Saturday, May 15, 2010

Electrical Therapy for a mean nurse

If someone's heart slows down and won't speed back up we are required to fix that. Our first line treatment is a drug called atropine. Atropine decreases vagal tone, more or less taking the body's brakes away. It's not a gas pedal like epinephrine, it just takes away the feed and breed functions so to speak. If that doesn't work and the patient is symptomatic, chest pain, shortness of breath, dizziness, low blood pressure, then we have to correct this. The way we do that is by using our handy dandy heart monitor to send a small jolt of electricity through their heart 70 times a minute. Essentially we take over the heart beat, which is too slow, and tell it to beat faster with this 70 beat per minute shock therapy. So the patient sits there going. "Ow, ow, ow, ow ,ow." Every time it fires. I imagine this hurts but we give them versed to make them forget and morphine to make them comfortable. You can see their whole chest, and even neck, contracting with each little shock.

We get a page for an intrafacility transport. The city ICU to an ICU about 50 minutes away. Cardiac patient getting paced. We got there, got report, moved the patient to my machines and I took over his pacing. The patient was concious but heavily medicated and the pacer was set extraordinarily high. The doc said it was the only way they could get capture. So we loaded up and head to the big city hospital with the lights and sirens on. The trip was completely uneventful. The patient did fine and the roads were clear.

We got to the hospital ICU and met the patient's new nurse. I have to say, right from the start we did not hit it off. She was griping about this nurse and that nurse, and the secretary wasn't doing her job, she had to come off break to come get this patient, why are we here early, and on and on and on. Whatever. I don't get paid to care about her problems, only about my patient's problems. I shake my head and she jumps down my throat, "Why aren't you moving him, get him moved over now!" Really? My partner, the patient, and I all make eye contact. I kind of felt bad for the patient now.

Of course she doesn't lift a finger to help us. As she rifles through the paperwork we transfer the patient to the new bed and start moving equipment. All of the sudden she's in my face again. "Why don't you have the right paperwork!?! You are supposed to be health care professionals, you should know what paperwork you need!" Now I'm getting pissed. I asked her what she was looking for and she told me. I showed her where it was, she just missed it. Instead of being grateful she gripes some more and indicates it was my fault she missed it.

I kind of snapped and told her to get her monitor ready, we need to transfer pacing to her machine.

She looked at her monitor and the at my pads and chicken little the sky is falling! We had different machines and the pads were not interchangeable. All it means is that we would have to shut off the pacer for a minute while changing to her machine. While that can be dangerous to a patient being paced, if we timed it right it is not too big of a deal. She's now speaking acid at me. Throwing paperwork down and medical paraphernalia around. I am the devil according to her. All that's wrong in this world is my fault. I should have had the foresight to know that her machine wouldn't match mine and force my company to buy the right kind of heart monitors just prior to this transport. You may think I am embellishing here but I assure you I am not. This woman was possibly the meanest person I had ever met and she was pissed at me. The patient is now looking rather alarmed and is throwing looks my way suggesting I take him to another hospital and my partner is standing in the corner steaming.

The nurse looked at me and said "WELL!! What are you waiting for?" With that she stomped over to the patient and ripped both pacer pads off his chest violently, pulling two big patches of chest hair off the poor man. Wait! It's still on! I promise I tried to warn her but she was moving too quickly. Both pacer pads slapped together on her right hand, one on top, one on bottom. And those things are sticky. She suddenly yelped and convulsed, followed immediately by another yelp, and another. Then she screamed and began shaking her hand in front of her, rapidly hopping across the room in a very animated imitation of a rabbit on speed. She got faster and faster and louder and louder. We were stunned. Speechless. Frozen. Am I really seeing this?

After a few moments of her spasmodic break dance across the room I reached over and turned the pacer off. The nurse doubled over gasping for breath, ripped the pads off and ran from the room. The patient giggled. Then my partner giggled. I could feel the twitch of a smile and couldn't help myself. We started laughing, and laughing and then laughing some more. We were in there braying, honking snorting, eyes watering and falling over. Couldn't have happened to a better person.

I then remember the patient's not getting paced so I looked at the monitor and his heart rate was normal. I checked his pressure and that was good too. Huh. Looks like she fixed him. His color was better and he was in good humor now. A few minutes later a different nurse came in and introduced herself as the patient's new nurse and we never saw the other one again.

Thursday, May 6, 2010

A Thanksgiving to Remember

My seventh grade Thanksgiving was something to remember, more different then any before or any yet since. It started off slow, had pain and suffering through the middle, and an ending that left us full of gratitude and a house that smelled for weeks. It definitely was an occasion that I hope stays a memory and does not refresh itself with even one of the offending events. Our house full of strangers, my brother and I had cooked the whole dinner, and there was the permeating perfume of skunk everywhere. You could almost get used to it and then you would forget and inhale too deeply through your nose. Gag!

Let's go back four days. Mom was working at a ship yard and a boat had come in with several sailors with no family to go to for thanksgiving. My mother felt bad for them and decided we could use their company as much as they could ours. So she informed us that she had invited several over for Thanksgiving and that we would need to really clean the house to help to welcome them.

Count down T-Minus three days to Thanksgiving. Mom is sewing my brothers pant up, right before school, we're almost late. She get in a hurry and then lets out a yelp and holds up her finger and the needle from the sewing machine is sticking out of both side of her right index finger. She goes to the doctor and they removed it and told her she can't cook, clean, or otherwise use her finger or get it wet. My two younger brothers and I met this information without too much concern. Mom was okay and dad can cook.

Down to two days to thanksgiving. Everyone is strung tight, there's going to be a lot of people showing up, everything needs to be really nice. Me and my brothers can not seem to stop arguing. Mom is ordering us around now and trying to get us all working on something(kind of like trying to herd cats). What is that I smelled? Is that the faint odor of skunk? While doing dishes that evening my brother and I were in rare form. Fighting, yelling and otherwise being nasty to each other. My dad, finally having enough growls “That's it!” and storms towards us. The kitchen was completely soaked from top to bottom, with water dripping off the ceiling. I could immediately tell that this was not a false run, dad's really irritated. He got within range and reached up for my brother at the exact moment he stepped into water. His momentum was too great. He suddenly shot forward in a half standing, half crouching, ice skating slide across the kitchen. It would have been comical if I didn't already know he meant to teach us some sense. Then, faster then the blink of an eye his glorious first attempt at ice skating ended. He fell and broke his arm on the cabinet on the way down. He went to the doctor and they put him in a cast and told him, no cooking, cleaning, or other wise using your right hand or arm.

The day before that most remarkable Thanksgiving. Now my brothers and I are quite concerned. With both mom AND dad out of commission all the cleaning and cooking is in our less then competent hands. Not good. By now the smell of skunk is fierce and my dad's disposition is close to that of a bear just left hibernation. My brother and I are arguing while peeling apples for an apple pie when dad comes in through the sliding door and announces that there is a skunk under the house in the proximity of his bedroom. I think it should be said that he showed unbelievable restraint by keeping the growling and tearing at his cloths to a minimum. Dad called one of his friends and procured a live trap, not wanting the skunk to by killed and, well, unleash under the house as it were. I watched with deep interest as dad filled the bait bin with canned dog food and then pushed the trap under the crawl space. We crossed our fingers.

Thanksgiving morning. D-day. We all pile outside in our pajamas to check the trap. Dad and mom don rain slickers from head to toe, complete with a hat. You know, the yellow kind. Mom warned us to stay back and dad opened the crawl space and sure enough, the beady eyed monster was staring out from inside the trap. Dad grabbed a plastic bag and slowly wrestled the trap out while placing the bag around it and a lively discussion took place about what to do with this house cat sized pain. I vote on a public execution with which my father vehemently agreed. But my mom and brother decided it was too cute to kill and needed to be humanely reintroduced to the wild. My poor dad is now so unamused he is talking to himself and twitching a little. We all load up in the car and go for a drive into the woods. My dad tried to stop in several driveways to which my mother told him “No, farther out hon. Wouldn't want this to happen to anyone else.”

Finally we find the spot and we all get out to watch. I would like to point out here that I expected something very exciting from the next few minutes and I was not disappointed. Dad gets the trap out of the car and puts it on the ground. Mom and dad, still in yellow rain gear, warn us to stand back. Dad pulled the bag from the trap and used a stick to open it. The skunk didn't move. Dad, now cussing, takes a whack at the back of the trap and the skunk chose that moment to play it's ace in the hole.

Springing from the trap like a convict suddenly set free, he shot across the dirt road straight at my mom and us kids. All four of us raised to new heights of fear, rose straight up into the air and shot in random directions I even ricocheted off of my brother once or twice while trying to find a skunk free place to go and we all decided simultaneously on the family van. The skunk skidded around a tree and headed for my dad who nearly climbed out of his slickers and broke the sound barrier while fleeing around the our family van with the skunk closely behind him. After two laps around the van the skunk ran up under the van and disappeared into the under carriage. My dad by then was gnashing his teeth and hitting the ground with the stick hard enough to break it several times. In his opinion the humor had long fled the situation. My hopes increased again for a public execution. Also it suddenly didn't seem so safe in the van. Dad paced the van twice looking under it from a distance hurling Skunky expletives the whole time. Finally he yelled “Pop the hood!” and mom did. Dad yanked the hood up and shoved his head in looking down near the ground. And there was the skunk, sitting on the battery less then three inches from my dad's head. The air was shattered by my dad's ear splitting shriek and the skunk jumped straight up in the air, higher then the hood and his little legs were making three hundred mile an hour revolutions when he hit the ground and sped off into the brush. Finally having enough of this crazy family and their shenanigans.

We drove in silence back to the house. Thanksgiving dinner went off without a hitch and we had several navy men over. Only one of them had a good sense of smell or maybe less social grace. He looked at me and said “Weirdest thing. I keep thinking it smells like skunk in here.” All I could do was smile and nod when I told him “Why yes, yes it does.”

Routine Stabbing

It was 3am and I was sleeping soundly. We had been having radio tower problems with the local dispatch so sometimes our pagers didn't trip, or only one would. I woke to a persistently, irritating drumming on my bedroom door.

"What?" I rolled over facing the wall.
Sarah my partner opened the door, "I said get up, we have a stabbing, sounds bad."
I rolled over again. "Don't mess with me Sarah it's not funny." I put the pillow over my head.
She walked in the room and pulled me off the bed and said "GET UP! I'm not kidding!"
I grumbled and got up, putting my boots on, then I remember the radio problem. Maybe she's telling the truth.
"If this is a joke it's not funny." In our area we don't get a lot of stabbings.
We run out and hop in the rig and put ourselves in route with dispatch. We had a rider that day and she hopped into the back.

The radio keyed up, "District 111, and County Medic 111, you are responding to a 42y/o male reported with multiple stab wounds to chest and back. Bleeding heavily. Scene is secured by PD."

Wow. Sarah wasn't just being mean and telling me it was a stabbing when we really had an intrafacility or something like that. Please note, Sarah is not normally mean, but having me as a regular partner tends to change people's personalities. I am one of those guys that cannot sit still and often this gets me into trouble. I also have a little bit of a sadistic steak and like to play jokes on the unwitting.

Sarah lights it up and we clip off down the road. There is some confusion as to where the patient is located once we get there. Apparently the stabbing happened in one house and he ran a few blocks to another to get help.

When we got to the scene the was a long run up to the house, so I hopped out with just my stethoscope and ran up to see what we had. Just inside the front door, the patient is laying on the tile in a pool of blood gasping for breath. He's white as a sheet and profoundly diaphortic.(means he's extremely sweaty, that he's in shock). I lean out the door and yell to Sarah and the rider, "Leave the gear! Grab the bed, we need to get out of here!"

I bend over and ask the guy where he's hurt while slicing off his shirt with my trauma shears.

He looks at me incredulously and says, through his gasping, rapid respirations, "Dude!(gasp)I'm bleeding like(choke) a pig and I can't(hack) breath!"

I see four wounds in his front and one in his back, most seem superficial but the one over his upper right quadrant is right in line with his liver and diaphragm. And it is the one that is bleeding. I listened to his lungs, left was clear and right was dull and very quiet with little movement of the chest wall. Hemo/pneumo I think. A Tension Hemothorax is when the lung cavity fills with blood, collapsing the lung. It is fatal left untreated.
Sarah came in the door with the bed and I helped the guy stand to transfer to it. As soon as he stood, blood literally gushed out of the hole over his liver. Ok, gushed is not a good description. You know when you turn on the hose full blast without a nozzle? It was like that. At least a liter of blood shot out of him and splashed all over the gurney and on Sarah's legs. He looked at me and said, "You gonna stop that?"
I replied "No! Sit down!" It suddenly seemed breathing was better. I even asked him, "Hows your breathing. sir?"

"Uh, it's a lot better..."

I give him a dressing to hold at the wound and I tell him not to block the blood. There's no way my little 14g chest needle is going to make a big enough hole to compete with that big of a hemothorax. We pick him up and run for the ambulance. A volunteer EMT met us on the way and jumped in the back. Our scene time was 6 minutes. I called for an airlift to the trauma center, which is about 2 hours away by ground. In the back of the rig I had plenty of help, the rider was an EMT too. We got bilateral 14g IVs with warm saline flowing great as we tore off for the local hospital.

En route to the ER the patient exhibited increased shortness of breath again so I had him uncover the wound and stretch a little and blood again gushed out, over the patient's leg and sloshed across the floor. I had to do that 3 more times on the way in. Each time it relieved the patient's breathing. By the time Sarah opened the back doors at the ER, the blood made a macabre waterfall off the floor and back step onto the ground. Pouring out.

When we got inside the doctor started in on me. I let him off easy because it was his first day there and he didn't know the medics yet. But he argued that it wasn't a hemo, canceled airlift and stitched up the hole. I warned him to get his chest tubes out if he was going to insist on stitching the guy and he told me to leave, so I went out to write my report, a little miffed. Within a minute he came out and said "Uh, the patient's getting really short of breath, what makes you say it's a hemo." So I described it to him again(third time), and he ran back in and did an emergency chest tube, blood covering the floor of the ER room. I tried hard not to gloat. He also called airlift back and started the man on bloods.

Once at the ER we got the rest of the story, the guy had gotten drunk with a buddy and he decided to shut up his friend's wife by hitting her. His friend took exception to this and carved him up like a Christmas Turkey. The patient did well after having the hemo and his liver repaired and lived to assault another day.

Hope I don't see him again.

Tuesday, May 4, 2010

Things that go bump in the night

Most of the time EMS is fun. Sometimes it can be sad. Sometimes it can be downright dangerous. We do things to protect ourselves, like staging for law enforcement on assaults or drug ODs or if something just doesn't sound right. (Here's my hats off to the police out there, love you guys and gals, thanks for keeping us safe!) Despite our best efforts to stay out of harms way and return to our families, things can quickly move out of our control. There have been times when for my own safety I have dropped my gear and left the scene, read that as tactical withdrawal, not ran like hell. But it does happen from time to time.

The darkness shattered for the hundredth time as lightening crackled across the late night sky. Thunder drowned out the radio in the front of the rig. Trees whipped back and forth in a frenzied dance, leaves shooting across the road. It was one of those nights that evil things happen. We were assigned to the city and en route to an assault. Domestic Violence. I hate DV with passion. I nearly get enraged by the idea of some psycho beating on his wife or girlfriend. That was how I was thinking on the way to the call. Let them pick on someone their own size, or heck they could try it on me and I'm not very big. We pull up on scene and step out into the torrential downpour and a city cop leads us over to the entryway of this low income apartment complex. The lights are out in the entry hall so I use my flashlight to talk to this crying woman in the recessed area in front of the door. The cop tells us that they believe the man left the scene and that he'd stay there to keep an eye out.
The patient's face is ruined. Not from the trauma she experienced tonight, but the years of abuse etched into her features. She's shaking and flinches like a startled rabbit when I touch her arm to take a blood pressure, even though I asked her first. Her wounds on the outside aren't bad, but I'm not sure if the wounds inside will ever heal. I'm sad for her and while my partner conducts an interview I entertain thoughts of what I'd do to this guy. Oh yeah, I'd break him. I don't care how big he is. I was in old fashioned Okinawan Shoto Kan Karate for years, used to teach it. So sometimes I give myself the license to feel tough. We are there for around ten minutes, trying to get her to go in, thinking that the social workers could get to her then but she doesn't want to go. Even with as tough as I was feeling the night was wearing on me, all the thunder, the lightening, the darkness. Things were out tonight. Bad things. As I was thinking about this, lightening suddenly flashed right above us. So close that the thunder came at the same time as the flash. Hair standing on end, ground shaking, bright as daylight. No, brighter. And with that light we were able to see the door next to us, it had a window in it the full size of the door. And there, standing on the other side of the glass, was a man that looked like a giant Charles Manson. The lightening lit him up shedding ethereal light across his evil glaring visage three inches from my face!
In the sudden eye gouging, hair pulling, crazed wrestling match to be the first out of the entryway I saw my partner take two elbows from the cop and a kick to the back from the patient.
Breathing heavily, I sprinted past the patient about a block away. "That him?" I asked her on my way by. Both of us still fleeing the scene.
"Yeah, that's him." She replied through her gasping retreat.
"Well, better hurry if you're gonna tell the cop that, he's already out ran us by a full block."