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.