Monday, April 02, 2012
* * * *
And King David was much moved, and went up to the upper chamber of the gate, and wept; and as he went, he cried, "O my son Absalom, my son, my son Absalom! Would God I had died in thy stead, O Absalom, my son, my son!"
2 Samuel 18:33
* * * *
It sounds like an old folk tale. It is not.
Far, far away from anything, up in the mountains, is a high lake, ice-cold and terribly beautiful, surrounded by steep hills, and full of trout. A great place to go fishing. Two brothers sat on the lake, in a tiny boat, while their father watched from shore. And something happened – one stood up too quickly, or the other shifted his weight – and the boat went over. Flipped them both into the water.
* * * *
We're seventy miles away when the call goes out, a long set of whistle tones, eight or ten pairs, followed by the dispatcher announcing a water rescue at a remote lake in the other end of our district. The fire department goes and the sheriff's deputies go and the closest city ambulance goes and our rescue ambulance goes. Screaming down the mountain, around the curves, listening to the chatter as everyone goes enroute and dispatch gives us updates.
"You know," I say, quietly, almost contemplatively, to my partner, as we rip past a semi, "by the time we get there – by the time anyone gets there – it will all be over."
"Yeah," he says. He's junior to me, but definitely has more water experience. Worked River Rescue in the summers before he got on the car. I jokingly call him our rescue swimmer sometimes, like we're a Coast Guard helo or something.
Now he looks out the window, into the growing dark. "Yeah."
* * * *
They swam for shore, as their father watched, urging them on, running for a rope and a life jacket, swimming out himself to meet his older son halfway across. It was maybe a hundred yards to shore.
* * * *
Dispatch updates us that a civillian truck is bringing one patient down to the ranger station. Hypothermic. One other still unaccounted for. The first ambulance says they'll meet up with the truck and take care of the patient. Everyone else – boats and cops and firemen and us – continues for the lake, up gravel roads, single lane, hairpin turns.
We get there a few minutes after the fire rescue boat. They're zipping up drysuits and getting their little zodiac put in the water. We talk to the deputy who's in charge, get the story. The second patient – the younger son – was last seen fifty feet from the boat. Well over two hours ago.
We can see the boat, half-submerged, out in the lake. The water is calm and the whole scene is eerily lit by floodlights and headlights, criss-crossing in the dark.
The deputy indicates a small SUV with a toss of his head, a forest ranger's first-response vehicle. I can just make out someone sitting in the passenger seat.
"Dad's still here. Just so you know."
* * * *
For a mercy, it doesn't take the firemen long to find him, in the clear water. We bring the ambulance gurney down to the water, so they don't have to put him on the ground with his father watching.
My daughter at home is barely a month old, and suddenly I can put myself in this man's shoes, and realize that there is no cutoff for when a parent can stop being afraid for their child. No magic age when they're safe.
And – though I am not a Christian, by any stretch of the imagination – I am reminded of the story of David and Absalom, and the heart-wrenching description of the king crying over his son.
This is far, far worse.
* * * *
Sunday, November 13, 2011
* * * *
Last week I went on a call for "sick person, vomiting." We found a woman, maybe sixty-five, sitting cross-legged on the floor. History was hard. I don't speak Farsi. We managed to get from her husband that he'd woken up to find her vomiting and confused.
I tried to ask her what was going on. She replied and even I could tell that it was word salad, gibberish. Nothing made sense.
She raised her right hand to wipe her mouth, but her left remained obstinately in her lap, unmoving. The fireman called out a blood pressure; "two-ten over one-forty."
"What?!" said her husband, trying to read the Lifepak. "What was her blood pressure?"
"Sir," I asked, "When was the last time you saw her normal?"
"Her blood pressure was what?!"
"Sir ... sir ..." I finally grabbed his shoulder. "Sir. When. Was. She. Last. Normal."
"Uh, uh ... midnight, I talked to her at midnight."
"Okay," I said, changing my grip on his shoulder to a comforting pat, trying not to show the disappointment on my face. "Okay. We'll take her to the hospital."
We carried her downstairs, put her in the ambulance, ran with lights and sirens to the hospital.
I stayed long enough to see the scan.
No one needed a radiologist.
* * * *
A man woke up to find his wife vomiting, and a picture changed their lives.
* * * *
A few months ago my wife woke up vomiting.
A picture changed our lives.
* * * *
So today, my readers, I would ask you to do one thing: Think about what you get frustrated about, what you long for, what you are unhappy with. Then think about what kind of black-and-white picture a doctor could hand you, how it could change your whole world in the space of a heartbeat, and how grateful - how terribly, earnestly, jaw-clenchingly, tearfully grateful - you should be for your life, and what you have, and the opportunities that will open up before you.
For the truth is that life is fragile, and short, and even the best surprises in life means that everything will change. Embrace the change, appreciate every day, and go hug your family. That's what I'm doing.
Thursday, July 21, 2011
* * * *
The fireman -- a friend of mine -- starts to give me report, but it's an hour before the end of my shift and the hospital is a thirty minute drive away. I brush him off and speak more harshly than I intend to her.
"Still puking? Yeah? Taking your meds? Okay, let's go. Come on, the stretcher is outside."
She's a former drug addict and has the scars -- all up and down her arms, and just as much in her demeanor. There's something in the attitude of many addicts that is a bit whiny and pathetic; it's like the drugs have robbed them of all their dignity and self-worth, and they can never really get it back.
Or, it could be that she's been hurling for a week.
* * * *
Paramedics don't love these calls. Even though we know we aren't actually there to save lives, we want to make a difference. We want to take care of breathing problems and heart attacks and gunshot wounds and car wrecks; not nausea and foot pain and difficulty urinating and all the minor, non-emergent complaints that we end up handling as the healthcare safety net.
We run the calls anyway, and we either get bitter or make our peace.
* * * *
I climb into the back of the ambulance, trying not to sigh audibly.
"Anything different?" I ask, and she shakes her head. Just not getting any better. Couldn't get an appointment to see my primary doc.
I hook her up to the monitor, get a blood pressure, glance at the EKG, all the usual business. When I go to attach the electrodes, I find one that I attached yesterday on her shoulder. Huh. I put the fresh electrode in my hand down and clip the wire on the old one. It works just fine.
The old scars on her arms are now mixed with a fresh crop of track marks from the past week. I know, I've put four or five of them there myself. She's not an easy stick, but the past couple nights I managed to get something, maybe get a bit of fluids in, give her some meds.
Last night I went all the way to the end of the nausea protocol and gave her the quarter-cc of inapsine, as she filled up three biohoop bags.
I rub my face with the back of my arm. I know there's no line to be found on her arms. Whatever. I put one in her leg, mid-calf, in a big vein that I spot without even a tourniquet, hoping the hospital won't raise their eyebrows too far. I dump half a liter of fluid and some zofran in it, and she doesn't puke for a bit.
Great. I pull up my chart from last night and copy her meds, allergies, history. I contemplate copying and pasting my narrative.
* * * *
"I don't want to go to the hospital, you know," she tells me as we unload her. "This is the last thing I want to be doing. I wish I was sleeping, not in the ambulance. I just feel so awful."
"I know," I say, patting her shoulder briefly as my partner punches in the code to open the door to the ER. "I know."
Friday, July 01, 2011
* * * *
It's a long drive, and the fire department EMTs have been there for a while when we arrive.
They're still doing CPR.
My partner heads for the monitor and asks the firefighter what she's got for access and what drugs they've given.
I sling the heavy green canvas airway bag at the foot of the staircase, and lean over the firefighter squeezing the BVM. He's got the mask clamped over the patient's face. A crumpled King airway lies on the floor.
"Hm," I say, almost to myself. The red-and-black intubation roll is already coming out of the airway kit. "King didn't work?" I ask the fireman - a good EMT who is in paramedic school - and he shakes his head.
"Nah, man, it just wouldn't advance."
It takes me maybe ninety seconds to get everything together, and then I edge in. Slip the largyngoscope in his mouth, no, no, keep doing CPR, that's fine, aaaand --
I see why they had trouble with the King, and why I will have trouble with the tube. I can barely reach his epiglottis with the tip of the Mac 4, and I certainly can't see the cords.
In a second, I know what I have to do. I just wish I'd practiced it more.
I pull the blade out and turn back to my kit. "Bag him," I tell the confused fireman.
"You're not even going to try?" he asks, wondering why I never asked for the tube.
"Nope," I say, unscrewing the cap on a short length of PVC pipe in the bottom of the kit. "Not with that."
The bougie is a long, flexible plastic rod, a couple millimeters across. I slide an ET tube onto it, making sure I have a good eight inches of bougie below the end of the tube. A quick swap for the long Miller blade, and I'm back in the mouth.
Wait - yeah - there. I can just see the bottom of the cords. I hold up my hand, and the fireman carefully passes me the loaded tube. I fish the bougie down until I see it go between the goalposts, and as the fireman holds the top I can slide the tube in ...
* * * *
Of course it doesn't really matter, other than confirming a dismal end-tidal CO2, for the man is dead, and has been dead for some time now. All we are doing is confirming that he is really, exceptionally dead. I never met the man.
So why does it matter?
If we are not challenged, we don't grow. To be challenged by another, to be placed in a position where we have no choice but to stretch our capabilities or risk failure -- that is a gift.
I rarely use a bougie, because it's rarely necessary, and so I am thankful for the unknowing gift of a dead man, who pushed me to use this tool -- because someday there will be someone who isn't dead, who desperately needs an airway, and the bougie is going to let me put it there.
Sunday, April 17, 2011
4am. The inside of our quarters are dark and we leave them that way, ducking out of the rain, locking the door. My partner flops on the couch, benefit of being a lead. I curl up awkwardly on a recliner, trying to get the damn thing to stay back while I lie on my side. I push a few buttons on the pager; it asks, SET AUDIBLE ALERT? and when I confirm it chirps happily.
Radio just a quiescent brick of plastic, sometimes murmuring softing with the voices of dispatchers and other crews, engine nine medic three twenty a trauma at three nine st and southern ave stage for police map page six nine two four dee delta. I clip the pager to my shirtfront so it won't be muffled by my jacket, and think about snuggling up with the radio held close. Maybe if I keep it happy it will stay quiet.
No. I'm more likely to roll over and key it up, treat the entire county to my snores. Instead, I set it on the table next to the chair. Sooner or later one or the other will go off, the startling, not-quite-synchronized tenor BEEP BEEP BEEP BEEP of the radios alerting for a call, or the high soprano DWEEEE DWEEEE DWEEEE of the pager, telling us to move posts.
On days, when the radios went off, I'd always be listening for the one tuned to the fire dispatch channel. What are we going on, I have to know. Punching the button on mine hastily to make it stop alerting, happy little radio with CALL RECIEVED flashing on the tiny screen, the beeping covering up the voice of the dispatcher, FD1 Dispatch up at the comm center, sitting in front of her five screens, maybe occasionally talking to FD2 FireTac sitting next to her. They sound so serious and professional on the air. Go up to the dispatch floor, through three or four remote-locked doors, and they're all laughing and fun, middle-aged women mostly, in jeans and sweatshirts.
But still the radios beep, and FD1 reads out the call that CT1 or CT7 or CT13 just entered, and FD2 waits patiently for us to switch channels and tell her we're going.
At first all we hear is the type of call. There are the meat and potatoes calls, abdominal pain, sick person, minor trauma, was unconscious but awake now. Assaults, ass kicked in a bar fight. Stage for police. Chest pain and breathing problem, could be something, could be nothing. Random calls we hear less frequently. General OB problem. Tyke on the way. Allergic reaction. Animal bite. Too hot or too cold. The ubiquitous traffic accident, could be minor, could be hellacious. And then there are three types of calls that do get our attention, at least a bit. Major trauma. Shooting or stabbing. And unconscious and not breathing. On days I always listened for the type, tried to figure out what was gonna happen.
And then, when we get in the car, I can look at the computer, nuggets of data hidden among vast strings of computer abbreviations. A call might come up looking something like this:
04/17/2006 1RUN#1100320041 CHPN
FMAP: 6284D TMAP: 656D2 FBLK: 0065
1298 MAIN ST <3000>
( HIGH XST: 12TH PL )
BROWN, JOE, SON
SA/C 503 555 1234
0041 ENTRY: M, 41, CH PAINS
0041 FIRSTSUG E23
0041 NEXTENG 'E9 'E4
0041 DISP E23
0041 $ASNCAS E23 #PF0041672384
0041 EMSSUG M321 M315 ?M329 M334
0041 ASST M321
0041 $ASNCAS M321 #MD0128495672
0041 TALKGP OPS1
0041 R1 --> O1
0042 SUPP (CT13 ): SOB, SWEATY, HEART HX
0042 ENRT M321
... and out of that all that's useful is that it's a diaphoretic guy with chest pain and trouble breathing who's had heart trouble before.
At 4am I could care less. I just have to get up, glasses on, make the radio stop beeping, tell someone we're enroute, get to the car. If I'm driving I may not know what we're walking into until we arrive. It's a call.
Doesn't matter what.
Someone told me nights are all bullshit or ohshit. Much more of the former than the latter. I marvel at the way my partner goes from cussing out the patient, dispatchers, fire department, anyone on the road while we drive to a call, to kind, attentive, and caring when we're in someone's house.
And then, well, all of a sudden you're at someone's bedside and they're guppy-breathing, or have crushing substernal chest pain radiating into the left arm, or are seizing, or have stroked out, and it's all you, baby.
Delegation always buys me a few seconds for thought. Get vital signs, fireman. Get some o's, oxygen, on. Start looking for an IV site, partner. Get the monitor. Get a sugar. Get the gurney. When it's bad -- start bagging. Get suction. Get versed. Draw up the sux and amidate. Get the intubation roll. Get the patches on. Continue CPR. Very demanding, when you're the almighty PIC, Person In Charge.
But you have to be, because while they're doing all that crap, all the skills that we could train a moderately clever rhesus monkey to do -- no offence to firemen OR monkeys -- you've got the tough job, the detective work.
When did it start. What does it feel like. Has it happened before. What happened then. Does it radiate. What makes it worse. Better. How bad is it.
And you're standing there, behind the shield of your professionalism and your questions and your neat blue uniform shirt and colorful PARAMEDIC patch, with the firemen in their turnouts and the big red engine and big white ambulance, strobes stuttering lightning in the predawn dark, low rumbling diesels, heart monitor and oxygen bottle and medkit all arrayed. And they look up at you with scared eyes, breathing fast, clutching their chest, pale, diaphoretic, shaking, puking, swaying, bleeding. And they tend to ask the same two questions -- what's happening? Am I going to be okay?
Maybe you know what's happening. Maybe you have no clue. Tell them a carefully edited version of the truth. It looks like you may be having a heart attack. We're not sure, everything looks good so far. I think you're having an allergic reaction. I think your asthma, your heart failure, your diabetes, your chronical medical condition with a long latin name, that thing, is acting up. We'll have to see. The hospital can run more tests.
But some things we don't say. It looks bad. Your EKG is all wrong. We're behind the eight-ball. You should have called hours ago. You need to be tubed. Your car is destroyed. Your passenger is dead. Ohshitohshit I've never done this -- a surgical airway, decompressing a chest, whatever -- before. I'm as scared as you are.
Which hospital, we say instead. We'll take good care of you. That's a good hospital. Can we lock up your house. Here's your keys.
Do I look worried, sir? No? Then you shouldn't be. A reassuring pat. You can be scared when I looked scared, ok?
I don't explain that I'm a very good actor.
Tuesday, January 04, 2011
This was written a few years ago. Names have been changed, of course.
* * * *
One slow winter night, Emily and I were doing the long, boring loop between downtown and southwest. We'd get sent out southwest. A call would drop downtown, and we'd come back. Someone would clear the hospital, and we'd turn back around. We were chatting about nothing, listening to the radio, and generally being terrifically bored. It had been a while since we'd run a good call.
Another call dropped, and we turned back towards downtown. Barely a minute after she flipped us around, the dispatch radio came to life again.
"Truck 1, Medic 325, stage on a shooting, Southwest Second and Ankeny streets, ..."
I thumped the dash. "Dammit! We're second-out for that! Why do we always miss the good stuff?"
Emily shook her head, a bit exasperated - though I couldn't tell if it was with missing the call or her high-speed, over-eager lead. "I dunno..."
Our tones went off, sudden and jarring as always. We paused, waiting for the computer to come up with the call or the dispatcher to start talking. But the computer remained blank - we were in a dead spot for the wireless data, coming out of the hills. And, strangely, there was no voice dispatch.
This was seriously weird.
The seconds stretched; thirty, forty, and nothing. My pager buzzed, and I looked at it to see the address of the shooting we'd heard dispatched a few minutes before.
Okay, I thought. Second patient?
And finally the dispatcher started talking, and we understood the lapse.
"Medic 327, Medic 324, Medic 326, Medic 322, respond with Truck 1 and Medic 325 already enroute at Two and Ankeny for a multiple shooting, at least five patients ... " Another pause. " ... And Fire Dispatch now calling box 0140, Truck 1 requesting a full first alarm. Assignment is Engine 1, Engine 3, Engine 4, Truck 3, Squad 1, C-2, C-4. Ops channel six."
There was a long moment of silence in the ambulance.
"Holy shit," Emily said.
"Yeah," I told her. "Put your foot down."
We flew down the long boulevard into downtown, and jerkily stopped-and-started our way through traffic lights on mostly deserted streets. Occasionally we'd see cops up ahead, blasting through intersections. I put on a pair of gloves, draped my stethoscope around my neck, and tried not to hassle Emily to go faster. I tried to ignore the icy clench in my gut. The radio traffic wasn't helping.
"... all units responding, police onscene say the scene is secure and you are clear to enter. Correction. Police are asking for medical to expedite ..."
"... Truck 1 assuming command ... and dispatch, we may have as many as seven patients per police. Add two more ambulances ..."
Christ. This might be bad. Might be. Then again, two people could be bad, and five could be shot in the foot or ass or something. I somehow fixated on that idea, and decided we had to get there early, to get a "real" patient. I told Emily to hustle it up, and she shook her head.
As we slammed down 2nd Avenue, I saw the lights of another ambulance approaching across one of the bridges. The offramp would drop them onto 2nd, right in front of us – or behind us. As we closed, it became apparent that we'd get to the stoplight just barely ahead of the other unit.
Suddenly Emily hammered the brakes. The light was red, and the other ambulance was only a hundred yards up the ramp.
"Go, go go!" I yelled.
"But they have the green," she protested.
"Fucking go," I told her, and she buried the gas pedal in the floorboards. I could see the faces of the other crew – good friends of mine both – glaring as we burned past them. I gave them the finger.
Thirty seconds later we were sliding to a stop, among a mess of police cars, fire trucks, and a couple other ambulances. I looked out the window and saw a man laying against the side of a building, shoulders on the ground, chin touching his chest, blood and grey matter painting a cone out from one side of his head.
I was out of the car before it even stopped moving, and walked over to where I saw the first-in ambulance medic, a huge man named Sam, standing on the sidewalk. At least four people were laid out within ten feet, and as I looked over them I realized they were all teenagers.
Oh, Christ, this is that underage juice bar nightclub. Perfect.
I just looked at Sam. Dispassionately, as if we were chatting about a football game in the crew room, he started talking and pointing.
"This one is dead. This one is critical; we're taking her. This one is also critical. That one isn't as bad –"
"Great," I interrupted, tossing my head at the second critical patient. "We've got that one." One patient I can handle. If they're critical I can justify taking them right now. I knew, in theory, how to triage. I knew what criteria I'd need to use to classify patients – critical (red), delayed (yellow), walking wounded (green), or dead (black) – but on the street, in the cold January air, with a bunch of kids bleeding onto the concrete, I desperately didn't want to practice.
Sam nodded and turned away. I glanced behind me. Emily was standing there, holding a backboard, and a single firefighter was with her. No one else, yet. I took a step closer to the patient, and three things jumped out at me:
She had at least four holes in her torso.
She looked at least as confused and scared as I felt.
She was very, very young.
"Okay," I said, taking a deep breath. "Get her boarded and we'll put her in the car and go. We can do everything enroute. I'll grab the gurney, and then -" I'm going to throw up for a few minutes? "- I'll spike some bags and get things ready in the back. You got this?"
"Uh, yeah," she said. "Sure, boss. We'll meet you at the car."
I skittered back to the ambulance, hauled the gurney out, then jumped in the back and proceeded to make a mess. I pulled out everything I thought I could possibly need. Oxygen mask. Two bags of IV fluid. Everything I'd need to put a couple lines in. Monitor leads out and ready. I grabbed the chest decompression kit off the wall, and clenched a little tighter, wondering if she'd dropped a lung.
Okay. Okay. Slow down. I tried to take a few calm breaths, tried to pretend my hands weren't shaking a bit, and then the back doors were open and they were loading the gurney in.
We cut clothes, and I confirmed my earlier estimate of at least four holes in her torso. She was awake, and breathing, but neither of us could feel a pulse at her wrist or hear a blood pressure over all the noise. She couldn't talk much, and when she did it was with a foreign accent I couldn't place. I asked what her name was, but couldn't understand the answer. She told me she was eighteen. Alright, I told her, breathe easy. We've got you.
I listened to her lungs and decided they sounded about equal. No need, yet, for the whaling harpoon of a needle sitting on the bench behind me. Emily helped me get oxygen and the monitor on, and then asked if I wanted help with an IV.
"No," I said, "she's young and healthy. I can drop one on the way. Let's go."
"Alright," she said. "I'm still waiting for a destination from the sup."
Our medic supervisor had showed up a few minutes after us, and was now coordinating ambulances, making sure patients were split evenly between the two trauma centers.
"Well," I snapped, "tell him to hurry the fuck up, we need to leave."
"Copy that," she said, and hopped out. I took the minute's pause to look for a spot for a line. Whoops. Nothing. Great.
The back doors popped open again. "Okay, we're going to Charity."
"Right, let's roll."
She glanced at the patient, then me, and a ghost of a grin appeared on her face. "Code one or code three?" she asked, rhetorically.
"Fuck," I told her, emphatically, already looking at the girl's other arm for some kind of vein, anything.
The car dropped into gear, and the chaos and lights and sound disappeared behind us. The siren yelped occasionally, but otherwise it was abruptly quieter in back. I finally found a spot and slipped an IV in the girl's hand, a twenty-gauge, tiny for this sort of trauma but all I could do. She was trying to ask me something.
I grabbed the monkey bar and leaned over her face. "What did you say?"
"... 'm I gonna die?"
I wanted to tell her no, but my face had to have given away how scared I was for her. Don't lie to your patients. They will know. Thanks, nameless instructors. I put one of my hands over hers.
"I don't think so. We're going to take really good care of you, okay?"
She nodded. I felt awful. Hell of a pep talk, but she seemed a little calmer.
I glanced out the back window, and realized we were only about five minutes out. Still couldn't get a blood pressure. I listened to her lungs again, and now one of them sounded fainter. Way fainter. Shit. I glanced at the chest decompression needle, but decided we were so close, and she needed a chest tube. Hell, she needed to go right into an operating room. Luckily Charity could do direct to OR - but they'd need to know.
I spun the radio to the TRAUMA channel. No dice; I could have sat for half an hour and not gotten through. Screw it, I'll go against procedure and call the hospital direct.
"Charity Hospital, Medic 327, code 3 traffic."
"Charity, go ahead."
"Medic 327, we're, uh, three minutes out, eighteen year old, from the shooting, at least four GSWs to the torso, heart rate of 120, no radial pulse, can't get a BP, all we've got is a small line, and she's maybe got a pneumo."
"... ah ... we're not aware of this patient, 327. I think you were supposed to go to University Med."
Thump-thump. Well. That's the driveway.
"That's nice, Charity. We're on your doorstep. See you in about thirty seconds."
We unloaded quickly, and rushed her through the double doors. I got the fleeting impression of barely controlled chaos before a senior attending trauma surgeon blocked our way. He held out his hands in a placating gesture.
"Whoa, okay, what have you got? We don't know where you're going yet."
Emily told me later that my voice was high and stressed. "Doc, she's eighteen, at least four holes in her chest, I stopped looking after that. Airway is good, she's awake and talking, but I can't feel a blood pressure, we've only got one tiny line, and I think she's dropped a lung."
I raised my finger, pointing at her, and then behind him, to the next set of double doors. "We. Need. An. OR."
He blinked, clearly taken aback. "Uh, okay. Uh. OR 14."
"Thanks," I replied, already in high gear, rolling past him. We slid into the sterile whiteness of the OR, and lifted her from our gurney to the operating table. I stepped back as Emily pulled the gurney away and the nurses and docs crowded around. I'd later learn that it had only been twenty-five minutes since we got to the scene.
"Goddamn," I said to no one in particular, standing in the scrub hallway outside the trauma ORs. "God-damn."
"Well?" Emily asked when I came outside.
"She's gonna die," I sighed. "I mean ... yeah. Yeah. Shit."
* * * *
About six months later, my girlfriend had to ask me why I was sitting at the table, teared up over a picture of a very normal-looking girl at a high school graduation, healthy and happy and very much alive.
Tuesday, November 30, 2010
If you're an experienced provider, you've probably (like me) forgotten a lot of the nifty bits of clinical information that you were taught in school but didn't NEED to know. The stuff that got lost when you were cramming NREMT and ACLS skill sheets in your head. The stuff that might actually be more useful now that you're out in the field.
So that's what I'll try and bring you: Short, sweet tidbits that can help the experienced (or new) provider up their game.
We see syncope a lot. A lot of it is (or seems) harmless, and many of us like to wastebasket it into the vasovagal category, and don't mind getting a refusal.
Try to be more suspicious. Don't get suckered by how good they look now. Think about the patho. If it's not a seizure or low blood sugar, it's probably not enough blood or oxygen getting to the brain. Arrythmias? Stroke? Aortic stenosis or dissection? Occult (you know, hidden) bleed? Pulmonary embolism? There are some big, scary bears that cause syncope, and you should suspect them before you call it a vagal or psychogenic.
But how do you make that judgement? What should worry you?
First, most of these folks warrant a good assessment. Get a real detailed history. Find out if they had symptoms before they syncopized. Get a good set of vitals, and a 12 lead ECG is an excellent idea. Check neuros. Ask friends and family if they are acting normal. Go LOOKING for trouble.
But who are the folks to be worried about?
• Patients with chest or back pain, new onset, before or after the syncope, should be concerning for aortic aneurysm or dissection, or PE, or cardiac causes.
• Patients who don't return to their baseline after a syncope should be concerning for intracranial pathology (CVA/TIA/bleed).
• And patients who have no prodrome, no symptoms before passing out, no dizziness or tunnel vision, those folks should have you worried about weird rhythms.
Vasovagal syncope is not uncommon -- but just like anxiety attack, it should be a (presumptive, field) diagnosis of exclusion, the one you reach after everything else has been exhausted.
Hope this is helpful to some of y'all. More coming soon!
Friday, November 05, 2010
They say, they say. And in many cases - trauma in particular - I tend to agree.
* * * *
Drugs got him here, and drugs will be his salvation. He wasn't breathing when the fire department EMTs arrived. Narcan helped his respirations, but nothing else. They're not sure what he took.
They've barely stopped bagging when we walk in. Not down too long, they say. History of drug abuse and suicide attempts. So we start the workup.
I start a line in his ankle, the only site I can find. My partner hooks him up to the monitor. He's breathing forty times a minute, but his oxygen saturations hover around 85%. He won't wake up and his lungs sound like a tire chain in a tumble dryer. Even with suctioning, an NPA, and more bagging, he doesn't really improve. His jaw is locked tight, and all I can do is run the Yankauer over his teeth.
The nearest hospital is 35 miles away, on windy, rain-slick country roads.
We load him in the ambulance, make a few more desultory attempts at BLS airway managment, and then make the decision.
My partner draws up the drugs. I get out my tools -- Options A, B, and C.
My eye briefly lingers on the small cardboard box of Option D. I can picture what's inside, the plastic package and scalpel and Sharpie-scrawled message some wise-ass coworker has left: "GOOD LUCK. STAY CALM."
I leave the cric kit on the shelf. Everything else, though - tube, bougie, King - I lock and load. Line them up neatly. Lights up. Suction running. All the positioning tricks I know. He predicts like a difficult airway, no matter which mnemonic or scheme I use. Nothing good about this. We can't get his sats over 90%.
My partner, holding two syringes, asks if I'm ready. The firefighter assisting us looks at me expectantly.
Well. I suppose. I'd better be, hadn't I?
He pushes the drugs, and I wait until he stops breathing. His jaw loosens, and I slide the blade into his mouth. Everyone is gathered around - the firefighter holding cric pressure, my partner pulling the patient's head into a better sniffing position - and all of a sudden I can see the cords.
"Whoa! Okay, tube, tube. Good. Okay. Through the cords. Stylette out. Balloon up. Get that capnography on. Ears? Okay, bag. Yeah? Sweet."
And then it's all over but secure the tube, clean up, sedation, NG tube, and so on -- all during the long drive in.
He's hard to sedate and fights us some on the way in -- maybe a speedball? -- but his sats slowly come up.
By the time we leave the hospital he's at 100%, sleeping peacefully with the aid of a versed drip. The doc shrugs her shoulders.
"Don't exactly know what's up. We'll have to wait for labs and imaging. Could be a few different things. Sounds like it was a tough one out there. Good job, guys."
* * * *
They say, they say, and sometimes I think they are right, and sometimes I think they are wrong.
Monday, October 25, 2010
Chest pain, always chest pain. He has the history -- a zipper scar, a boxful of pills, a 12 lead with Q waves. He looks scary -- pale, clutching his chest, always telling you it's real bad this time, it's never been this bad. The first time, and the second, and the third, you get worried, you work him up hardcore, pushing the nitro and fentanyl and repeating 12 leads and bypassing the community hospital to go to a cath lab facility, just in case. Just in case.
But the fourth, and the fifth time, your concern start to wane. Despite everything, he's stable. He doesn't decompensate or throw PVCs. He doesn't get cathed. And then the doc at the recieving facility starts to tell you about all his visits. How he requests narcotics by name. The mysterious morphine allergy. And the picture starts to come together in your head.
* * *
We were out of district when the call came down for a domestic at his address. We sent the cover unit an MDC message. Just so you know, if the guy claims chest pain, he's usually not as bad as he looks. Work him up, but he's got a history of seeking. Just so you know.
A while later they write us back. Wasn't him. He beat up his brother. He went to jail.
Huh. Isn't that something.
* * *
But an hour after that, we're toned to the police station. Law enforcement request for medical. I bet my partner a dollar it's him, that he's developed chest pain in the cell.
We walk in. I turn to my partner. "You owe me." He laughs. The firemen are standing around, getting vitals. No one seems rushed. I ask the cops about what happened. Is he still in custody. Yes? Okay. Which hospital? The one by the county lockup? Sure, we can do that. No problem.
I walk back to the cell. Vitals okay? Right. And when did he say the chest pain started? How does the 12 lead look?
"Well," says the fire medic, "actually tonight it's this weakness. And he's acting like he can't talk."
I blink rapidly, and look at the patient. He's not moving anything on his right side. The corner of his mouth droops. A fireman asks him about allergies, and his answer sounds like Animal from the Muppets.
Are you kidding me?
I do the neuro exams. He's definitely a "good" stroke, by the numbers. He's got the risk factors. The fire paramedic rolls her eyes. "He's pulled this before, too. Haven't you seen it?"
No. No, I have not. We can't treat it like he's faking. We have to work it up like it's real. It looks real to me.
"Absolutely," she agrees, and she is in fact a decent paramedic, one of the better ones to ride an engine. "All I'm saying is, don't get too excited."
We load and go. Code 3 to the closest hospital, call the stroke alert, large bore lines in both ACs for CT scans, 12 lead just in case, the whole Happy Meal deal, with toy included.
At the hospital, the ED doc thinks it's genuine. He passes the Hand Drop Test, smacking himself in the face. His reflexes are absent on the affected side. He doesn't have a bleed, on the scans. We tell the doc about the history of seeking and faking, and he nods, but says it's no reason this couldn't be the big, bad, ischemic stroke it appears to be. I agree readily. Absolutely, doc. Just want to make sure you have all the facts in hand.
"Appreciate it," he says. "We'll see. Neurology is coming in -- and pharmacy is sending the tPA up."
Six hours later, dropping off another patient, they tell us he got the 'lytics, and went to the ICU with some improvement showing.
Huh, we say. He finally had the real thing happen. Poor guy.
* * *
A month later, I run into the doc again.
Hey, you remember that stroke? The one who had the history of faking, but turned out to be having the real one? How'd he do?
The doc just shakes his head. "They did CTs and MRIs and all the tests you could imagine. Never found any evidence that he'd actually stroked."
The doc sighs and rubs his head. "Oh yeah. Yeah."
"Wow," I say. "What happened? I mean -- he got the tPA. How'd that work out?"
A shrug. "Who knows."
Another doc pipes up. "Bled out, probably. Poor bastard."
Friday, July 02, 2010
A young woman, visibly upset, opens the apartment door when we are halfway up the last flight of stairs. Here, she says, in here, leading us to the living room.
He sits on the perfectly normal couch in the perfectly normal apartment, and there is no blood or gore, no gunshot wounds or impaled objects. And yet his eyes are full of fear. His right hand is white-knuckled around his own throat, and he doesn't say a word.
He is barely two months younger than me, and if he lets go of his throat, he cannot breathe.
* * * *
His girlfriend, or wife, tells us the story as she knows it. How he crawled into their room and woke her up. How between a few words he gasped out and his pantomimed gestures she gathered that he tripped over the cat, and struck his throat on the edge of the table. How she called 911 while he sat, trying to stay calm, stenting his own airway open.
He's able to answer questions by nodding. He's healthy. He didn't pass out. Nothing else hurts. We try to look at his throat, but as soon as he lets go his sats drop and he moves no air. We quickly abandon our exam and let him resume his careful hold on his trachea.
Can you walk? we ask. Nod, nod. Good. Let's get some shoes. And we pop a nonrebreather on and walk him down to the ambulance, simple as that, supporting him and taking a break when we need to.
At the car, my partner throws a quick line in while I call the trauma center on the radio. The fire engine has showed up, and I load a couple of friends for the quick trip up to the Level I center. The fire guys sit on the bench seat, doing vitals and reassuring him.
I sit in the airway seat, behind him, out of sight, the cric kit out and open, prepping an ET tube, RSI drugs handy, hoping fervently I won't have to use any of it.
* * * *
At the trauma center, at least twenty people have gathered. Trauma surgeons, emergency docs, anesthesia, respiratory ... they crowd the room. Trach trays are opened, sterile gloves donned. Game faces on.
He finally gets really, really worried when he sees everyone gathered for him, and I can see tears well up in his eyes. I'm standing at the foot of the bed -- I have no intention of leaving before I see how this ends. The social worker makes sure she has his girlfriend's information, and steps out of the room to call her.
They prep to attempt a tube with a Glidescope, ready to go into his neck if that doesn't work; anesthesiologists at his head, surgeons at his side. An anesthesiologist has taken over holding his throat. The room is full of quiet, professional chatter; let's go with a six-oh tube and etomidate and sux is fine and are you all ready? A nurse steps up with the syringes full of medicine.
I meet his gaze, and realize that in all the bustle and confusion, there's very little attention being paid to him as a person. And it strikes me how much more frightening that would be.
And so I reach out my hand, and he grabs it, tightly, and I hold his hand until the drugs take hold.