Wednesday, June 28, 2006

Too Fast

Tuesday was a hot day. Around a hundred degrees. We took the ambulance to the store to get some food, and while we were there saw $0.79 squirt-guns. How could we not? When we got back to quarters, it became obvious that the battle would be ambulance crew vs paramedic intern, and I took refuge in the bathroom while loading. We had a great battle going for a while, but of course, at the peak of the fight...

*beeeeeeeeep* "Unknown medical problem, 9876 Elsewhere Drive..." Our district.

Laughing and swearing, we piled into the ambulance. When they realized how wet I was, they laughed even hearder ... but as hot as it was, I was dry when I got there.

This was not to last.

* * * *

The call was for chest pain and near-syncope (fainting). We arrived to find an elderly woman sitting on the bed, looking a bit pale, a bit sweaty, but generally alright. We put her on some O's, start asking questions. Nearly passed out in the shower. Cardiac history. 3 out of 10 chest pain. Some shortness of breath. I was just getting the aspirin out when one of the firefighters got the monitor hooked up.

(For my non-medical readers, this is [presumed] ventricular tachycardia or v-tach, a very serious rhythm that is often seen in cardiac arrest. It's indicative of something being Very Wrong. Her heart is beating about 240 times a minute.)

((For my medical readers, while we can go back and forth all day between VT and PSVT with aberrancy, the fact is that we only have a 3-lead in the field and we treat all wide-complex tachycardias the same -- lidocaine if stable, cardiovert if unstable.))

Uh-oh. Everyone exchanges serious looks. One of the fire medics rips open the IV kit while I pull out the pads. They miss their first attempt but get their second as my preceptor and I scribble drug calculations on our gloves and agree on a dosage of lidocaine. I push the first bolus. She slows down to the 190s, but doesn't convert, and slowly begins creeping upwards again. We all conference briefly and agree to load and go, with a second bolus and lidocaine drip on the way, and cardiovert her if she becomes less stable.

I'm no longer dry.

We take off, loud and flashy. She doesn't really change enroute. The second bolus doesn't do much, and I go ahead and hang the drip anyway (my first!). Call my report. If you key up the mic with sirens in the background and wait a couple of second before talking, there's no wait for a nurse to answer.

At the hospital, she does alright for a bit. The doc looks at the 12-lead and says he's not sure if it's really VT, or SVT with a bundle branch block. He starts a beta-blocker to try and convert her.

A few moments later, while we're still standing around, she goes unresponsive and starts having gasping, agonal-type respirations. They check ... no pulse. The doc gives her a precordial thump, glances at the monitor, and barks, "Shock her!" They light her up at 300 joules and she converts right into a sinus rhythm.

She goes to the cath lab with a massive MI. No word on how she did after that.

* * * *

That was the first and best call of the day. We did a syncope, a sweet old lady with a fall, a r/o neck injury from an MVA, a kid with an allergic reaction who was stable and didn't let me touch her, and, in the middle of the night, an elderly man with new diabetes. Half an amp of D50 brought him right around, and we left him with his wife, a glass of orange juice, and a slice of pie.

"Do I chart that? Blueberry pie bolus PO x 1 slice?" I ask, as we pull into the fire station.

My fire preceptor grins at me, taking off his turnout pants. "Go back to bed," he says.

Thursday, June 22, 2006

Know Your Sources

At first I thought I'd call the day "Neb Day," because that was the theme of the first three calls. All elderly ladies, two with difficulty breathing and one with chest pain. All three got nebulizers because all three were complaining of shortness of breath. Ironically, I think the neb did the most for the chest pain patient, who we decided was more likely not cardiac. Nitro didn't touch her pain, but the albuterol and atrovent sure did.

One of the ladies was deaf, and I had to write everything out on a pad. She was terribly sweet, though, and informed me I should tell my mother that she raised a nice boy. I called my mom later on in the shift. Just doing as I'm told.

* * * *

But the defining call of the shift came later in the evening, when we went on an unknown medical that turned out to be a young lady who was, for lack of a better work, flipping out. Not psych flipping out, not upset flipping out, but crazy on drugs flipping out. She reminded me of patients on E and acid and more esoteric drugs (2C-T-7, anyone?) I'd treated at various concerts and events. Completely out of control.

We backboarded her, finally, just to keep her safe and us safe and get her down the stairs. She said, in lucid moments, that she'd only smoked some weed. We got her to the ambulance, headed off. She calmed down a bit, only to rile back up. I put a large-bore line in her, impressing both my preceptors. Fastest stick I've ever done.

Her sugar was fine. Narcan didn't do much. We left her at the hospital. I felt bad for her, really. During her calmer periods it was clear that she was pretty aware of what was going on, and very upset. It came out over the course of the call that the weed she had smoked came from a dealer she didn't really know. Hmm.

* * * *

In the morning, as I was getting ready to leave the fire station, my preceptor dropped a piece of paper in front of me. "Here's your girlfriend's lab results," he quipped. "I called the hospital after you went to bed."

Tox showed
- Cannabis
- Amphetamine
- Methamphetamine

Whoops. Poor girl.

Monday, June 19, 2006

Gone Too Long

I was working the ALS transfer car I usually work, on a Saturday. Just working as an EMT, with a very experienced paramedic alongside me.

We got tossed into the 911 system abruptly, given a code 3 call a long ways away out of the blue. No problem. Fire is there in a few minutes, so our long response doesn't compromise care. We get onscene eventually to a relatively simple chest pain. I drive, my medic does the regular ALS stuff on the way to the hospital. Prehospital 12-lead by the fire dept didn't show anything. We found out later it was cardiac.

Clear from the hospital. Cleared to quarters. Out of the system. We stop for fuel, and while we're doing so we're yanked back into the 911 system. The county's at low levels. We head back down the freeway, to a low-level post, basically on an overpass. As we're pulling up the onramp, the county alert tones go off, three monotone beeps on the fire radio, and--

"Dispatch with an echo response, 4321 Pringle street."

As the fire tones start to go off and I look for a place to turn around, I swallow nervously, and hope I misheard. As soon as I hear tones for a second station, I realize I was right.

Under the Medical Priority Dispatch System responses are coded (in order of increasing severity) Alpha, Bravo, Charlie, Delta, and Echo by calltakers, based on carefully determined criteria.

Alpha response is no lights and sirens, a nothing call. Bravo might be something. Charlie and Delta calls are serious. There are only a few things that can get an Echo response; generally they're for a patient not breathing or a full-on code (cardiac arrest). You rarely hear one.

Sure enough.

"For Engine 314, Rescue 332, Medic 34, echo response on a child not breathing, 4321 Pringle street. Repeating, Engine 314, Rescue 332, Medic 34, echo response, child not breathing, 4321 Pringle street. Fire map page 671 C-Charlie, working Tac 2, time out fifteen thirty."

Crap. I put the pedal to the floor as my partner starts talking to the dispatchers and mapping me in. We scream down the interstate, hop the divider at a traffic-clogged offramp, and go wailing up city streets.

On the way dispatch confirms that it's a pediatric patient. CPR in progress. Crap. But then a second update comes in: breathing now. Okay. Maybe this was new mom syndrome? Or something else less serious than it sounds?

As soon as we arrive I know it's exactly as serious as it sounds. The kid is primary-school-age, with a form of muscular dystrophy, lying on the ground next to a motorized wheelchair. Where he isn't pale as a sheet he's blue, and he's working hard to breathe.

We're on-scene for about nine minutes, just long enough for the medics to figure out they can't get a line easily and that he's not ready for a tube without the rapid sequence drugs. No IV, they can't sedate, paralyze, and tube this kid, and without that the only option is mask ventilation with high-flow oxygen. They can't get an O2 sat either.

We load and go, lights and sirens, my medic plus a firefighter paramedic in back. The children's hospital knows him, surely, and no doubt they can take care of him better than we can.

But a couple miles up the road he codes, for real, and I have to pull over, ask for the fire units to meet us (for more help), and jump in back to help do CPR and suction while the medics try and get him tubed. I glance at the monitor at one point, and I'm not sure if I'm seeing v-fib, or artifact from my compressions. Not my job. I remember the new CPR class I took recently, and push hard and fast with the heel of my right hand. With the other hand I reach over and poke the Yankauer into the corner of his mouth and suction vomit. It's all over everywhere, and the kid is gray.

They get their tube, finally, on the second attempt. I'm sure it would have taken me more than two tries. Tough airway. But now he's getting ventilated, effectively. Look at the monitor -- asystole. Flatline. The first dose of epi goes down the tube.

The engine and rescue show up again. I happily clear out of the back of the ambulance, making way for a few more medics. After looking briefly for an IV, they put an intraosseous line into his leg. At some point I realize I parked almost in the middle of the road, and somewhat blocking an intersection. Whoops. Someone from one of the fire units cones off the area.

Finally they've got what they need done so we can go again. We divert for the closest hospital. I don't even know how many fire department paramedics we have in back -- three, plus my medic, I find out later.

We arrive with the kid still in asystole. The back of my ambulance is destroyed. Supply wrappers are everywhere. Two or three laryngoscope blades lay on the flood by the airway seat. Suction tubing, oxygen tubing, IV tubing, monitor cables -- it's a spaghetti hell. My paramedic looks at me and says, "Just decon everything." As I'm getting started, one of the fire medics comes out of the ER.

"You guys aren't going to believe this, but he's got a rhythm. Narrow-complex. Sinus tach. I don't believe it."

We're all happy for a minute, then someone points out the downtime. Fifteen, twenty minutes. Too long? Hard to tell.

* * * *

Three months later, my name and the name of the medic I worked with that day are in the pat-on-the-back section of the newsletter at work. An excerpt from a letter about the call, presumably from the kid's parents, thanks us warmly. Nothing to suggest what the call was to anyone else. But to me the connection is clear, and when I go back and check the dates match. No outright statement of outcome, but the way it's phrased makes me think he died. They thank us for doing everything we could.

And a few days after that, I catch up with the medic I worked with that day. Yeah, he says, the kid died. Of course. Sick to start with, twenty minutes of downtime. No chance. But, he tells me, he got a nice letter from the parents, through our agency. Didn't I get a copy? No? He'll make me one.

They included a picture, the medic tells me, and I suddenly, desperately, want to see it, so that I can have a memory of the kid's face that isn't gray, limp, and streaked with puke.

* * * *

(Please note that like everything I write here, while this is based on a real call, circumstances, locations, and details have been obfuscated or changed. Any identifying information has been removed.)