Tricks

I don't think I am alone among medics in that I have a small "dirty tricks" bag that I bring to work. I don't mean "dirty tricks" in the sense of pressure points or joint locks -- though those have their place -- but instead little items that are not standard issue which we have found to be useful.

I recently went through and organized my little black bag, and when I was done, here's what I had:

- O2 wrench
- Small zipties
- Needle-nose pliers
- A Code Strap
- InforMed Emergency & Critical Care Pocket Guide
- Tarascon Adult Emergency Pocketbook
- County Protocol Pocket Guide
- RSI Dosage card
- Booties
- Extra-large Tegaderm
- One each adult and pediatric single-use adhesive SpO2 sensors
- King Airway syringe
- A Zerowet Supershield

So, readers, I ask you -- what do YOU bring to work that isn't standard issue, but you've found to be useful, or want to have in case of that particular unusual situation coming up?

Protocol 36

As part of our ongoing Web Based Continuing Education series, we here at Drug-Induced Hallucinations hereby present, for the discerning medic or EMT, a list of "street" synonyms for pandemic H1N1 flu that we may encounter in the course of our duties. Collected from various¹ sources².


Hamthrax

Tuporkulosis

Porklio

The Other Yellow Fever

Sowmonella

Whooping Oink

Porktussis


1. H. Tayler.
2. My "lady friend."

Freezeframe

03:30:00 - I'm fast asleep, curled up sideways in a recliner, jacket zipped all the way up. Out hard, REM-land, dreaming.

03:30:05 - Fire dispatch drops tones for a breathing problem in our district.

03:30:12 - EMS dispatch taps us out.

03:30:15 - My partner slaps my boot. I barely heard the EMS alert.

03:30:26 - I pop the tab of a Red Bull on the way to the bay. The motor on the garage door whines softly as it opens, letting the night in.

03:30:42 - My gut reels at a depth charge of caffiene, carbonation, and chemicals. My partner is talking to fire ops, pulling up the map on the laptop, and trying to find his seatbelt, all at the same time. I put the car in gear, slap the big red button, and away we go.

Conclusions

(If you haven't already, read the previous three posts.)

* * * *

I.

We scream down into the small town, and hockey-stop in front of the fire department. A young man in a fire dept t-shirt jumps in the back, wide-eyed and freshly awoken.

"I'm just a basic," he says, and I point with a free hand to the airway seat.

"Not a problem. Sit up there." I lean forward, towards the breezeway to the cab. "Okay, let's go."

Both lines are running wide open, and before even a few hundred of fluid are in he's looking better. His heart rate slowly creeps up, and his blood pressure slowly improves. The arrival at the hospital is anticlimactic, after the adrenaline rush of before, and the dozen providers waiting in the ER slowly disperse as it becomes apparent that the patient is now relatively stable.

Later, charting, I puzzle over the case, and the numbers. I look at the overall curve of the blood pressures, the heart rate, and slowly a conclusions dawns. Under the cover of my concern about a GI bleed, a relatively simple vasovagal event -- overstimulation of a nerve in the heart, causing heart rate and blood pressure to drop -- appeared to be something much more serious.

* * * *

II.

He has a head injury, probably a concussion, and repeats his questions. He wants to know everyone's names. Was he in a car accident? What's happening? Can we call someone for him?

The answers are patiently provided as he's IV'd, medicated, backboarded, and ultimately medicated. The flight nurse is standing there for the last moments of the extrication, and introduces herself to the patient as we start rolling the stretcher down the road to where the helo waits.

We roll past the other car, still on its top. A yellow blanket covers one window.

He asks where he's going, and again is told that he's to be flown to the trauma center.

And yet, when we reach the bird, and go to load him in, his eyes light up, and he reaches up to touch it.

"Whoa," he exclaims, "Is this a helicopter?"

* * * *

Moments (III)

3am. Another chest pain call.

Neither of us recognize the street name. Unfortunately, neither does the mapping program on our MDC. Or the map-book.

Finally, after turning into a dead-end, thinking we were right, and groaning at the absence of the bright red marker truck, we call them on the radio, get the lieutenant to guide us in.

He meets us at the door. "More like abdominal pain, not chest pain, guys." He shrugs, apologetically, as if this makes it a less important call.

Upstairs, on the bed, is a woman in her seventies. She is obviously uncomfortable, holding her belly, and rapidly trying to tell us everything we need to know about her symptoms and history.

At least, that's what I assume she's saying. I don't speak Cantonese, so it's hard to be sure. Her son tries to translate, with some success. Abdominal pain is her only complaint. Right here, pointing just above her belly button. One of the EMTs says he felt a lump there. My partner asks if it was pulsating. No, he says, he didn't think so.

As my partner leans over the bed to feel the woman's belly himself, he asks casually what the vitals are.

"Umm..." the EMT glances down at the monitor. "Pressure is 89/42. Heart rate is 48."

My partner does a beautiful double-take. I'm already going for the manual BP cuff, and toss it to him before pushing the button to run another automated pressure. Another firefighter asks what we need.

"Spike a bag," I say, "and check status of Podunk Hospital. And Big City Med Center."

The pressures are the same, and a 4 lead just shows a sinus bradycardia. My partner is concerned, and as soon as I have a wide-open 18 running in her arm, he starts saying, "Okay, let's go. C'mon, guys. Let's move."

We carry her downstairs on a blanket; as we do so, my partner and I share a terse conversation, like you do when things get serious.

"Thinking triple-A?"

"Mmm."

"Big City Med Center? Or one of the trauma centers?"

"Big City, I think."

"Take a friend?" Nodding at the firemen.

"Yeah, maybe."

We set her on the gurney, lift it up. I lay her back and pop her legs into Trendelenburg.

"Want help with anything?"

"12 lead, I guess. See about her rate."

I nod, and we hop in the back. He bustles with oxygen and getting a second bag of fluids together while I put the 12 lead on, pondering differentials for hypotension and bradycardia in abdominal pain.

Triple A? Definitely the front-runner.
Bad GI bleed? Could be, but no history for it.
Electrolyte imbalance maybe? T waves looked okay on the 4 lead strip. Hmm.

I reach around to stick V6 on. Out of the corner of my eye I see my partner pull pacer pads out.

"Okay. How old was she? Right. Uh, hold still, ma'am."

Click.

ACQUIRING 12 LEAD

Did we ever check hospitals? I snatch the radio off my belt.

"Firecom, Medic 601, status of Big City Med Center please."

ANALYZING 12 LEAD

"Medic 601, Big City shows green."

The Lifepak prints the short strip, calm and dispassionate.

*** ACUTE MI SUSPECTED ***

Moments (II)

"What's your name, man?" he asks, a little bit foggy, and I tell him, reaching in through the remains of the car window.

"I'm a paramedic with the ambulance," I add, lifting his arm up gently to wrap the blood pressure cuff around it. "What's hurting you?"

"My f'cking leg, man," he shouts, and I nod, looking at the door, shoved halfway to the center column. I can't tell, standing at the side, what model of car it is, or even the make. It's blue. Four doors. Sort of.

"I bet," I tell him.

On the other side, an off-duty medic and three volunteer firemen yard the driver out, onto a backboard, and set him on the ground. My partner stands back, spiking a bag of saline. A tiny flash of blue protruding from his thigh pocket betrays the syringe of fentanyl he has ready.

"Cutting!" a fireman shouts, and the Sawzall buzzes to work on the C-posts of the sedan. I step back, out of the way of flying glass. Diesels and generators rumble in the warm night air. Blue and red and yellow lights decorate trees and reflect off a stop sign, leaning halfway over.

Above, the helicopter does a slow loop over the whole scene, spotlight sliding over fire trucks and cop cars, debris and bystanders. Scoping the scene. Waiting.

Moments

We're a out deep, the rural end of our district extending far, far away from the station, into the lonely backcountry land of two-lane state highways and national forest roads and long, long driveways.

"And then, when I went, there was blood in the toilet, a lot of blood, you know?" he says, calmly enough. "I was going to drive in, but when I went in the living room I got dizzy, and saw stars, and almost fell down, and I figured I'd better call you folks."

I nod, and glance at the volunteer EMT, kneeling by the patient, blood pressure cuff hissing down.

"It's good," she says, "124/76."

"Perfect," I reply.

A few minutes later, in the ambulance, starting the thirty mile trip to the hospital, I punch the NIBP button on the Lifepak.

112/64. No worries at all. I putter through the comforting routine of starting an IV, chatting to the man about what I'm doing and what's going on.

I punch the button again.

101/62. Huh. I inch the roller clamp on the IV tubing upwards. The slow drip-drip-drip in the chamber becomes a steady patter. His heart rate stays low, not even 70 -- but there it is on his med list, the telltale -olol holding his heart rate down.

I force myself to wait three or four minutes. A hundred cc's of fluid run in. I run my finger over the blood pressure button in a tiny, nervous motion before thumbing it.

89/62. I take a deep breath, smile at the patient, and stick my head up front. We're still ten or twelve miles from the nearest town, and the hospital is another ten miles past that.

"Okay," I say to my partner. "Let's get there a bit faster." His finger goes down on the big red switch at the same time his foot goes down on the gas pedal, and the rumble of the diesel rises to a throaty roar.

I scoot back to the patient, ask how he's feeling. Yeah, we're driving a bit faster -- your blood pressure is a bit low. Nah, I'm not worried, but we don't want to dally. Feeling a bit faint? Here, I'll lay you back. Any pain? Trouble breathing? All this as my hands quickly run through the motions of spiking a second bag of fluid.

Poking what is rapidly becoming my least favorite button on the monitor, I glance out the back window. We're a few miles outside of the town. I grab a big, gray sixteen out of the cabinet and wrap a tourniquet around the man's right arm. Kindness and grace, he's got a big AC. Maybe his pressure has come back up.

62/43. And his heart rate is slowing, ECG complexes stretching out, further apart, big yellow numbers dispassionate on the screen: 45.

I swab the inside of his arm with alcohol, and yell to my partner that hey, while we're in town, we should grab a friend. I've barely got the needle in when my portable radio, forgotten on the bench seat, starts quietly whistling tones.

"Tones for Fire District 17 ... Station 30, meet Medic 601, enroute to your station, code 3 and requesting personnel to assist ..."

Overheard

I'm standing near the nurses station at one of the larger and busier local emergency departments, when I happen to catch two staff members discussing a patient...

Physician Assistant: "Hey, have you seen my crackhead?"

ED Tech: "Uh .. you're going to have to be more specific."

Truths (II)

EMS is not what they teach you in classes, in books, in school.

Or, rather, that is merely the surface of EMS, the way a history textbook's account of politics is merely the surface of the sweaty, ugly truth of marches and protests and speeches and backroom deals.

EMS is a journey, much like grief, with defined and common stages, and yet a differing experience for everyone.

EMS is opening a bar at 7am, rather than closing at at 2:30am, but getting just as drunk, stumbling tired into the daylight, cussing because now you'll sleep the entire day and get nothing done and you only have so many days off.

EMS is becoming comfortable with things than would have horrified you a few years ago, and finding wholly new things to horrify you.

EMS is an arranged marriage to a stranger who you will spend 48 hours a week with, locked in a box, in stressful situations, talking and eating and sleeping and laughing and fighting and working it out and fighting again and learning more about them and yourself than you ever wanted to know.

EMS is standing in the house of a stranger, telling his wife he's dead, and putting your hand on her shoulder or hugging her or making her a cup of tea, like you've been friends for years, because there's no one there but him, and he's three flat lines on a LifePak screen.

EMS is rolling into a trauma center with a critical shooting victim, more holes than you can count, walking right up to the senior attending trauma surgeon, and telling him, not asking but telling him that he needs to put this patient directly in an operating room, do not pass go, do not stop in the emergency department, and here's exactly why, do it now, sir.

EMS is pushing PLAY on the CD when the tones go off, cranking the rock up until it drowns out the siren, and cranking the radio up so you can hear Ops over the rock.

EMS is realizing that as much as you are there to help and care for your patients, you must help and care for yourself and your partner and everyone else in blue first, and learning that sometimes your "primary survey" will be their hands against the side of your bus as you search them for weapons.

EMS is walking into rooms or onto streets or into buses or onto planes with people who are dead, dying, bleeding, puking, crapping, coughing, and in many cases are just fine, and holding the same calm expression on your face.

And that's only the beginning.

Class

We're all in National Registry refresher class. A fellow medic is giving a pretty solid lecture on cardiac physiology, with plenty of audience participation.

This may or may not be a good idea.

* * * *

Instructor: "So, what causes cardiomyopathy in young, healthy adults?"

Medic In The Next-To-Back Row: "Cocaine!"

Instructor: "Yes, indeed, that's one cause ... What about our elderly population? What causes cardiomyopathy in old people?"

(pause)

Yours Truly, In The Very Last Row: "... Cocaine!"