Nausea

This is the third time we've transported her in three days. She can't stop throwing up. She goes to the hospital, comes home, feels awful for a while, and calls us again. I'm trying not to be grumpy, and failing. I was sleeping, comfortable finally, curled up just so that the pager and keys and trauma shears don't dig into my side and leg, waiting out the last few hours of a slow night.

* * * *

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."

Gifts

I have never met him -- will never meet him, not really -- and yet he still gives me a gift, in an odd way. Maybe not intentionally, certainly not knowingly, but a gift nonetheless. It's not even really a gift for me; just one for me to hold for a while -- I don't know how long -- until I find the ultimate recipient.

* * * *

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."

Hm, indeed.

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 --

Ah.

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.