Too close to home

I was on my way to lunch, passing through the ER as usual on the way to the deli. I noticed a significant number of Fire/EMS personnel standing around the Nurses' Station. I know from experience that something serious was going down.

I went through the doors and over to the 1st set of Trauma Bays and the entire ER staff was working on an 11-month-old girl in severe respiratory distress. I immediately got sucked-in. At the time I went in one of the MD's was attempting an I/O and one of the RN's and I started to look for venous access. (I'm proud to be one of the "go to" folks when it comes to difficult IV's). She got a peripheral line so we went w/that and abandoned the I/O.

We pushed the RSI drugs and the MD's began intubation attempts. I helped set-up the ventilator, but then we realized she didn't weigh enough-it only goes down to 10kg and she was 7.5. I ran to get some equipment and when I came back I noticed one of the RN's that used to work w/us coming through the Ambulance Bay doors. I thought to myself that she had come back on staff but then she walked over to the Trauma Bay and she flipped out, and I put it all together in my head. She had left our staff to give birth 11 months prior. It was her baby. The stress of a Peds resuscitation now became a major (controlled) freak-out b/c it was the child of one of our own.

The intubation took a long time. Her belly got a little distended and her heart rate kept dropping. I'm @ the head of the bed assisting the MD w/intubation and I notice her heart rate went down to 50. I said "We need to start chest compressions!" and someone did. I was really scared @ this point b/c when kids get to the need for CPR they usually don't come back. Thankfully, the MD got the tube in and I taped that damn thing down so it wasn't budging. We got her SPO2 to start going up and her heart rate followed, thankfully. Major relief!

We got the CXR to confirm the tube placement, and she had bilateral PNX's. Damnit! We placed two 16g IV catheters to decompress her lungs for transport to the PICU. They did the trick and her SPO2 was 100% when she rolled out the door.

We heard a lot of reports the first few days about her condition, and it wasn't looking good. We also had a CISD in the days following. The staff was all very upset. The last report we got was that she had hemiparesis.

Last week, the mom brought the baby by, and she's moving all her extremities after 2 weeks in a Rehab Hosp. She's alert & appropriate, w/only a tiny little brace on her hand. It's amazing that she's doing so well, much less alive at all. We're all so grateful that it turned out so well when things looked so bleak. As a total aside, she's also completely adorable. =)

Happy F$cking New Year

Several years ago, I was on duty New Year's Day. Shortly after dark, we received a call just a few blocks away from the station We made the short response over, and walked up to the front door. We were greeted by a 71y.o. lady dressed in a shirt and nothing else, with some newspapers wrapped around her below the waist. She stated that she'd been raped. Initially, she was so darn calm, I thought maybe she was a kook. But, we soon realized that this was a real-life nightmare.
An 18y.o. M from the neighborhood (that she knew) had waited until after dusk and walked to her place. He unscrewed her porch light so she couldn't see who was at the door before he knocked. When she opened the door, he forced his way in and raped her on the floor of the hallway just off her living room.
We later discovered that PD had apprehended the suspect just a few blocks away, even before we had arrived on scene. I did my assessment while the rest of my crew remained @ the door so as not to disturb the crime scene. The patient was perfectly stable medically so I didn't need their assistance.
While speaking with her, she became more and more upset. I think the reason she'd been so calm initially was because of shock. By the time PD arrived @ the house we were ready to transport. Before we took her to the ER for her rape exam, they wanted her to identify the suspect. This is when she became very fearful and began to cry. They assured her that he wouldn't be able to see her through the window as they would be shining a light directly on him. I assured her as best I could and helped them convince her it would be OK. They drove her a few blocks to where the kid was in the car and she ID'ed him. Then it was time to go to the ER.
Enroute, we talked a lot and I held her hand. Thankfully he hadn't hit her or anything, so I was able to concentrate almost entirely on psychological support as best I could. I had no illusion that I could make things better, I just wanted to comfort her. At the ER, one of my colleagues was the S.A.N.E. on duty, and I left the patient in her good hands.
The kid confessed and got a really long sentence (I can't remember exactly).
Less than two years later, I was in the ER doing my clinical rotations as part of my Medic training. Lo and behold, I saw the old woman again. I cannot begin to describe how much of a shell of her former self she had become since the rape. She had greatly decompensated both psychologically and physically. She was in the ER that day because of suicidal ideations. It just broke my heart even further than the call did initially. I still feel an almost physical pain when I think about her, what she endured, and the effect it had on her.

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.

An enigma, wrapped up in a puzzle, wrapped up in a conundrum

I ran w/MedicJon ("Hazbulance") Sun. and we ran a doozy of a call (as you can surely tell by the title of this post).
We got a call for an Unconscious at a nearby hotel. We get there and find a lady who is semi-conscious, laying on the bathroom floor in a pool of her own urine. The type of semi-consciousness we witnessed would not be inconsistent w/someone who had low blood sugar or was postictal, or maybe had ODed on Opiates. There was Insulin and liquid Methadone in the hotel room. Her blood sugar was normal so we pretty much put our stock in the Opiates.
We dragged her out of the bathroom and loaded her up on our cot. She was with it enough to swat at us w/her arms, but not w/any accuracy. She was also, for all intents and purposes, non-communicative.
Once in the back of the unit, I started an IV, and this chick had crap for veins. This further pushed us down the Opiates trail. I got one in (Supah-stah!), but I had to float it, and leave the catheter part of the way out. It was tenuous at best, and on top of that, I had to hold her arm straight for it to work. She fought the IV a bit, to be expected. I held her arm while Jon pushed 1mg of Narcan. I kept the IV flowing, but not too much longer after that. As we're waiting for the Narcan to take effect, her respiratory effort was getting less and less. I said something to that effect, and asked how long we should wait for it to work. Before we could really decide, she was nearly apneic, so Jon laid the head of the cot down and we called for the Engine Co. to come back-things like this never happen before we release them, dontchaknow.
Well, of course her jaw was clenched, and her two front snaggle teeth securely clamped down over her bottom lip. So, Jon wrenched an OP airway in her and started bagging while I went for an EJ. She had a pretty one, until I went for it... then it magically disappeared. Doh! By this time, we've pulled a driver off the Engine and are headed to the ER. Calls like this make you grateful for a short transport time.
Jon gave her another mg of Narcan IM (that never did anything either), then he and I switched seats so he could make a couple more attempts at a patent IV, but no luck. I was not getting really good compliance bagging, but it was the best we could do. We showed up at the ER w/a respiratory arrest, no line, no tube. Fan-freakin'-tastic.
We transfer her over to their stretcher, and I tell our Asst. OMD that they'll probably have to put in a central line. He kinda pooh-pooh's that, but I ended up being right. Took 'em 3 tries, too. I felt like even more of a rock star, then. =) They also got her intubated. 'Round about the time they'd blown both femoral line attempts and they were poking her subclavian area, she up and went into VTach... then VFib. I hate it when that happens!
Jon and I stood by/assisted while they worked her for a good 40-60 mins. (I'm guess-timating) I mostly felt in the way, but Jon was doing some damn fine compressions with one hand. His turn to be the rock star!
The staff threw everything in the book at this lady, and nothing was happening. We were all ready to throw in the towel when she suddenly developed a perfusing rhythm again. The Primary RN was trying to figure out what rhythm to chart and Jon said "UFB". Can I get an Amen?
Well, we never did figure out what her underlying problem was. She had a bad case of metabolic acidosis, but more so than a witnessed, agressively-worked arrest would cause. She was on her 3rd amp of Bicarb, but had a serum Bicarb of 10, Ph of 7. They were talking about starting a Bicarb drip by the time we finished all our paperwork and were ready to head out. Her other labs were remarkably unremarkable, esp. for a person who had died.
We left the ER and immediately got punched for seizures way down on the Interstate, so we ran down there, picked up the postictal patient, and ran him in. When we dropped him off, I asked the Primary RN how our lady was doing, and her words were "She's hanging on by a thread." The RT told me her lungs were full since all told, she'd gotten like 3L of NSS, and the woman barely weighed over 100lbs. Whoops!
Real interesting call. Plus, we had fun. A good day in all!

Why I Volunteer

Recent posts from DTXMATT12 and MedicChris have inspired me to tell my own story. It's long and complicated, but I will try and keep it as condensed as possible.
My mom is an RN. I've always had an interest in medicine. I had the "Visible Man" puzzle/model, I took apart my "Stretch Armstrong" doll, I watched "Emergency!" and I played "Operation". There was a theme early on!
In High School, I took a Sports Medicine class, and it was hands-down my favorite elective ever. The teacher taught us CPR (I've been certified ever since, 20+ years), and encouraged us to do ride-alongs w/EMS. This was the first time I expressed interest in being an EMT. Later on in High School, I got rather sidetracked with a misspent youth, and didn't get back around to the interest for another 10 years.
In my early 20's, I developed a life-threatening Thyroid condition. Between that experience and my best friend dying some years later, I decided it was finally time to pursue my interest. I just happened to live within walking distance of the station where I've now been assigned for 10 years, so I went down one Friday evening and signed-up. My whole life changed.
Due to scheduling, I didn't actually start EMT class till I'd been a member of the VFD for 3 months. In that time, I got my other courses out of the way, and became an Ambulance Driver (really-that's all I was at the time).
Once I got into EMT class, I moved away from the county where I volunteer, and haven't lived there since. I was working full-time in the Publishing industry and traveling 70 miles round-trip two nights a week to class. I was definitely serious about it! I remember when I took my exam, a Medic named Tim that I admired very much was the Examiner at my Trauma station. When I went a smidge over 10 minutes and failed, I was outside the Academy crying. He saw me. I almost died. But, he was kind, told me to stop crying, go back and re-test, and that I'd pass. I did just those things.
For the next 4 years, I ran as an EMT-B w/the VFD and kept my Publishing career going. Then I decided to become a Medic. I started classes at GWU, and that experience also changed my life.
I went through the pilot program for EMT-Intermediate in our state. Believe me, the fact that it was a pilot program was obvious. It was a big CF. We had 8 different textbooks, a number of instructors pretty close to 20, and every one of them contradicted each-other. It was so much harder than it had to be! Between the difficulty, the time commitment, and my tendency to be a perfectionist, I thought I was going to have a nervous breakdown. But, I prevailed again. Out of 5 people in the class from my Dept., I was one of only 2 who passed the National Registry the first time.
Becoming a Medic (in VA, I and P are no different, which is why I call myself a Medic and not a Paramedic) changed me in a more profound way. I decided to give up my successful career in Publishing and work in Healthcare full-time. I accepted a job at a brand-new, free-standing, full-service ER. I still work there today. I credit the job for outrageous amount of clinical experience and knowledge it gave me every single shift for getting me through my Internship as a Medic quicker than anyone else from our class. I also credit my Preceptor, Leon-what an amazing person! He's been a Medic over 20 years, and is the most laid-back guy. He helped counter my borderline OCD, thankfully.
The family atmosphere that DTXMATT12 and MedicChris speak of was not a reality for me until about the time I became a Medic. I developed a few friendships in the Dept., and along the way I even fell in love with my partner (now my spouse). But those family-like bonds were not something I truly understood until I was finished with my Internship and had to rely very heavily on the Engine Co. at our station. The I/O on the Engine became like a father to me. He was on my first ever duty crew, as was the DPO, who I also became close with. There was one guy who was the younger brother of another who I'd befriended in the past, and I got to know him well, too. It was just me, my current spouse, and those three guys most days. The week after I finished my Internship, I was on my own-Leon was sent elsewhere. I was so vulnerable that I quickly forged those bonds that mostly eluded me in the past.
Becoming a Medic also helped me understand other Medics better. Class is like a Rite of Passage, and finishing is like entering into an exclusive club. You speak the same language, and have shared experiences that really, no one else can totally understand. EMS in general is pretty unique, as I'm sure Fire Fighting is (although I don't know that for sure-not my cup of tea).
Why am I not a member of a paid FD? Well, I have a lot of physical shortcomings when it comes to the street. I'm better off in an environment where I'm not as physically taxed, and don't have to work 24-hour shifts. I'm the first to admit I can't hack it out there on a full-time basis. I don't know how anyone could do that til they retire. I'm not even 40 yet and the thought of a 24 makes me want to go take a nap. So, I'm a wussy. But, I know my shortcomings, and in EMS, there is no room for ego. I'd just be a burden to myself, my colleagues and my patients, and that's the last thing I ever want to do.
I love my job, I love my volunteer work and the extended family that goes with it. I never regret taking a 50% pay cut to change careers, even when the bills come. I know I'm doing something important, and I'm proud of myself. I've got confidence I never had until I started this journey.
Here's to another 10 years w/the VFD-with it will come Life Membership, and no more working BINGO! =)