yadda yadda. She peed on our stretcher, which shouldn't have been a big shock seeing as she was sitting on a chux @ home. Old ladies frequenty have some "leakage". However, when we went back to the ER later on, her RN corners us to say she had something to tell us about her. I was wondering if my dx of PNA was on the mark. Turns out, she wanted to tell us about her antics. She gets off the stretcher, walks all the way across the room and sits in a chair. She then proceeds to take a huge crap in the chair. Not some incontinent crap, either, mind you-but one she had to have on purpose. Passive-aggressive, much?
We ran several other calls, nothing to write home about. Our second-to-last call was for an MVC on the Interstate. We were placed in service, and got dispatched to another call 16 or so miles south of there. It took us 17 mins. to get there with lights & sirens. En route, we hear that the Rescue Chief from the 1st-due Co. was there, asking for help w/an arterial bleed. He called for a Medevac. I knew it had to be bad, this guy is no slouch and has loads of experience. The patient was drinking (he admitted to a 6-pack-can you believe it?) and fell onto a glass jar out front of his trailer. He had a full-thickness lac to his forearm, with damage to his radial artery. In the time it took us to get there, he'd lost so much blood, he was already in compensated shock. I was glad that he was already bandaged when we got there-he was covered in blood as was everyone who took part in the bandaging process. The girl from the Ambulance was holding direct pressure & elevating his arm, and a guy had pressure on the brachial artery proximally. He was barely conscious and the girl kept having to yell at him to wake up. I put two huge IV's in him, started fluid resuscitation, and he started to wake up and dry off from the profuse diaphoresis. As he woke up more, I explained that he'd be going on the helicopter, and that's when he started to realize the gravity of his situation (no pun intended-OK, maybe it was). He started to cry, asking if he was gonna die, and talking about his two kids. I hope this serves as a wake-up call for him, but I doubt it. Coincidentally, the week before (after I left) MedicJon ran a guy who had nearly amputated his arm after shoving it through a glass window in a fit of rage at his girlfriend. He got himself a helicopter ride, too. The scary thing about his case was, he already had a cast on his other arm from punching an inanimate object 3 weeks prior, under similar circumstances. It takes all kinds.
The following day I worked a shift in the ER. A sweet LOL from India came in complaining of nausea/vomiting/dizziness. She had a boil on her back that she'd been on ABX for, and she'd just finished the 10-day course that day. I mention this because when I went in to start an IV on her and help the RN get her into a gown, we discovered she was covered in hives. Thankfully, she was done w/the ABX that obviously upset her GI tract and she was allergic to. The MD goes in the room to do a hx & PE. He goes to look at her boil and lo and behold, it's not a boil at all, but a tick! Her MD mistook the parasite for a boil and gave her unnessecary medicine. What a quack! The tick had been there at least 10 days, certainly longer but who knows how much longer. We were all horrified. The damn thing was so engorged it was unbelievable. It was also still alive. We showed it to her and her husband before we flushed it down the toilet, and they were equally (if not more) horrified. They were also incredibly grateful that we discovered the true cause of the series of events. Poor lady had to get more ABX IV as prophylaxis for Lyme.

Nothing is as it seems...

this being the converse of "if it walks like a duck and quacks like a duck...". I ran w/MedicJon this weekend and we had two "zebra"patients.
The first call we got was for a Diabetic emergency. LOL (little old lady) had been vomiting all day. We show up and of course she's upstairs at the end of the hall (that damn Murphy). I get in the room and she's lying in bed, lethargic but arousable/appropriate. The Engine Co. had already gotten a set of vitals, including a blood sugar, which was normal.
The family said she was just behaving more "slow" than usual. I figured she was probably just dehydrated, so as I said hello I checked her skin turgor. It was fine, too. No sooner did I ask for the Reeves stretcher & our cot @ the door (only to discover Jon was 10 steps ahead of me-as expected), she turns her head all the way to her left and becomes unresponsive. I'm thinking she is having an absent seizure. She slowly progresses to grand mal, at the end of her seizure she'd been at it a total of about 20-30 seconds. I've rarely seen someone wait til we arrive to have a seizure right in front of us! I asked the family if she'd ever had one before and they said that "they thought she did" once. Mmmmm-kay.
I go for an IV while we get O2, suction and hook her up to the cardiac monitor. I get good blood return but am unable to thread, or "float" the catheter in. Dangit. I just hope she waits to seize again until we get her in the back of the rig. When we carried her out, her respirations were somewhat snoring but that resolved itself, thankfully.
Once in the back of the unit, Jon asks me to test her grip strength. He had noticed she had a facial droop. Sure enough, she's not moving her left side at all now. We called the ER and initiated a "Code Stroke". We went enroute and I got a better IV while we made our trip. The rest of the trip was uneventful, as was the hand-off to the ER staff.
The next call, which we went to directly from the hospital, was for a man who fell of his bicycle and cut himself. I was thinking it would be a BLS injury. We arrive on scene and find this guy who just looks like poop. He's pale, diaphoretic, has an obvious closed head injury (as evidenced by his goose egg), and looks kinda mottled to boot. He also managed to sustain an open fracture of his clavicle. All together now-OW! The looks of him and his being amnestic to the accident made Steve (another Medic on board) and I both wonder if he really was a simple, minor trauma patient. His BP was a tad low and he really looked like hell, so we decided to keep him as an ALS patient. We put the Engine Co. and BLS unit in service after we put a makeshift sling on him and got him loaded up on our cot.
In the back of the unit, we did a 12-lead EKG which showed changes. Bingo! This guy had a cardiac event which caused him to take a spill. Steve got an IV in him and we were on our way. We also put him on O2 but didn't give him any Aspirin-he had Crohn's Disease and wasn't supposed to take it, plus it would've been bad had he ended up w/a bleed in his head. We also refrained from giving him Nitro or Morphine because his BP stayed low-last reading before we reached the ER was 80 Systolic.
The patient had a good attitude and sense of humor, making the trip to the ER more pleasant for me. We kidded around while Steve called report and I did a few more 12-leads.
We dropped him off @ the ER and wished him well. The ER staff insisted he wasn't having an MI. All 3 of us were completely stymied by that. It was obvious to us. The RN even said "his EKG is perfectly normal"-with a straight face. Hellooooo, lady, ever heard of an NSTEMI? Not to mention, it wasn't normal when we did one!
We got a similar response from our Assistant OMD-"He's not having an MI. His EKG is totally normal." He says this to me before he'd even lain eyes on the patient yet (he'd only seen the EKG the ER staff did). Also, when asked about our stroke patient from before, he says "She's fine. There's nothing wrong with her." Well allrighty then!
We all complained about the staff on the way back to the station. At that point, I had to get home before I turned into a pumpkin. Jon told me later on the phone that they went back to the LOL's house from earlier and had to transport her son w/a blood sugar of >600. New onset Diabetes. He told them they couldn't call anymore, our limit was 3 family members per day. :-/

Shut up or get out

I've thought a long time about whether to post this or not. On one hand, I don't want to air my dirty laundry. On the other hand, it's my blog, and nobody but those who knew about it beforehand will know who or what I'm talking about anyway. It was also some years ago, and I don't plan on naming names. So, I post.

My partner and I got called in the middle of the night. I can't remember what it went out as. We arrived and found it to be a code. The BLS unit was already there w/the pt. hooked up to the AED. She was an end-stage Cancer patient w/a DNR... that was not signed by her MD. Otherwise, the story would end here.
I had to tell the family I was terribly sorry, but I had to attempt resuscitation because of a technicality. To my surprise, they said it was OK, that they wanted me to try and resuscitate. I'm in an even better mood hearing that. 3 strikes on this one already (the first being the unGodly hour).
We draged the patient into the living room, as she was wedged in between the doorway and her bed initially and I wanted more room to work. I set about starting an IV while my parter went for an airway. I'm not sure when the Engine Co. got on the scene. They were there in the living room and that's my first recollection of them being there.
I got the IV and yelled for the first round of Epi & Atropine. I love the color-coding system on the bristo-jets, so I can just say "toss me a tan one and a purple one" to anyone and get the right thing. Of course I always double-check!
I get the first round on board, and go to try intubation as my partner was unable. About this time I'm aware that the Engine Co. I/O is heckling me. He's yelling at me that we're taking too long, yadda yadda. I'm annoyed and not just for myself-he's doing this in front of the family. I'm also pissed because not only is this a patient who I am assaulting against her wishes, but everytime we get a round of drugs on board, she goes from Asystole to PEA. I think it would have been atrocious to actually succeed at this resuscitiation, but I've got no mattress to squirt the drugs into. (No, I wouldn't really do that, it's just a saying.)
I get the tube in, and then we're ready to package her up and move on down the road. I said something to the effect of "There is a God" when I got the tube, due to my wanting to have it done, and being flustered by the Engine I/O.
We got outside the house w/the patient on the Reeves stretcher (or maybe a backboard, I can't remember) and the I/O is still barking at us to hurry up. He also makes some comment to me about how things weren't going well. I said something to the effect of her being dead so it can't be any worse. I reiterate that this is outside, away from the family. I was flustered, but by no means stupid.
We transport to the hospital where the patient (thankfully) is pronounced. We are getting ready to clean up, do paperwork and replace our drugs. I go outside to get the drug box, and the Engine Co. is there to pick up one of their personnel I borrowed. The I/O is there. He and I proceed to get into a screaming match w/each-other in the Ambulance Bay. He actually told me he thought some things I said to the family were inappropriate. Me?!?! What about his verbal abuse of the Medic Crew in front of the family? Surely that's not winning any awards for professionalism. I was stymied. The argument was mercifully halted by my partner coming out and yelling at him that we had work to do. I'm still grateful to her for doing that.
We went inside and talked about things. She was pissed, too. She was pretty newly released as a Medic and this was our first code together. This was a good situation for us since the pressure should have been off to some degree. I feel like we lost a good opportunity there to feel each-other out. On the other hand, we received a different kind of bonding experience.
After all was said and done, I had an exhaustively long talk with the Chief at the time as did the other party involved. I left that person a message saying that I didn't think that we should have argued when and where we did, it wasn't the time or place, could we talk about it, yadda yadda. He never called me back. I've not spoken to him since. I gave him one chance, which apparently was more than I should've. I still do not understand what the damn hurry was for a patient who was dead and wanted to stay that way.