So fairly recently I was working rescue with one of the more "talkative" medics in the area when we get a call for a fall. Ugh! I don't want to start my day off with a fall! It's funny how in this job the more stressful, demanding, and even difficult the call is, the more we want it. Well...that is how I am anyway. I would rather do back to back priority 1 calls for a 24 hour period than do 12 hours of slinging renal pts to and from the chair.
Anyway, as I digress...as we are enroute to our call were we would have to put on our happy faces and BLS the hell out of this call we hear the FD state over the radio "Priority one pt. CPR in progress". My partner and I look at each other and start to speculate on the matter at hand. Keep in mind that he has already surpassed his expect amount of word I thought he was going to say to me throughout the following 12 hours. I come up with a very plausible scenario to bounce off of my partner. "Where did this pt fall from, the Moon?". He shrugs and swears and complains to the steering wheel as he drive faster now that our priority one call is real.
Upon arrival we find our friends on the FD doing CPR on average size man who was acting strange before they got there and went unconscious in front of them. They are doing great compressions and ventilations but the AED was screaming no shock advised.
The strangest thing happened after we did another round of CPR, swapped out the pads for our own monitor...the pt started breathing again and had a relatively good pulse. It was certainly a "WTF?" moment for all of us. Then he tries to sit up. We all jump in because he is now trying to roll all over the place and not exactly being the most cooperative pt at this point. I glance over at the monitor and he is in V-Tach. Then he goes unresponsive again with no pulse. Boooooooooo.....Clear! And he is hit with 200J (Biphasic) of Detroit Edison (DTE). And we start the CPR game again. Right after the shock, the pt was in a wide, regular, and very odd looking brady rhythm. However, this rhythm quickly upgraded to a much more friendly looking sinus tach at about 130.
With CPR going on immediately in the post defib phase, the FD was getting ready to drop a King LT airway when I notice the pt reaching up for his chest. STOP CPR! The pt is again breathing and has a pulse. The game of sit on the pt starts again, making placing a line that much more difficult. I find my self sitting on his knees and placing a large bore IV at the same time. Thankfully my years of military experience have taught me the importance of multitasking in stressful situations. This allowed for a good line and a bolus dose of an anti arrhythmic to be given.
We are sinus tach still on the monitor with a great pulse and BP. He was still combative and confused so we restrained him and transported him to the closest hospital where he could undergo emergent interventional cardiology. As we are transporting with disco balls and noise makers, the pt starts asking more lucid questions like "What happened", "Why am I tied up", and "Where are we going". Looks like we got a CPC 1 upon arrival and a CPC 2 immediately upon gaining ROSC.
We get to the hospital and give report to the receiving team in the ER. He was actually stabilized and immediately transported to another facility by our MICU team for an emergent CABG.
It is always nice to put one in the win column. More often than not people usually do not survive SCA out of the hospital. This was a great example of how a quick response and teamwork can really save someones life and make you look and feel like a rock star.
Thursday, December 29, 2011
Saturday, December 10, 2011
Bloody boot prints
You ever have one of those call where you end up tracking blood into the ER? Had one recently. We got the call for a laceration. Could be something crazy or it could be nothing. Well on this call, it was most certainly something crazy. Well, crazy may be a bad word to describe this call, but none the less, it was an interesting situation.
As my partner and I pull up on scene to a collection of PD and FD vehicles, we hear what I can only describe as "ruckus" and "Hootenanny" coming from the open door of where our pt is located. I use those terms in hopes it paints a better picture of the scene. For those of you that have not figured it out yet, we are very much in red neck territory. Oh and before I go any further, you don't have to live on 100 acres of farm land that more deer stands, "shine stills", and meth labs than people to be in red neck territory. Red neck territory is anywhere one who fits this description sets up shop and plants their rebel flag. So it could very well be in the middle of a trendy part of town, the burbs, or a rural area. At any rate, "abandon all hope ye who enter in" should have been on the door. Anyway, as I digress...
The Appalachian American melee that is going down in front of me is actually in the middle of a pool of blood. There is also blood everywhere! The floor of the kitchen, living room, and all over clothes. Looked like the set of an amateur horror film. And of course this particular individual didn't want to go to the hospital. Of course. Who would want to leave a 1/5th of their circulating blood volume on the floor unattended? Whatever...
So after a phone call to medical control, a set of handcuffs, and an excellent bandaging job by the FD (good job as always guys), we are off to the hospital. Just FYI, the phone call to med control was not for the handcuffs. I left out the details of the call on purpose. Anyway, an IV is placed and a fluid bolus is given. The pt at this point is telling dirty jokes and being very much the social butterfly. However, as soon as you ask him about his medical history and what happened, the mood changes and he turns away. Ugh!
Upon arrival to the ER the doc asks if the bleeding was arterial or venous and if there was what appeared to be "spurting" patterns on the wall. Answer to the question was "no". So I give report, hand off care and go to finish my paperwork. However, as I walk out of the pt's room I notice bloody foot prints on the floor. Those foot prints belonged to me. I tracked blood, mud, and whatnot all over the ER. You have to admit that a bloody foot print is a eerie sight to see. Especially when it is yours. At least the blood wasn't mine.
As my partner and I pull up on scene to a collection of PD and FD vehicles, we hear what I can only describe as "ruckus" and "Hootenanny" coming from the open door of where our pt is located. I use those terms in hopes it paints a better picture of the scene. For those of you that have not figured it out yet, we are very much in red neck territory. Oh and before I go any further, you don't have to live on 100 acres of farm land that more deer stands, "shine stills", and meth labs than people to be in red neck territory. Red neck territory is anywhere one who fits this description sets up shop and plants their rebel flag. So it could very well be in the middle of a trendy part of town, the burbs, or a rural area. At any rate, "abandon all hope ye who enter in" should have been on the door. Anyway, as I digress...
The Appalachian American melee that is going down in front of me is actually in the middle of a pool of blood. There is also blood everywhere! The floor of the kitchen, living room, and all over clothes. Looked like the set of an amateur horror film. And of course this particular individual didn't want to go to the hospital. Of course. Who would want to leave a 1/5th of their circulating blood volume on the floor unattended? Whatever...
So after a phone call to medical control, a set of handcuffs, and an excellent bandaging job by the FD (good job as always guys), we are off to the hospital. Just FYI, the phone call to med control was not for the handcuffs. I left out the details of the call on purpose. Anyway, an IV is placed and a fluid bolus is given. The pt at this point is telling dirty jokes and being very much the social butterfly. However, as soon as you ask him about his medical history and what happened, the mood changes and he turns away. Ugh!
Upon arrival to the ER the doc asks if the bleeding was arterial or venous and if there was what appeared to be "spurting" patterns on the wall. Answer to the question was "no". So I give report, hand off care and go to finish my paperwork. However, as I walk out of the pt's room I notice bloody foot prints on the floor. Those foot prints belonged to me. I tracked blood, mud, and whatnot all over the ER. You have to admit that a bloody foot print is a eerie sight to see. Especially when it is yours. At least the blood wasn't mine.
Now how exactly did you get out here...on top of that?
Fairly recently I was working a fairly busy 24 hour shift out in my usual coverage area. We did our fair share of calls during the day, but nothing that was too exciting or in this case, blog worthy. So we get back to the station to hopefully settle in for what we always hope is a slow, quiet, uneventful, and basically filled with hours and hours of sleep. However, just the lights go off in the station, so do the tones. Ugh! Now what! Do people know not to get hurt or have a medical issue after 10pm?
The call is actually right down the street (figuratively) for a traffic accident. So far it doesn't really get our adrenalin pumping. That is until the dispatcher states that it was a roll over and the pt had been ejected from the vehicle. Lights and sirens, here we go!
3,2,1 we are on scene with the FD who had shown up just a minute or so before us. The collection of metal and plastic pieces that used to be a car was now nothing more than a heap of twisted metal. Mechanism of injury = bad. But where is the pt? Sometimes under the haze of midnight, flashing lights, and the flurry of activity between passing on lookers, PD, and fire, things can get a bit hectic. However, we find our pt awake, in pain, and on top of what I thought was the front windshield. As it turns out it was actually the rear windshield. WTF? How did you do that?
Apparently this pt was not wearing a seat belt and was subject to the totally random injury pattern/movement of the vehicle when it rolled more times than a hot dog at 7-11. As it turns out, the pt was actually laying on top of the rear windshield. Apparently he felt he needed to take it with him on his 20ft flight from his vehicle to the lawn of the person that I hope called 911. Now I am very much an advocate for the whole "Seat belts save lives" concept, but this guy was very much the exception. If he had his belt on, he would have to be cut out of the jungle gym that was now the front compartment of his vehicle. Then things would have to get more complicated, helicopters would need to be called, injury would probably be worse, and so on.
So what we start the typical trauma/pre-hospital checklist with a sense of urgency. A,B,C's are good but our pt with the wreck any NASCAR driver would be proud to have caused looks uncomfortable to say the very least. Oh and our rapid trauma assessment (eyes and scissors) revealed that it would have been a very bad idea to roll him to the right side since he had what could be either a hip or femur fracture. Either way, a bunch of orthopedic badness that requires surgical intervention.
At this point he is carefully manhandled in a calm and professional way to ensure he is packaged properly for transport to a trauma center. His vitals are stable-ish but due to the injury and the crazy damage to the car, we felt it would be a good idea to get two big antecubital lines in this particular pt. My partner and I both pop in 16g IVs and I am sure the collective thought process in the back of this ALS rig was "boom goes the thunder".
And now we are off towards the interstate to take us to the trauma center so this pt can make it to a surgeon, preferably an orthopod. The ride is uneventful and the pt is well enough to tell a couple of dirty jokes and complain about the "great roads" we have in the area.
As we roll into the trauma bay, report is given and care is transferred to the trauma team. Sometimes you can get complacent with the idea that nothing other than diabetics and COPDers live in your are, but severe trauma can happen anywhere.
The call is actually right down the street (figuratively) for a traffic accident. So far it doesn't really get our adrenalin pumping. That is until the dispatcher states that it was a roll over and the pt had been ejected from the vehicle. Lights and sirens, here we go!
3,2,1 we are on scene with the FD who had shown up just a minute or so before us. The collection of metal and plastic pieces that used to be a car was now nothing more than a heap of twisted metal. Mechanism of injury = bad. But where is the pt? Sometimes under the haze of midnight, flashing lights, and the flurry of activity between passing on lookers, PD, and fire, things can get a bit hectic. However, we find our pt awake, in pain, and on top of what I thought was the front windshield. As it turns out it was actually the rear windshield. WTF? How did you do that?
Apparently this pt was not wearing a seat belt and was subject to the totally random injury pattern/movement of the vehicle when it rolled more times than a hot dog at 7-11. As it turns out, the pt was actually laying on top of the rear windshield. Apparently he felt he needed to take it with him on his 20ft flight from his vehicle to the lawn of the person that I hope called 911. Now I am very much an advocate for the whole "Seat belts save lives" concept, but this guy was very much the exception. If he had his belt on, he would have to be cut out of the jungle gym that was now the front compartment of his vehicle. Then things would have to get more complicated, helicopters would need to be called, injury would probably be worse, and so on.
So what we start the typical trauma/pre-hospital checklist with a sense of urgency. A,B,C's are good but our pt with the wreck any NASCAR driver would be proud to have caused looks uncomfortable to say the very least. Oh and our rapid trauma assessment (eyes and scissors) revealed that it would have been a very bad idea to roll him to the right side since he had what could be either a hip or femur fracture. Either way, a bunch of orthopedic badness that requires surgical intervention.
At this point he is carefully manhandled in a calm and professional way to ensure he is packaged properly for transport to a trauma center. His vitals are stable-ish but due to the injury and the crazy damage to the car, we felt it would be a good idea to get two big antecubital lines in this particular pt. My partner and I both pop in 16g IVs and I am sure the collective thought process in the back of this ALS rig was "boom goes the thunder".
And now we are off towards the interstate to take us to the trauma center so this pt can make it to a surgeon, preferably an orthopod. The ride is uneventful and the pt is well enough to tell a couple of dirty jokes and complain about the "great roads" we have in the area.
As we roll into the trauma bay, report is given and care is transferred to the trauma team. Sometimes you can get complacent with the idea that nothing other than diabetics and COPDers live in your are, but severe trauma can happen anywhere.
Thursday, November 10, 2011
Working with an audience
The other day I was working my pseudo regular shift when a call went out for a seizure in the middle of an intersection right down the street from one of the hospitals we go to on a very regular basis. According to FD, PD, and by standers, the pt had stopped his motorcycle at a red light, put the kick stand down and then slumped to the ground.
Since details were sketchy at best, I will just give you what I have from the time we arrived on scene. Our sister agencies that responded with us did a fabulous job of surrounding the pt and making a pretty safe environment for us to work. Not too bad for the middle of a busy intersection. So from my seat in the ambulance I see a fire fighter holding c-spine on a male pt with a motorcycle helmet on. As we get out with our super hero reflective vests and walk up to the pt, I notice he is not breathing. We quickly and carefully get his helmet off and it was then I realize that the pt is in full cardiac arrest. I cut off his shirt and then received a crazy look from one of the fire fighters when I told him to start CPR. It was one of those "You gotta be !@#$% kidding me", kind of looks. Now I have been known to be a smart ass on scene from time to time. Nothing rude, just fun little jabs at my fellow responders. However, the middle of a busy intersection with a patient in full arrest is neither the time, nor the place. At any rate, he reluctantly started CPR.
Now that BLS measure were implemented, ALS and transportation were being organized and deployed. My partner threw on the pads while I attempted to intubate the patient, breaking many of my own rules of intubation. I will explain in a minute. So our "seizure" patient is in course V-Fib and received 200J of home grown, biphasic DTE energy. He jolted and we again started CPR while my partner secured vascular access.
Now on to me and breaking my own rules of intubation. As emergent of a procedure as it was in this particular situation, the first step is to not rush. Broke that rule. Next, I didn't get the pt positioned properly for the greatest view. I tried to placed the tube without the external auditory meatus with the menubrium. It's a great way of ensuring that you goose the tube instead of being the man with the plan and passing it through the chords. So I didn't have greatest view when instrumenting the airway. Lessons learned. Oh and attempting to intubate with sunglasses on may look cool, but you won't be able to see shit.
Now, back to the intersection of CPR and defibrillation. In the short period of time it takes to shock, get an IV, shock again, attempt to intubate, package, shock, and transport down the street (literally) to the hospital, the patient received 6 or 7 doses of electricity and remained in V-Fib the entire time. Calling report was interesting to say the least. BLS ventilations and using a cell phone at the same time probably looked a bit funny to John Q. Public passing by.
So we code him in to the ER and take him to resus where the docs use the glidescope to make intubation look like the easiest thing in the world and start pushing some meds. They work him for a few minutes but end up calling it.
This was one of those calls that really drives home the point that anything can happen doing this job and to expect the unexpected. EMS will always throw you a curve ball. You just have to be ready to recognize it and adjust your actions accordingly.
Since details were sketchy at best, I will just give you what I have from the time we arrived on scene. Our sister agencies that responded with us did a fabulous job of surrounding the pt and making a pretty safe environment for us to work. Not too bad for the middle of a busy intersection. So from my seat in the ambulance I see a fire fighter holding c-spine on a male pt with a motorcycle helmet on. As we get out with our super hero reflective vests and walk up to the pt, I notice he is not breathing. We quickly and carefully get his helmet off and it was then I realize that the pt is in full cardiac arrest. I cut off his shirt and then received a crazy look from one of the fire fighters when I told him to start CPR. It was one of those "You gotta be !@#$% kidding me", kind of looks. Now I have been known to be a smart ass on scene from time to time. Nothing rude, just fun little jabs at my fellow responders. However, the middle of a busy intersection with a patient in full arrest is neither the time, nor the place. At any rate, he reluctantly started CPR.
Now that BLS measure were implemented, ALS and transportation were being organized and deployed. My partner threw on the pads while I attempted to intubate the patient, breaking many of my own rules of intubation. I will explain in a minute. So our "seizure" patient is in course V-Fib and received 200J of home grown, biphasic DTE energy. He jolted and we again started CPR while my partner secured vascular access.
Now on to me and breaking my own rules of intubation. As emergent of a procedure as it was in this particular situation, the first step is to not rush. Broke that rule. Next, I didn't get the pt positioned properly for the greatest view. I tried to placed the tube without the external auditory meatus with the menubrium. It's a great way of ensuring that you goose the tube instead of being the man with the plan and passing it through the chords. So I didn't have greatest view when instrumenting the airway. Lessons learned. Oh and attempting to intubate with sunglasses on may look cool, but you won't be able to see shit.
Now, back to the intersection of CPR and defibrillation. In the short period of time it takes to shock, get an IV, shock again, attempt to intubate, package, shock, and transport down the street (literally) to the hospital, the patient received 6 or 7 doses of electricity and remained in V-Fib the entire time. Calling report was interesting to say the least. BLS ventilations and using a cell phone at the same time probably looked a bit funny to John Q. Public passing by.
So we code him in to the ER and take him to resus where the docs use the glidescope to make intubation look like the easiest thing in the world and start pushing some meds. They work him for a few minutes but end up calling it.
This was one of those calls that really drives home the point that anything can happen doing this job and to expect the unexpected. EMS will always throw you a curve ball. You just have to be ready to recognize it and adjust your actions accordingly.
Monday, October 31, 2011
Now that's love...
Recently I worked a very long 24 hour shift. We were pretty much awake the whole time. The odd about the shift though was that we only did 2 transports out of 8 or so 911 calls. Now I know what you're thinking, that's a pretty high sign off to transport ratio for the day. It would be if most of these calls resulted in contact with an actual patient. We were cancelled on two calls before we got there, signed off some guy that ended up being transported with PD (I will elaborate in a bit), and got cancelled off the scene of an MVA where the driver wrecked his car pretty bad and took off on foot. Good times. The transports we did do were an LoL NAD with a possible broken hip, and an acute methadone OD which was actually related to the guy that was carted away with PD.
So now let me paint you a better picture of the more interesting call(s) of this 24 hour shift. So we get a call to come "check out" two individuals at a location in a wonderful school district that is known for things like meth, heroin, and all around red neckery. No meth lab explosions...yet. At any rate we show up and there is half the paid on call FD for the area and 3 cops with the K-9 unit on the way. This is going to be "fun". As I walk through the door I am hit with the all too familiar smell of menthol cigarettes, stale beer, and old pizza boxes. One of the "patients" has been put in time out by PD but still feels the need to call the shots.
To digress a bit, I love how the more subdued (hand cuffs, tazers, zip ties, police cell) the more verbal they are about what people should do and what needs to be done. I believe it is an attempt to salvage a little bit of control that they have lost. Usually these people are already manipulative and controlling anyways. So this is new territory for them. Well perhaps not new, but uncomfortable territory. So our guy who just so happens to be wearing a "tapout" shirt is yelling at his family and calling people names and is overall not very cooperative. But he does admit to drug use that day.
Ok back to the scene, his girlfriend, baby momma, boo, or whatever red neck ghetto hood rats call their significant other looks about as strung out as strung out can be. She is confused and says she really needs a cigarette. However, she eventually tells us that she has an extensive medical history, has taken some benzos, smoke some pot...excuse me, "medical marijuana" which she has a prescription for...just not here, and that she rode her bike here. And as she is giving us all this useful information, the cops pile up a bunch of what I can describe as make shift gas station fodder. In other words, drug paraphernalia. She grabs her "prescription meds and her boyfriends legitimately prescribed methadone and leaves with a friend. And right about this time her hand cuffed lover (not in the fun way that requires a safety word) starts to get irate and is dragged off with the cops.Good our episode of cops is over and we can have dinner. Or so I thought.
So about an hour or so later, we get a priority one call for a young lady with abnormal breathing and is semi conscious. We sigh as we jump into our trusty ALS unit and respond priority one. Once we get there, the first words out of my mouth are "Hey I know her!" in stealthily sarcastic pseudo professional tone. Our pt who probably is a GCS of about 5 is picked up and placed on our gurney and we start the process to administer 2mg of IV sobriety, AKA Narcan. Oh and btw, her pupils were almost non existant. So we push the meds and 3,2,1 to quote Eminem "Snap back to reality"! And off to the hospital we went. To the same hospital that her lover boy was at. I'm sure that made for some controversy later in the ER and a few colorful words were yelled at one another for her stealing his methadone.
I know I have written a few of these short stories about overdoses, but they are just so entertaining. However, it boils down to just another day in the life of this particular paramedic.
So now let me paint you a better picture of the more interesting call(s) of this 24 hour shift. So we get a call to come "check out" two individuals at a location in a wonderful school district that is known for things like meth, heroin, and all around red neckery. No meth lab explosions...yet. At any rate we show up and there is half the paid on call FD for the area and 3 cops with the K-9 unit on the way. This is going to be "fun". As I walk through the door I am hit with the all too familiar smell of menthol cigarettes, stale beer, and old pizza boxes. One of the "patients" has been put in time out by PD but still feels the need to call the shots.
To digress a bit, I love how the more subdued (hand cuffs, tazers, zip ties, police cell) the more verbal they are about what people should do and what needs to be done. I believe it is an attempt to salvage a little bit of control that they have lost. Usually these people are already manipulative and controlling anyways. So this is new territory for them. Well perhaps not new, but uncomfortable territory. So our guy who just so happens to be wearing a "tapout" shirt is yelling at his family and calling people names and is overall not very cooperative. But he does admit to drug use that day.
Ok back to the scene, his girlfriend, baby momma, boo, or whatever red neck ghetto hood rats call their significant other looks about as strung out as strung out can be. She is confused and says she really needs a cigarette. However, she eventually tells us that she has an extensive medical history, has taken some benzos, smoke some pot...excuse me, "medical marijuana" which she has a prescription for...just not here, and that she rode her bike here. And as she is giving us all this useful information, the cops pile up a bunch of what I can describe as make shift gas station fodder. In other words, drug paraphernalia. She grabs her "prescription meds and her boyfriends legitimately prescribed methadone and leaves with a friend. And right about this time her hand cuffed lover (not in the fun way that requires a safety word) starts to get irate and is dragged off with the cops.Good our episode of cops is over and we can have dinner. Or so I thought.
So about an hour or so later, we get a priority one call for a young lady with abnormal breathing and is semi conscious. We sigh as we jump into our trusty ALS unit and respond priority one. Once we get there, the first words out of my mouth are "Hey I know her!" in stealthily sarcastic pseudo professional tone. Our pt who probably is a GCS of about 5 is picked up and placed on our gurney and we start the process to administer 2mg of IV sobriety, AKA Narcan. Oh and btw, her pupils were almost non existant. So we push the meds and 3,2,1 to quote Eminem "Snap back to reality"! And off to the hospital we went. To the same hospital that her lover boy was at. I'm sure that made for some controversy later in the ER and a few colorful words were yelled at one another for her stealing his methadone.
I know I have written a few of these short stories about overdoses, but they are just so entertaining. However, it boils down to just another day in the life of this particular paramedic.
Monday, October 24, 2011
Just in time...
I was working my pseudo regular shift the other day with a new partner. I don't know if it is Michigan, the county, the company, me, or EMS in general, but I have worked with a handful of people that just don't talk for 12-24 hours. If it is not related to the call we are on at the moment, I am lucky to get 5 words out of some of these people. Oh well, I guess awkward silence is better than hostile "conversation".
At any rate, we get a call for a choking in progress that has gone unresponsive in one of the neighboring cities, so off we go priority 1. On the way there we are thinking we are going to be walking into a situation where CPR is in progress or the family has DNR/DNI papers present. However, that was not the case.
When we walk in, we find three PSOs around the pt providing o2 therapy, have an AED placed, and getting a baseline set of vitals on their pt that is currently lying in the "recovery position". The pt is an elderly female that is probably a GCS of 9-10 at the moment. But with each passing minute, she is increasing her GCS and will eventually be at 15 and a/o x3ish. All the hard work was done by the PSOs on scene. And they did a fantastic job. They saved this woman's life. Now let me paint you a better picture of what happened before we arrived on scene.
The PSOs received a call for one choking. When they arrived there was a family member that was attempting to do the Heimlich but was not ever successful. The officers tried and the pt became unresponsive. After laying the pt on to the ground they were able to yank out a large wad of pizza and start ventilating the pt with the BVM and some high flow oxygen. They said they bagged her for about a minute or two before she started coming around and breathing on her own. This is a great example of how simple BLS maneuvers can save a life. This "young lady" was very fortunate to have survived such a traumatic ordeal. Kudos to the PSOs and the fantastic job they did in saving this woman's life.
As I said earlier, they did all the hard work and saved her life. All we did was take her to the hospital. But it was nice to be part of the team. The family was very appreciative and I am happy that they have their "grandma"around for a while longer. We[EMS] always strive to be the hero, unfortunately we usually end up having to be the bearer of bad news. However, this was certainly one we can put in the win column between us and the reaper. The score on the other side is always higher, but it doesn't mean we will ever stop trying. Now on to the next adventure in public safety. Bye for now.
At any rate, we get a call for a choking in progress that has gone unresponsive in one of the neighboring cities, so off we go priority 1. On the way there we are thinking we are going to be walking into a situation where CPR is in progress or the family has DNR/DNI papers present. However, that was not the case.
When we walk in, we find three PSOs around the pt providing o2 therapy, have an AED placed, and getting a baseline set of vitals on their pt that is currently lying in the "recovery position". The pt is an elderly female that is probably a GCS of 9-10 at the moment. But with each passing minute, she is increasing her GCS and will eventually be at 15 and a/o x3ish. All the hard work was done by the PSOs on scene. And they did a fantastic job. They saved this woman's life. Now let me paint you a better picture of what happened before we arrived on scene.
The PSOs received a call for one choking. When they arrived there was a family member that was attempting to do the Heimlich but was not ever successful. The officers tried and the pt became unresponsive. After laying the pt on to the ground they were able to yank out a large wad of pizza and start ventilating the pt with the BVM and some high flow oxygen. They said they bagged her for about a minute or two before she started coming around and breathing on her own. This is a great example of how simple BLS maneuvers can save a life. This "young lady" was very fortunate to have survived such a traumatic ordeal. Kudos to the PSOs and the fantastic job they did in saving this woman's life.
As I said earlier, they did all the hard work and saved her life. All we did was take her to the hospital. But it was nice to be part of the team. The family was very appreciative and I am happy that they have their "grandma"around for a while longer. We[EMS] always strive to be the hero, unfortunately we usually end up having to be the bearer of bad news. However, this was certainly one we can put in the win column between us and the reaper. The score on the other side is always higher, but it doesn't mean we will ever stop trying. Now on to the next adventure in public safety. Bye for now.
Monday, October 10, 2011
And it just kept coming...
So recently, I have been working a steady schedule of rescue and it seems as though my partner and I will work an arrest every shift. Good practice, I guess. This call was a bit of a mess though. Mainly because of the thick viscous and sometimes chunky (gravy-ish consistency) fluid that was pouring out of his airway that never really stopped. I mean it looked as though there was a good liter of it next to his head when all was said and done.Gross! Now let me paint you a better picture of the situation.
My partner and I first get the call for someone bleeding. No specific reason why this person is hemorrhaging or where the blood is coming from. So we get there just as the local FD is applying the AED pads. "NO SHOCK ADVISED. BEGIN CPR" is heard through the doorway. As we walking we see a middle aged pt with black-ish fluid/stuff on his face and in his mouth. So we quickly switch the AED pads over to our monitor thinking that this will be an easy pronouncement, and the monitor says...PEA. Great. So we start CPR in this very cluttered and cramped bed room and start the process of ACLS care.
Now I am at the head of the pt and start to work on managing the airway. This putrid black liquid just keeps coming out of his mouth. It clogs up the suction machine several times and I even had to pull off the yaunkauer off and just use the tubing from time to time. Bagging is basically impossible right now. Repositioning, suctioning, and BLS maneuvers were not giving us good chest rise. As I said earlier, this fluid just keeps coming. So while I am continuing to stain the carpet with this horrible death gravy, my partner is getting a line, a CBG, and pushing drugs. The pt is still in PEA so mostly just epi after epi. We did find out that the pt had a CBG of 60mg/dL. We corrected that with no change in status.
Great CPR is being done right now and the airway is still not clear. So I guess better now then never, I attempt to find what might possibly be chords in the sea of black that is still coming out of this persons mouth. Nothing. Try to bag again with basic airway adjuncts and more suctioning. Still nothing. I try one more time as the FD is getting a combi tube ready. Again nothing. Better drop the humility airway (hate to admit it, but medics sometimes have to put their ego aside to place the most appropriate airway. Me included). So the airway is placed and immediately black garbage pops out of the top of both tubes. Again, gross! So suction and more suction to both tubes just to be able to use the damn thing. Finally we get the tubes clear and the correct one receiving positive pressure ventilation. Which still needs a bit more suction. Ugh!
ACLS protocol is still being followed and we are reaching a point where we should terminate resuscitation. We call the local hospital and don't get any crazy orders this time before calling the code. Time of death, right meow. Now we have to break the news to the family.
Don't ask me why I said I would do it, but I did and I feel I did an especially bad job at it. Now I have done these many times and have had to break the news to family. But for some reason, I think I just F'd this one up. I was to the point and didn't use euphemisms but it just didn't go well. I will spare the details, but I need to look at this as a learning experience.
So we finally clear and clean our truck and get a new drug box. Just to reiterate, messiest code ever. Ugh!
My partner and I first get the call for someone bleeding. No specific reason why this person is hemorrhaging or where the blood is coming from. So we get there just as the local FD is applying the AED pads. "NO SHOCK ADVISED. BEGIN CPR" is heard through the doorway. As we walking we see a middle aged pt with black-ish fluid/stuff on his face and in his mouth. So we quickly switch the AED pads over to our monitor thinking that this will be an easy pronouncement, and the monitor says...PEA. Great. So we start CPR in this very cluttered and cramped bed room and start the process of ACLS care.
Now I am at the head of the pt and start to work on managing the airway. This putrid black liquid just keeps coming out of his mouth. It clogs up the suction machine several times and I even had to pull off the yaunkauer off and just use the tubing from time to time. Bagging is basically impossible right now. Repositioning, suctioning, and BLS maneuvers were not giving us good chest rise. As I said earlier, this fluid just keeps coming. So while I am continuing to stain the carpet with this horrible death gravy, my partner is getting a line, a CBG, and pushing drugs. The pt is still in PEA so mostly just epi after epi. We did find out that the pt had a CBG of 60mg/dL. We corrected that with no change in status.
Great CPR is being done right now and the airway is still not clear. So I guess better now then never, I attempt to find what might possibly be chords in the sea of black that is still coming out of this persons mouth. Nothing. Try to bag again with basic airway adjuncts and more suctioning. Still nothing. I try one more time as the FD is getting a combi tube ready. Again nothing. Better drop the humility airway (hate to admit it, but medics sometimes have to put their ego aside to place the most appropriate airway. Me included). So the airway is placed and immediately black garbage pops out of the top of both tubes. Again, gross! So suction and more suction to both tubes just to be able to use the damn thing. Finally we get the tubes clear and the correct one receiving positive pressure ventilation. Which still needs a bit more suction. Ugh!
ACLS protocol is still being followed and we are reaching a point where we should terminate resuscitation. We call the local hospital and don't get any crazy orders this time before calling the code. Time of death, right meow. Now we have to break the news to the family.
Don't ask me why I said I would do it, but I did and I feel I did an especially bad job at it. Now I have done these many times and have had to break the news to family. But for some reason, I think I just F'd this one up. I was to the point and didn't use euphemisms but it just didn't go well. I will spare the details, but I need to look at this as a learning experience.
So we finally clear and clean our truck and get a new drug box. Just to reiterate, messiest code ever. Ugh!
Monday, October 3, 2011
48 hour shift....why did I think this was a good idea again?
When I was in the military, I was always busy. I worked in the ER, was a preceptor for the medic students, ACLS/BLS/EMT instructor, etc, etc, etc. I thought I would be less busy when I got out of the military and only had to work and go to school. Turns out I was wrong. My need to be constantly busy has made me a glutton for over time. Hence why I just worked 60 hour this past weekend. I did a 12 on Friday and then a 48 from Saturday to Monday morning.
So I was a bit tired at the half way mark with my 48. We didn't get a lot of sleep but we didn't have that many calls. I guess that is the silver lining right there. The back half of my 48 however, was a different story. I think we ran 8 or 9 calls and most of them were a bit of a challenge for some reason. We had the diabetic with a sugar of "low" that was a bit of a vascular challenge that ended up getting a 24g in his thumb to get the wake up juice, a chest painer with a serious case of denial, and to top it all off, a cardiac arrest.
The arrest was a bit of a mess. Well, more so normal. It was a witnessed arrest with a short downtime. However, the presenting rhythm was asystole. We work the code per protocol. I had trouble getting the tube and had to stop, bag, suction, and try again. I got it on the second try but I was having a bit of trouble getting the tube past the chords, but we made it happen. The initial EtC02 was not too bad for an arrest (25mmHg) but there was a lot of fluid in the lungs and it compromised the detector. We had good chest rise and fall, colormetric changes (go for the gold), and no sounds over the epigastric area. The tube was in, but there was just a lot of stuff that needed to be either in the suction container or on the floor.
Oh and this pt was another vascular nightmare. No EJs, my partner bent the I/O needle (probably is own endogenous catacholamine circulation), and so on. One of our friendly neighborhood fire fighters got the line. Thanks man, we always appreciate the help. So 6 rounds of drugs later the pt is in a sinus PEA at a rate of 75. We have exhausted all of our options and made the call to medical direct if they want us to transport the pt or not. The result of that conversation was "time of death 0'dark-30". Surprised this MD didn't have me do bilateral needle decompressions again.
It was now time for the worst part of my job, breaking bad news. I would much rather work arrests and transport them just to avoid such difficult situation. However, that would not be safe for the crew, beneficial to the pt, or the family most of the time. However, in order to be a true professional, one must step outside of his or her comfort zone and do the appropriate thing. In this situation you have to be blunt and not use terms like "passed away", "no longer with us", or "is in a better place". You need to be clear and say "your loved one is dead". Then we have the horrible task of having to get signatures and insurance information. I hate that part of the job. Ugh!
After all of that, the second worst part of working an arrest is the paperwork involved and the clean up. Usually the clean up is faster than documentation. Our new e-pcr software can be very time consuming with involved calls like this. Usually putting all the drugs/interventions in chronological order is the most time consuming. I did use my full code IPhone app for this code and it really helped out. It helped us to swap out CPR providers and kept good track of our ALS interventions. So it helped cut down on documentation time.
Overall, I am (probably) not going to work a 48 again anytime soon. Oh well, clean the truck, write the report, and get 10-8 as soon as possible. Off to the next adventure.
So I was a bit tired at the half way mark with my 48. We didn't get a lot of sleep but we didn't have that many calls. I guess that is the silver lining right there. The back half of my 48 however, was a different story. I think we ran 8 or 9 calls and most of them were a bit of a challenge for some reason. We had the diabetic with a sugar of "low" that was a bit of a vascular challenge that ended up getting a 24g in his thumb to get the wake up juice, a chest painer with a serious case of denial, and to top it all off, a cardiac arrest.
The arrest was a bit of a mess. Well, more so normal. It was a witnessed arrest with a short downtime. However, the presenting rhythm was asystole. We work the code per protocol. I had trouble getting the tube and had to stop, bag, suction, and try again. I got it on the second try but I was having a bit of trouble getting the tube past the chords, but we made it happen. The initial EtC02 was not too bad for an arrest (25mmHg) but there was a lot of fluid in the lungs and it compromised the detector. We had good chest rise and fall, colormetric changes (go for the gold), and no sounds over the epigastric area. The tube was in, but there was just a lot of stuff that needed to be either in the suction container or on the floor.
Oh and this pt was another vascular nightmare. No EJs, my partner bent the I/O needle (probably is own endogenous catacholamine circulation), and so on. One of our friendly neighborhood fire fighters got the line. Thanks man, we always appreciate the help. So 6 rounds of drugs later the pt is in a sinus PEA at a rate of 75. We have exhausted all of our options and made the call to medical direct if they want us to transport the pt or not. The result of that conversation was "time of death 0'dark-30". Surprised this MD didn't have me do bilateral needle decompressions again.
It was now time for the worst part of my job, breaking bad news. I would much rather work arrests and transport them just to avoid such difficult situation. However, that would not be safe for the crew, beneficial to the pt, or the family most of the time. However, in order to be a true professional, one must step outside of his or her comfort zone and do the appropriate thing. In this situation you have to be blunt and not use terms like "passed away", "no longer with us", or "is in a better place". You need to be clear and say "your loved one is dead". Then we have the horrible task of having to get signatures and insurance information. I hate that part of the job. Ugh!
After all of that, the second worst part of working an arrest is the paperwork involved and the clean up. Usually the clean up is faster than documentation. Our new e-pcr software can be very time consuming with involved calls like this. Usually putting all the drugs/interventions in chronological order is the most time consuming. I did use my full code IPhone app for this code and it really helped out. It helped us to swap out CPR providers and kept good track of our ALS interventions. So it helped cut down on documentation time.
Overall, I am (probably) not going to work a 48 again anytime soon. Oh well, clean the truck, write the report, and get 10-8 as soon as possible. Off to the next adventure.
Thursday, September 29, 2011
Top 5 things not to get stuck in your airway
I had a call recently where I had to use a pair of magill forceps to clear out a patients airway. The call was also a bit of a challenge because the pt had a valid DNR/DNI and we were only able to provide supportive care. Nothing super ALCS or BLS other than suctioning, removing the obstructions, and BVM ventilation.
At any rate, it got me thinking about a few things I have read about, heard from other medics, and have seen in my time in medicine. I understand that just about anything can be an airway obstruction, but these are the ones that stuck with me. Here they are in order of worst to not as bad.
1.) Gel caps
I heard about this from JEMS magazine and it was probably the worst call the responding crew had to deal with. I will spare the details of the call, but it is important to note that once gel caps (pills) get wet or come in contact with wet surfaces, they can become very sticky if they are not allowed to completely dissolve. Imagine that in the airway of child. It can and will completely occlude the airway making an immovable obstruction and cementing the airway shut. No bueno. I have to say thank you to JEMS for the teaching moment on that one.
2.) Watermelon
I bet you were not thinking about that. A nurse friend of mine told me a story of a patient took care of that choked on some watermelon. Think about the flesh of a watermelon for a minute. It's fairly soft and mostly fluid. The problem with that is that once it becomes lodged in a confined space, like in someone's airway, you will have a heck of a time pulling it out. If you try and pull it out with your trusty magills, it will just fall apart. The one good thing about it (from my point of view) is that you might be able to push an ETT through it to initially get the airway some what open. Still a nasty situation.
3.) PB&J
This was my pt. They were eating a PB&J sandwich and started choking. The problem with PB&J is that once it gets all mushed together with saliva and what not, it forms a very thick paste. It looked similar to a hair ball the cat I had as a kid coughed up. The other bad thing about this is particular hazard is that it conforms to the shape of the airway very well and can pile up quickly and compact well completely occluding the airway. Another problem I see with it is that if you do the himlech, it has enough play where it could expand with the increased pressure from abdominal thrusts and not actually move out of the airway. The one good thing about this is that it can be removed fairly easily with magills and direct laryngoscopy if you get there in time.
4.)Bananas
This choking hazard shares a similar shape of the airway and can occlude it easily if it fell into the trachea. The good thing about bananas, (other than the fact that they are high in potassium) is that they can be broken up easily and pushed down into the airway and at one lung can be ventilated until definitive care can be started. Pulling out an overly ripe banana with forceps may be an exercise in futility since it may not have enough structure to it to be pulled out in one or two pieces.
5.) Hotdogs
If/when I have kids I don't want to give them hotdogs. Not because of the risk of developing HTN and all other sorts of badness, but because a hotdog cut up in to coins or medallions is perfect for occluding an airway. Sure a whole hotdog can do this too, but most people don't eat hotdogs like they owe them money. They are a bit easier to remove because they usually stay intact and do not break apart as easily as the previously mentioned foods. Still bad, but a bit more manageable.
I think that this was the first time I did a "top 5" or so post. I don't expect to be doing that very often, or even again. But you never know.
At any rate, it got me thinking about a few things I have read about, heard from other medics, and have seen in my time in medicine. I understand that just about anything can be an airway obstruction, but these are the ones that stuck with me. Here they are in order of worst to not as bad.
1.) Gel caps
I heard about this from JEMS magazine and it was probably the worst call the responding crew had to deal with. I will spare the details of the call, but it is important to note that once gel caps (pills) get wet or come in contact with wet surfaces, they can become very sticky if they are not allowed to completely dissolve. Imagine that in the airway of child. It can and will completely occlude the airway making an immovable obstruction and cementing the airway shut. No bueno. I have to say thank you to JEMS for the teaching moment on that one.
2.) Watermelon
I bet you were not thinking about that. A nurse friend of mine told me a story of a patient took care of that choked on some watermelon. Think about the flesh of a watermelon for a minute. It's fairly soft and mostly fluid. The problem with that is that once it becomes lodged in a confined space, like in someone's airway, you will have a heck of a time pulling it out. If you try and pull it out with your trusty magills, it will just fall apart. The one good thing about it (from my point of view) is that you might be able to push an ETT through it to initially get the airway some what open. Still a nasty situation.
3.) PB&J
This was my pt. They were eating a PB&J sandwich and started choking. The problem with PB&J is that once it gets all mushed together with saliva and what not, it forms a very thick paste. It looked similar to a hair ball the cat I had as a kid coughed up. The other bad thing about this is particular hazard is that it conforms to the shape of the airway very well and can pile up quickly and compact well completely occluding the airway. Another problem I see with it is that if you do the himlech, it has enough play where it could expand with the increased pressure from abdominal thrusts and not actually move out of the airway. The one good thing about this is that it can be removed fairly easily with magills and direct laryngoscopy if you get there in time.
4.)Bananas
This choking hazard shares a similar shape of the airway and can occlude it easily if it fell into the trachea. The good thing about bananas, (other than the fact that they are high in potassium) is that they can be broken up easily and pushed down into the airway and at one lung can be ventilated until definitive care can be started. Pulling out an overly ripe banana with forceps may be an exercise in futility since it may not have enough structure to it to be pulled out in one or two pieces.
5.) Hotdogs
If/when I have kids I don't want to give them hotdogs. Not because of the risk of developing HTN and all other sorts of badness, but because a hotdog cut up in to coins or medallions is perfect for occluding an airway. Sure a whole hotdog can do this too, but most people don't eat hotdogs like they owe them money. They are a bit easier to remove because they usually stay intact and do not break apart as easily as the previously mentioned foods. Still bad, but a bit more manageable.
I think that this was the first time I did a "top 5" or so post. I don't expect to be doing that very often, or even again. But you never know.
Monday, September 26, 2011
555 and some unexpected orders.
So a couple of things today. First of, as a "part timer" I have run 555 calls to date. I will not go into the who, what, when, where, or why that number was brought up, but it is still an interesting bit of information.
Now for what I feel is the more interesting topic of one of my latest rescue shifts. We were busy pretty much all day. I didn't even have a chance to eat until about 6pm. I ended up getting pad tai. Now I am not sure if it really was that delicious or I was that hungry, but man was it good. I will have to hit that place up again. Anyway, as I digress...we finally get back to the station around 9pm. Just in time to watch an episode of American Dad and grab some shut eye.
Unfortunately, the tones go off about an hour and change later for "one unresponsive" in our coverage area. So we hop in our trusty rescue truck and roll out priority one. En route we hear over the radio via the FD radio that we have a priority one patient and that CPR was in progress. Great. So I start going though the protocols and algorithms in my head and start my documentation as best I can before we arrive on scene.
Quick question here, why is it that most people die on the toilet? I'm not trying to be disrespectful or callous, but I have been doing this long enough to have run into that situation more than I would like to admit. At any rate, good CPR/BLS care is being provided by one of my favorite FDs in a cramped little bathroom in a nice clean little home to a run of the mill retired medicare recipient. They have also placed a combitube. Not my favorite airway, but hey it was working and it didn't perforate the trachea. Works for me. Oh and the AED stated "no shock advised". PEA at a rate of 50 in what appeared to be a junctional-ish rhythm.
So the ABC's of BLS care are all taken care of. Now it is time for some ALS interventions.With such cramped conditions, starting the IV was a bit of a backwards affair. I placed a 14g EJ. Partially because I could and partially because I could justify it for the resuscitation attempt. So the line is good and we get our first epi on board and swap out our CPR pumpers (thanks again guys). As we go we hook up the EtCo2 monitor to the combitube and get a reading of 25. Not bad. Since this was a pseudo witnessed arrest with minimal down time, I could see this possibly being a case that we transport.
As time goes on and epi after epi is pushed and people are switching out to do CPR, we start to reach the point where we should probably terminate resusitative efforts. After all, five epis is a lot. So I get medical control on the phone at one of our friendly neighborhood ERs and give them the scoop. Old person, down approx. 10 prior to EMS arrival with 30min of ACLS care and no ROSC at any point. The pt was still in PEA which was kind of odd. I am attributing that to the short down time. So the doc orders 2 amps of Bicarb and an amp of Calcium chloride. OK, I could see that. I would probably tried it anyway. Then came the order out of left field.
The MD asked me to do bilateral needle decompressions and let him know what the response was in 5 minutes. He would stay on the line. It was a bit odd having the phone to my ear and actively running a code at the same time. So the needles are place in the 2nd intercostal space at the mid-clavicular line and no drastic rush of air is noted. Conclusion, no pneumos. The pt is still in PEA at a rate of 30 in the same junctional-ish rhythm. I was surprised to have him call it at that point and not request us to transport. So we discontinued resusitative efforts at that point and printed our final strip (asystole) and broke the news to the family. They were very understanding. My heart goes out to them.
I have to say it was a bit of surprise to have such a stubborn arrest pt that never went into v-fib. We then spent the next hour and change cleaning up the truck and finishing the documentation for our code. Goes to show you that you never know what will happen on call or in a code for that matter. Until next time.
Now for what I feel is the more interesting topic of one of my latest rescue shifts. We were busy pretty much all day. I didn't even have a chance to eat until about 6pm. I ended up getting pad tai. Now I am not sure if it really was that delicious or I was that hungry, but man was it good. I will have to hit that place up again. Anyway, as I digress...we finally get back to the station around 9pm. Just in time to watch an episode of American Dad and grab some shut eye.
Unfortunately, the tones go off about an hour and change later for "one unresponsive" in our coverage area. So we hop in our trusty rescue truck and roll out priority one. En route we hear over the radio via the FD radio that we have a priority one patient and that CPR was in progress. Great. So I start going though the protocols and algorithms in my head and start my documentation as best I can before we arrive on scene.
Quick question here, why is it that most people die on the toilet? I'm not trying to be disrespectful or callous, but I have been doing this long enough to have run into that situation more than I would like to admit. At any rate, good CPR/BLS care is being provided by one of my favorite FDs in a cramped little bathroom in a nice clean little home to a run of the mill retired medicare recipient. They have also placed a combitube. Not my favorite airway, but hey it was working and it didn't perforate the trachea. Works for me. Oh and the AED stated "no shock advised". PEA at a rate of 50 in what appeared to be a junctional-ish rhythm.
So the ABC's of BLS care are all taken care of. Now it is time for some ALS interventions.With such cramped conditions, starting the IV was a bit of a backwards affair. I placed a 14g EJ. Partially because I could and partially because I could justify it for the resuscitation attempt. So the line is good and we get our first epi on board and swap out our CPR pumpers (thanks again guys). As we go we hook up the EtCo2 monitor to the combitube and get a reading of 25. Not bad. Since this was a pseudo witnessed arrest with minimal down time, I could see this possibly being a case that we transport.
As time goes on and epi after epi is pushed and people are switching out to do CPR, we start to reach the point where we should probably terminate resusitative efforts. After all, five epis is a lot. So I get medical control on the phone at one of our friendly neighborhood ERs and give them the scoop. Old person, down approx. 10 prior to EMS arrival with 30min of ACLS care and no ROSC at any point. The pt was still in PEA which was kind of odd. I am attributing that to the short down time. So the doc orders 2 amps of Bicarb and an amp of Calcium chloride. OK, I could see that. I would probably tried it anyway. Then came the order out of left field.
The MD asked me to do bilateral needle decompressions and let him know what the response was in 5 minutes. He would stay on the line. It was a bit odd having the phone to my ear and actively running a code at the same time. So the needles are place in the 2nd intercostal space at the mid-clavicular line and no drastic rush of air is noted. Conclusion, no pneumos. The pt is still in PEA at a rate of 30 in the same junctional-ish rhythm. I was surprised to have him call it at that point and not request us to transport. So we discontinued resusitative efforts at that point and printed our final strip (asystole) and broke the news to the family. They were very understanding. My heart goes out to them.
I have to say it was a bit of surprise to have such a stubborn arrest pt that never went into v-fib. We then spent the next hour and change cleaning up the truck and finishing the documentation for our code. Goes to show you that you never know what will happen on call or in a code for that matter. Until next time.
Thursday, September 22, 2011
Of all the words to say...
The other day I was working the back half of a rescue shift at one of our out stations. It was looking as though we were going to end up with a "no hitter". In other words, no calls. Our one and only call was about 10 hours into the shift at 0400. Of course it was. Why wouldn't be?
So my partner and I are dispatched priority one for a "man down". Don't get too excitied. That could be everything from a cough to a cardiac arrest. Usually they are something in between and they usually have medicare and want to be taken to the hospital. We are enroute to the location of the call when a little bit more information is given to us by that little black box that likes to tell us what to do. Apparently our pt has been lying in bed for an extended period of time (days) but is conscious and breathing. Great. We might as well down grade to a priority 3 at this point.
Upon arrival we find the typical disheveled house with way too much um...stuff all over the place that is an all too common setting for a majority of our calls in the area. Or pt is indeed conscious and has been in the same place for at least 12 hours. However, this pt was not answering questions and appeared confused. So we do the typical ALS assessment stuff. ECG, BP, SPO2, CBG, and so on. Turns out the pt was tachycardic (135 bpm) and borderline hypotensive (90ish/60ish) and was breathing about 30/min. Oh and the sugar was normal. Now these findings as well as environment this pt was in supported the idea that they were indeed lying in bed for about a day or more. Also upon further investigation, the pt is a chronic abuser of ETOH and it usually exacerbates bouts of pancreatitis. But the pt has yet to say a word to me other than a few mumbling of what I am certain were requests to turn on the Tivo'd NASCAR race.
So after some creative manuvering of a stairchair by the FD on scene we get our pt out into the truck for transport and further care. The pt was a bit of a vascular challenge, but not the worst I have ever seen. Mean while the pt is still watching me the whole time and is pseudo cooperative. So our emaciated ETOH abuser was the now the proud owner of an antecubital intravenous line with some NACL going to hopefully bring down that heart rate a bit. As soon as the IV is in, suddenly I get a request for dilaudid. Umm...Really? You don't say a damn thing to me the entire time you are under my care and then suddenly "can I have some drugs"?
Now I don't want to sound like I am with holding pain meds to someone that needs them. However, if you are not going to talk to me the entire time and not even answer questions like "Are you in pain", "does this hurt [pushes on abdomen]", or "on a scale of 1-10, what is your pain" then I cannot just assume you are hurting and send you off into La-La land.
The rest of the transport was uneventful and we transport her to the local hospital. I don't want to sound bitter, but the whole time I kept asking myself "I had to get up for this"? Just another day in the life...
So my partner and I are dispatched priority one for a "man down". Don't get too excitied. That could be everything from a cough to a cardiac arrest. Usually they are something in between and they usually have medicare and want to be taken to the hospital. We are enroute to the location of the call when a little bit more information is given to us by that little black box that likes to tell us what to do. Apparently our pt has been lying in bed for an extended period of time (days) but is conscious and breathing. Great. We might as well down grade to a priority 3 at this point.
Upon arrival we find the typical disheveled house with way too much um...stuff all over the place that is an all too common setting for a majority of our calls in the area. Or pt is indeed conscious and has been in the same place for at least 12 hours. However, this pt was not answering questions and appeared confused. So we do the typical ALS assessment stuff. ECG, BP, SPO2, CBG, and so on. Turns out the pt was tachycardic (135 bpm) and borderline hypotensive (90ish/60ish) and was breathing about 30/min. Oh and the sugar was normal. Now these findings as well as environment this pt was in supported the idea that they were indeed lying in bed for about a day or more. Also upon further investigation, the pt is a chronic abuser of ETOH and it usually exacerbates bouts of pancreatitis. But the pt has yet to say a word to me other than a few mumbling of what I am certain were requests to turn on the Tivo'd NASCAR race.
So after some creative manuvering of a stairchair by the FD on scene we get our pt out into the truck for transport and further care. The pt was a bit of a vascular challenge, but not the worst I have ever seen. Mean while the pt is still watching me the whole time and is pseudo cooperative. So our emaciated ETOH abuser was the now the proud owner of an antecubital intravenous line with some NACL going to hopefully bring down that heart rate a bit. As soon as the IV is in, suddenly I get a request for dilaudid. Umm...Really? You don't say a damn thing to me the entire time you are under my care and then suddenly "can I have some drugs"?
Now I don't want to sound like I am with holding pain meds to someone that needs them. However, if you are not going to talk to me the entire time and not even answer questions like "Are you in pain", "does this hurt [pushes on abdomen]", or "on a scale of 1-10, what is your pain" then I cannot just assume you are hurting and send you off into La-La land.
The rest of the transport was uneventful and we transport her to the local hospital. I don't want to sound bitter, but the whole time I kept asking myself "I had to get up for this"? Just another day in the life...
Monday, September 5, 2011
The good, the bad, and the very ugly.
Being a paramedic is not all intubation and cardioversion. However, every day on the job is different. And unfortunately, every time you put on the uniform you have the possibility to be one of the first people on the scene of something horrific. Thankfully everyday is not like that, but there is always the possibility of it.
For example, I was working rescue recently when my partner and I were dispatched for a cardiac arrest. As odd as this may sound, it was really no big deal. Working an arrest is fairly routine but does make for tense situations and has it's own sets of challenges. On our way there we hear the FD state over the radio that the situation is under control and all other responding units can downgrade. This usually is done for a person that has been down for a very long period of time or injuries that are incompatible with life. Like a GSW to the head. Now I know what you're thinking..."A GSW to the head does not always mean obvious death". And you are correct. However, when the top of the pts skull is on the roof of the house they were found leaning against and their parietal lobe was exposed and lying on the ground, it usually means resusitative efforts would be futile. And this particular incident was self inflicted...with a shotgun. Now I am no ballistics expert, but there is a simple equation that 99.9% of the time holds true. [Fire arm + Face or mouth = Death]. Call it being cavalier about the situation, but the damage done, whether it be fatal or not is still pretty catastrophic.
At any rate, it was an easy call. Just a quick phone call to medical control to obtain a time of death and then document the whole thing. As with most cardiac arrests, the documentation takes longer than the actual resusitative efforts. Or in this case, the pronouncement.
For example, I was working rescue recently when my partner and I were dispatched for a cardiac arrest. As odd as this may sound, it was really no big deal. Working an arrest is fairly routine but does make for tense situations and has it's own sets of challenges. On our way there we hear the FD state over the radio that the situation is under control and all other responding units can downgrade. This usually is done for a person that has been down for a very long period of time or injuries that are incompatible with life. Like a GSW to the head. Now I know what you're thinking..."A GSW to the head does not always mean obvious death". And you are correct. However, when the top of the pts skull is on the roof of the house they were found leaning against and their parietal lobe was exposed and lying on the ground, it usually means resusitative efforts would be futile. And this particular incident was self inflicted...with a shotgun. Now I am no ballistics expert, but there is a simple equation that 99.9% of the time holds true. [Fire arm + Face or mouth = Death]. Call it being cavalier about the situation, but the damage done, whether it be fatal or not is still pretty catastrophic.
At any rate, it was an easy call. Just a quick phone call to medical control to obtain a time of death and then document the whole thing. As with most cardiac arrests, the documentation takes longer than the actual resusitative efforts. Or in this case, the pronouncement.
Friday, September 2, 2011
Gotta love unannounced protocol change...
Since April, the area that I currently run ALS in has revamped their protocols and added a few new drugs to our advanced life support arsenal. Normally I am all for this sort of growth/change in an EMS system. However, I don't think that this should be slipped in under the radar and no one being told of the change. Granted, I understand that it is the responsibility of the EMT-Whatever to know their local protocol. However, I think if there are changes, especially substantial ones, that there should be some sort of notice. Now, with that being said let me tell you about my latest ALS adventure...
So we were dispatched to an elderly female with abdominal pain. Let me just say this now, I hate abdominal pain calls. Most of the time dispatch and the pt might as well just say "I don't know what's wrong, just take me to the hospital". Mainly because it could be so many different thing and a large majority of the time we can't do much about it. This call was the exception to my previous ranting. Anyway, as I digress...we arrive on scene to find a very sweet little old lady that has called everyone she has encountered from the time she was 50 either "honey" or "sweetie". I have definitely been called worse, so no big deal there. But this poor medicare beneficiary says she has been feeling weak and had some belly pain since last night. Its mid morning at this point. That will be important later. So we do the usual IV, O2, and monitor. This revealed a relatively hypertensive pt with an irregular heart rate between 180-209. No wonder she has been feeling weak. There were several follow up questions to which the pt looked at us blankly or answered no. One of which was, "Do you have A-fib?" to which I received a blank stare. Gotta love that. I guess if you don't have anything nice to say, don't say anything at all. Or in this case, if you don't know the answer, don't say a damn thing.
Now that we have a better picture of what is going on, we decided to start treatment in the back of the truck. That gave the FD time to get the pt loaded up and my partner and I time to get the meds, tubing, and math ready. The only medicine we have that can be used to treat A-Fib with RVR is Amiodarone. The funny thing with that is that using it for treatment in this such scenario is considered "off label". However, after 150mg over 10 minutes she went from tachy and irregular to tachy and sinus and eventually normal sinus. We were not too concerned about the whole clot thing due to the time in which her symptoms started.
She did fine for the rest of the trip to the hospital and on our subsequent return trips, she was still in normal sinus rhythm and doing well. Gotta love it when you have a positive outcome on calls like that. No big rants, insights, or epiphanies in this post. Just sharing a war story.
So we were dispatched to an elderly female with abdominal pain. Let me just say this now, I hate abdominal pain calls. Most of the time dispatch and the pt might as well just say "I don't know what's wrong, just take me to the hospital". Mainly because it could be so many different thing and a large majority of the time we can't do much about it. This call was the exception to my previous ranting. Anyway, as I digress...we arrive on scene to find a very sweet little old lady that has called everyone she has encountered from the time she was 50 either "honey" or "sweetie". I have definitely been called worse, so no big deal there. But this poor medicare beneficiary says she has been feeling weak and had some belly pain since last night. Its mid morning at this point. That will be important later. So we do the usual IV, O2, and monitor. This revealed a relatively hypertensive pt with an irregular heart rate between 180-209. No wonder she has been feeling weak. There were several follow up questions to which the pt looked at us blankly or answered no. One of which was, "Do you have A-fib?" to which I received a blank stare. Gotta love that. I guess if you don't have anything nice to say, don't say anything at all. Or in this case, if you don't know the answer, don't say a damn thing.
Now that we have a better picture of what is going on, we decided to start treatment in the back of the truck. That gave the FD time to get the pt loaded up and my partner and I time to get the meds, tubing, and math ready. The only medicine we have that can be used to treat A-Fib with RVR is Amiodarone. The funny thing with that is that using it for treatment in this such scenario is considered "off label". However, after 150mg over 10 minutes she went from tachy and irregular to tachy and sinus and eventually normal sinus. We were not too concerned about the whole clot thing due to the time in which her symptoms started.
She did fine for the rest of the trip to the hospital and on our subsequent return trips, she was still in normal sinus rhythm and doing well. Gotta love it when you have a positive outcome on calls like that. No big rants, insights, or epiphanies in this post. Just sharing a war story.
Sunday, August 21, 2011
Extrication via a slide
Yup. That's right you heard me. We "extricated" someone via a slide. Now let me paint you a better picture...
I was on what was the beginning of a very busy 24 hour shift when my partner and I get a call for a teeny-bopper having a seizure. So this is not the type of call that as one of my fellow medics puts it, a "red cabinet call". You know, the red cabinet that says "only for emergencies" and requires two keys to be turned simultaneously to be opened, and for some reason there is a man standing next to it with a briefcase hand cuffed to his wrist. That kind of call.
Anyway, as I digress...we arrive on scene with the local FD on scene doing their BLS thing for this pt who was in obvious distress. This kid was A/O x 0 and was unresponsive. Still a pretty vanilla scenario. It gets better. For some reason this kid in his early teens was at the top of a slide on a children's playground when he decided to just not respond anymore and start twitching. There were some concerns as to how we should get him down from this monument to the recess period. A few of the guys wanted to get this kid on to a back board and off the top of the slide. Oh, side note ... this "kid" weighed more than me. He was a good 200 lbs. Ok, back to the story. Our "fluffy" teen was unresponsive to pain, breathing approx. 20/min and appeared to be contracted in all extremities. But since he was at the top of the slide, I decided it was best/easiest on everyone if we just slid him down it. So after some careful maneuvering, we got him from the top of the slide onto our gurney with me at his feet making sure he didn't go to fast or over the sides. After all, he was a big boy.
So we get him onto our gurney and do the usual IV, O2, monitor, v/s protocol. This poor kid was tachy, hypertensive, and contracted. When I say tachy, I mean really tachy. Like 190-200. Not SVT, but seriously over stimulated. Oh and his pressure was 180/100. So we get the fluid going and a phone call to the local hospital for some good old fashion online medical direction. I tell them what I got and ask for an order of Valium to help calm him down. Again, I was pleasantly surprised to find a cooperative physician. So the pt gets a dose of 5mg of IV Valium and shortly there after he relaxes his extremities and slows his breathing down to a more acceptable rate and depth. Still unresponsive to pain at this point but his V/S are starting to calm the #$%@ down.
We continue our transport and reassess frequently with a gradual return to baseline. He never got there for us but a few minutes in the resus room and he was talking again. And of course, he had no idea what happened and never took anything a day in his life. But before he started talking, as we rolled into resus we move him over to the bed and his IV gets pulled. WTF? Really? I guess it was better than pulling a central line on a CCT transfer. Just saying...
Anyway, as it turns out he finally admits to using K2 or Spice earlier. I have to say nothing about that stuff sounds appealing. I guess it is easy to get so kids will use it and brag about it. Nothing like being tachycardic, hypertensive, contracting, and being completely out if that sounds like a good time.
I was on what was the beginning of a very busy 24 hour shift when my partner and I get a call for a teeny-bopper having a seizure. So this is not the type of call that as one of my fellow medics puts it, a "red cabinet call". You know, the red cabinet that says "only for emergencies" and requires two keys to be turned simultaneously to be opened, and for some reason there is a man standing next to it with a briefcase hand cuffed to his wrist. That kind of call.
Anyway, as I digress...we arrive on scene with the local FD on scene doing their BLS thing for this pt who was in obvious distress. This kid was A/O x 0 and was unresponsive. Still a pretty vanilla scenario. It gets better. For some reason this kid in his early teens was at the top of a slide on a children's playground when he decided to just not respond anymore and start twitching. There were some concerns as to how we should get him down from this monument to the recess period. A few of the guys wanted to get this kid on to a back board and off the top of the slide. Oh, side note ... this "kid" weighed more than me. He was a good 200 lbs. Ok, back to the story. Our "fluffy" teen was unresponsive to pain, breathing approx. 20/min and appeared to be contracted in all extremities. But since he was at the top of the slide, I decided it was best/easiest on everyone if we just slid him down it. So after some careful maneuvering, we got him from the top of the slide onto our gurney with me at his feet making sure he didn't go to fast or over the sides. After all, he was a big boy.
So we get him onto our gurney and do the usual IV, O2, monitor, v/s protocol. This poor kid was tachy, hypertensive, and contracted. When I say tachy, I mean really tachy. Like 190-200. Not SVT, but seriously over stimulated. Oh and his pressure was 180/100. So we get the fluid going and a phone call to the local hospital for some good old fashion online medical direction. I tell them what I got and ask for an order of Valium to help calm him down. Again, I was pleasantly surprised to find a cooperative physician. So the pt gets a dose of 5mg of IV Valium and shortly there after he relaxes his extremities and slows his breathing down to a more acceptable rate and depth. Still unresponsive to pain at this point but his V/S are starting to calm the #$%@ down.
We continue our transport and reassess frequently with a gradual return to baseline. He never got there for us but a few minutes in the resus room and he was talking again. And of course, he had no idea what happened and never took anything a day in his life. But before he started talking, as we rolled into resus we move him over to the bed and his IV gets pulled. WTF? Really? I guess it was better than pulling a central line on a CCT transfer. Just saying...
Anyway, as it turns out he finally admits to using K2 or Spice earlier. I have to say nothing about that stuff sounds appealing. I guess it is easy to get so kids will use it and brag about it. Nothing like being tachycardic, hypertensive, contracting, and being completely out if that sounds like a good time.
Sunday, July 31, 2011
Let's upgrade to a priority one.,,
The other day I was working one of the rescue station when we received a call for syncope. So we respond priority one to the local race track for someone who was probably betting on the ponies.
So we arrive to find our pt, a sixty-ish cantankerous male that actually would not let the FD even touch him before he dropped a deuce. I think the FD and my partner were a bit over zealous and followed the guy all the way to the stall and would have probably sat on his lap if he let them. So he does his business and walks out in a hurried and a "I can't be bothered" type of way but agrees for us to take a look at him.
The usual test/procedures are done. V/S, ecg, 12 lead, cbg. All which came back mostly normal. He didn't have any elevation or depression on 12 lead but tells us he was complaining of some heaviness in his chest. So we get an IV going and start the MONA protocol. Since he was stable with no ECG findings consistent with badness, I was comfortable with transporting him to the hospital of his choice that was a super hospital about 20 miles away.
While we are enroute I ask my pt about his pain, when it started, and how it feels. Getting answers out of this guy was like pulling teeth. He did not want to give up any information. Either he didn't know the answer or he was just in denial about the situation. At any rate, NTG number one had a slight affect on his BP. Nothing too exciting. 5 minutes later NTG number two is given and his pain feels different and he has the typical nitro headache. His pain is now going across his chest from left to right and his BP is 90/40-ish. He gets placed in "ambulance trendellenburg" and gets a fluid bolus. He had clear lungs, it's cool. But his BP continues to fall along with his heart rate and mental status. His v/s are now: BP 74/33, HR 30 and irregular, resp 12 and labored and he looks very ill. Now what?
Pacer pads! That's what. I get the pads out and put them on this guy and get ready to deliver some "Edison" transcutaneously. However, he converts back to a borderline Brady/sinus rhythm with a rate that goes from 56-61. When we got our initial vitals, he had a similar heart rate when he was pissed. Fluid resuscitation is still going at this point and his BP is still 70s/badness and serial 12 leads do not show any ST changes, flipped T waves, or ectopy. WTF? Oh and at this point we just passed the exit on the interstate that would take us to our parent hospital if we needed to divert to a closer facility. So we are committed to the long haul to the super hospital. I ask my partner to light it up and upgrade to a priority one because I don't want our pt to code. Granted we have an auto pulse on our truck but I don't want to use it.
I have to say, that stretch of interstate is bad luck for me. I had a pt with a subdural hematoma stop breathing on me on the way to the "D" from the boonies. Gotta love that.
At any rate, I call a head and give a quick report while I am trying to get a second IV. I tell all my students and new medics "Everyone misses IVs. It happens". It was my turn to miss that day. I tried twice while we were going priority one but no dice. He had good ones too. I was just off that day. Oh BTW, his pressure had reached pucker factor. It was 54/30! Heart rate was maintaining though. I hooked up a quick pressure bag and informed the pt what was happening.
Thankfully the boluses were finally working and his pressure was climbing. By the time we got to the super hospital his pressure had improved but I was still very concerned. We roll into the facility and I give report. And in true fashion of this place one of the RNs say question why we brought him in priority one. One even said "he doesn't look like a priority one pt". What the "F" ever! I'm just glad he was feeling better. It was an interesting call and a bit of a learning experience.
So we arrive to find our pt, a sixty-ish cantankerous male that actually would not let the FD even touch him before he dropped a deuce. I think the FD and my partner were a bit over zealous and followed the guy all the way to the stall and would have probably sat on his lap if he let them. So he does his business and walks out in a hurried and a "I can't be bothered" type of way but agrees for us to take a look at him.
The usual test/procedures are done. V/S, ecg, 12 lead, cbg. All which came back mostly normal. He didn't have any elevation or depression on 12 lead but tells us he was complaining of some heaviness in his chest. So we get an IV going and start the MONA protocol. Since he was stable with no ECG findings consistent with badness, I was comfortable with transporting him to the hospital of his choice that was a super hospital about 20 miles away.
While we are enroute I ask my pt about his pain, when it started, and how it feels. Getting answers out of this guy was like pulling teeth. He did not want to give up any information. Either he didn't know the answer or he was just in denial about the situation. At any rate, NTG number one had a slight affect on his BP. Nothing too exciting. 5 minutes later NTG number two is given and his pain feels different and he has the typical nitro headache. His pain is now going across his chest from left to right and his BP is 90/40-ish. He gets placed in "ambulance trendellenburg" and gets a fluid bolus. He had clear lungs, it's cool. But his BP continues to fall along with his heart rate and mental status. His v/s are now: BP 74/33, HR 30 and irregular, resp 12 and labored and he looks very ill. Now what?
Pacer pads! That's what. I get the pads out and put them on this guy and get ready to deliver some "Edison" transcutaneously. However, he converts back to a borderline Brady/sinus rhythm with a rate that goes from 56-61. When we got our initial vitals, he had a similar heart rate when he was pissed. Fluid resuscitation is still going at this point and his BP is still 70s/badness and serial 12 leads do not show any ST changes, flipped T waves, or ectopy. WTF? Oh and at this point we just passed the exit on the interstate that would take us to our parent hospital if we needed to divert to a closer facility. So we are committed to the long haul to the super hospital. I ask my partner to light it up and upgrade to a priority one because I don't want our pt to code. Granted we have an auto pulse on our truck but I don't want to use it.
I have to say, that stretch of interstate is bad luck for me. I had a pt with a subdural hematoma stop breathing on me on the way to the "D" from the boonies. Gotta love that.
At any rate, I call a head and give a quick report while I am trying to get a second IV. I tell all my students and new medics "Everyone misses IVs. It happens". It was my turn to miss that day. I tried twice while we were going priority one but no dice. He had good ones too. I was just off that day. Oh BTW, his pressure had reached pucker factor. It was 54/30! Heart rate was maintaining though. I hooked up a quick pressure bag and informed the pt what was happening.
Thankfully the boluses were finally working and his pressure was climbing. By the time we got to the super hospital his pressure had improved but I was still very concerned. We roll into the facility and I give report. And in true fashion of this place one of the RNs say question why we brought him in priority one. One even said "he doesn't look like a priority one pt". What the "F" ever! I'm just glad he was feeling better. It was an interesting call and a bit of a learning experience.
Thursday, July 21, 2011
Narcan = dose of reality
I just have to say that it was way too hot the other day. Yet my company doesn't think we should change uniforms and continue to wear winter weight uniforms all the time. OK, enough complaining...
Anyway, my partner, our students, and myself get dispatched to what is basically the wild wild west of the area. This was very much out of our regular response area. But like good Paramedics we took our call and tried to do our part to save the world, one priority one at a time. The area we responded to usually requires us to have some sort of police presents at all times. Like I said, not the safest place in the world.
So we show up to the little police substation to be met by one of the officers. He stated that they found a known heroin user in the back of their station semi conscious and "not breathing right". He was able to get him up and inside. Oh and did I mention it was approaching 100 degrees that day too? It sure was. It was so hot my balls were sticking to both of my legs!
When we actually encounter our pt he was sitting/lying on a couple of chairs and was apparently feeling very good. He would just say "yup" to everything and had a big stupid grin on his face. Not that he was stupid, but it was one of those faces you would make if you just pulled a prank or are drunk and thought of something funny. But our altered mental status pt we have before us was very cooperative. Well, he didn't really fight us but wasn't really doing anything either. His vitals were mostly stable, but he was a bit tachycardic. Probably from the heat. He was sweating like pig. But then again, everyone was. Like I said, it was hot!
I was proud of my student for getting an 18g IV on a known IV drug user. Our pts pupils were so small that almost looked like he didn't have any. So we did the usual AMS work up, IV, o2, EKG, CBG, and some fluid. We then started with a small dose of Narcan, the wonder drug. We did this enroute to the hospital. Started with one milligram and titrated to effect. He didn't have any real airway problems, but he wasn't breathing that fast so we figured we would give him a dose of reality.
So we give the drug and a few minutes later our pt that was high as a kite came back to life with a very animated display. He suddenly goes from just saying "yup" to "What in da hell! Where am I at?!". We talked him down and told him the story and filled him in on the who, what, when, where, and why. He was cool with it and was all and all a nice guy.
Now this may sound a bit jaded, but I am pretty sure he lied right to my face. He said he was clean for 9 months and that he is trying to quit. Now I am not a figure of authority so you don't have to blow smoke up my ass. The cops even know that he is a regular abuser of narcotics and that he does this all the time. But its not a good idea to accuse people of things like that when you are in a confined space with them. Narcan calls are always interesting.
Anyway, my partner, our students, and myself get dispatched to what is basically the wild wild west of the area. This was very much out of our regular response area. But like good Paramedics we took our call and tried to do our part to save the world, one priority one at a time. The area we responded to usually requires us to have some sort of police presents at all times. Like I said, not the safest place in the world.
So we show up to the little police substation to be met by one of the officers. He stated that they found a known heroin user in the back of their station semi conscious and "not breathing right". He was able to get him up and inside. Oh and did I mention it was approaching 100 degrees that day too? It sure was. It was so hot my balls were sticking to both of my legs!
When we actually encounter our pt he was sitting/lying on a couple of chairs and was apparently feeling very good. He would just say "yup" to everything and had a big stupid grin on his face. Not that he was stupid, but it was one of those faces you would make if you just pulled a prank or are drunk and thought of something funny. But our altered mental status pt we have before us was very cooperative. Well, he didn't really fight us but wasn't really doing anything either. His vitals were mostly stable, but he was a bit tachycardic. Probably from the heat. He was sweating like pig. But then again, everyone was. Like I said, it was hot!
I was proud of my student for getting an 18g IV on a known IV drug user. Our pts pupils were so small that almost looked like he didn't have any. So we did the usual AMS work up, IV, o2, EKG, CBG, and some fluid. We then started with a small dose of Narcan, the wonder drug. We did this enroute to the hospital. Started with one milligram and titrated to effect. He didn't have any real airway problems, but he wasn't breathing that fast so we figured we would give him a dose of reality.
So we give the drug and a few minutes later our pt that was high as a kite came back to life with a very animated display. He suddenly goes from just saying "yup" to "What in da hell! Where am I at?!". We talked him down and told him the story and filled him in on the who, what, when, where, and why. He was cool with it and was all and all a nice guy.
Now this may sound a bit jaded, but I am pretty sure he lied right to my face. He said he was clean for 9 months and that he is trying to quit. Now I am not a figure of authority so you don't have to blow smoke up my ass. The cops even know that he is a regular abuser of narcotics and that he does this all the time. But its not a good idea to accuse people of things like that when you are in a confined space with them. Narcan calls are always interesting.
Monday, July 18, 2011
A priority one trauma, a young pattawan, and 100mg dose of reality.
One of my most recent shift I was working one of the rescue stations with both a new medic as well as a student. No big deal, I have worked with a whole gaggle of students before and have kept them intellectually stimulated and gainfully employed. So I didn't have an issue with it at all. Now, I hate to drive. However, the good thing about this particular shift was that I didn't have to do any of the documentation.
The one issue I did have was that there was way too much talk about how we shouldn't take this call or bad mouthing other services and hospitals. now I am not a fan of a few facilities and services just like everyone else is. However, I have also been doing this a while and have formed my own opinions based off of experience.
For the most part the day is steady with a good amount of posting and calls that require little more than IV, 02, and monitor. However, our last call of the day was a trauma call with a significant mechanism. We were second unit in for a head on collision with vehicle roll over going about 45 mph with entrapment. It was a pretty gnarly scene. Not the worst, but a good one for experience for both the student and the young pattawan.
I will spare the details for the sake of time and for the ego of young medic working with me. But it boiled down to a few key points:
Scene safety
Let those in turnout gear do the extrication
Working as a team
Sense of urgency
You don't have to be in charge
Communication
As you can see from the list above, these are topics and issues that classroom instruction may touch on but will not go into great detail about them or how important they can be. Well, other than scene safety. Point being that you have to truly experience these things in order to learn from them. Mistakes are going to be made by everyone. It is up to the person that made them to either learn from them or get upset. I think it was a learning experience for the rookie.
Now with all that being said, I was not going to let him get hurt or chewed out for no reason. I made sure that he was going to ask all the questions that needed to be asked and have as many of the answers as possible at the hospital without taking over report or care of the patient. After all, the best way to learn is by doing.
It was an interesting end to an otherwise vanilla day. Hopefully this was seen as a learning experience and not as a failure. All and all, good job.
The one issue I did have was that there was way too much talk about how we shouldn't take this call or bad mouthing other services and hospitals. now I am not a fan of a few facilities and services just like everyone else is. However, I have also been doing this a while and have formed my own opinions based off of experience.
For the most part the day is steady with a good amount of posting and calls that require little more than IV, 02, and monitor. However, our last call of the day was a trauma call with a significant mechanism. We were second unit in for a head on collision with vehicle roll over going about 45 mph with entrapment. It was a pretty gnarly scene. Not the worst, but a good one for experience for both the student and the young pattawan.
I will spare the details for the sake of time and for the ego of young medic working with me. But it boiled down to a few key points:
Scene safety
Let those in turnout gear do the extrication
Working as a team
Sense of urgency
You don't have to be in charge
Communication
As you can see from the list above, these are topics and issues that classroom instruction may touch on but will not go into great detail about them or how important they can be. Well, other than scene safety. Point being that you have to truly experience these things in order to learn from them. Mistakes are going to be made by everyone. It is up to the person that made them to either learn from them or get upset. I think it was a learning experience for the rookie.
Now with all that being said, I was not going to let him get hurt or chewed out for no reason. I made sure that he was going to ask all the questions that needed to be asked and have as many of the answers as possible at the hospital without taking over report or care of the patient. After all, the best way to learn is by doing.
It was an interesting end to an otherwise vanilla day. Hopefully this was seen as a learning experience and not as a failure. All and all, good job.
Wednesday, July 13, 2011
You gotta be kidding me...
Recently I worked with a shift with a fairly new medic who apparently knew everything. Now I am pretty easy going so for the most part it was an easy shift. However, constant complaining can be a bit of a downer. The silver lining to this 12 hour piece of my life was that we did not have to do a single dialysis transfer. However, we did get held over for a list minute call, but that was nothing super interesting.
So we do a few calls that morning and are dispatched priority 2 to a residence in the "D" for a CHF exacerbation. As we pull up we see a typical house in a typical neighborhood in this area of town with a 60ish year old person waving us down. So we walk in and find a retirement age female talking, ambulating, and having breakfast. Btw, breakfast smelled amazing. Our pt told us that she had just made breakfast and if it was alright if she ate breakfast. We said it was fine since she in no immediate distress. However, the meal she had consisted of three different pork products that were all probably fried in some sort of grease and some white bread. Oh and she salted it too. It probably tasted like hypertension and same, which incidentally smelled delicious. I just thought it was funny how she was complaining of shortness of breath for a few days after admitting to not taking her meds and eating the caloric equivalent to what most people should have in a day. Then she wonders why she was short of breath...I don't get it.
So we do our usual assessments, treatments, and diagnostics and take her to the hospital. She even said she was a hard stick. Of course she was. Why wouldn't she be? Who would have thought that 6 different cardiac, pulmonary, and endocrine disorders would mess with your peripheral circulation? At any rate, I think it is odd how people can either ignore their health conditions or better yet have the mentality that "I already got it, why change now?". Job security, job security, job security...puppies and Jesus, puppies and Jesus!
Oh and if you think having a baconator for breakfast wasn't good enough, she was also telling us a story about how one of her eyes popped out of her head last week. WTF!?! Really? Who, what, when, where, and why to that. I calmly sat there putting info into my tablet and said "I have been doing this for 8 years and that's a new one for me". She said it was no big deal and continued to demolish her pig in a blanket-esk breakfast. Just another day on the job in EMS.
So we do a few calls that morning and are dispatched priority 2 to a residence in the "D" for a CHF exacerbation. As we pull up we see a typical house in a typical neighborhood in this area of town with a 60ish year old person waving us down. So we walk in and find a retirement age female talking, ambulating, and having breakfast. Btw, breakfast smelled amazing. Our pt told us that she had just made breakfast and if it was alright if she ate breakfast. We said it was fine since she in no immediate distress. However, the meal she had consisted of three different pork products that were all probably fried in some sort of grease and some white bread. Oh and she salted it too. It probably tasted like hypertension and same, which incidentally smelled delicious. I just thought it was funny how she was complaining of shortness of breath for a few days after admitting to not taking her meds and eating the caloric equivalent to what most people should have in a day. Then she wonders why she was short of breath...I don't get it.
So we do our usual assessments, treatments, and diagnostics and take her to the hospital. She even said she was a hard stick. Of course she was. Why wouldn't she be? Who would have thought that 6 different cardiac, pulmonary, and endocrine disorders would mess with your peripheral circulation? At any rate, I think it is odd how people can either ignore their health conditions or better yet have the mentality that "I already got it, why change now?". Job security, job security, job security...puppies and Jesus, puppies and Jesus!
Oh and if you think having a baconator for breakfast wasn't good enough, she was also telling us a story about how one of her eyes popped out of her head last week. WTF!?! Really? Who, what, when, where, and why to that. I calmly sat there putting info into my tablet and said "I have been doing this for 8 years and that's a new one for me". She said it was no big deal and continued to demolish her pig in a blanket-esk breakfast. Just another day on the job in EMS.
Tuesday, June 28, 2011
The altered, hypotensive high lighter
I know it has been a bit since my last post. There just has not been much to write about. I could write about how certain drugs work or a new/better way of assessing pts, but that's not as much fun as sharing war stories.
Recently I worked the second worst shift in the company. For the sake of anonymity I will keep the partners name and the shift we were working to myself. At any rate, It was just "one of those days". We did a few non-emergent BLS transfers and then the truck died. And just for the record, you can't use a defibrillator to jump start your car. The silver lining in that situation was that it gave us a hour or so of mandatory down time to do nothing. The rest of the day was pretty uneventful until the inevitable laws of EMS struck. I'm going to refer to this one as time to acuity ratio. This means that the smaller the amount of time you have left on your shift, the greater the acuity of the call you will receive. And of course this law applied itself to our truck about 30 minutes before we are set to clear. At least it was a priority one.
As we start rolling in glitter ball mode we get our update from dispatch for a 50ish year old female with AMS that has not been out of bed for the last few days. Could be nothing or it could be interesting. However, we won't know until we get there. It was in one of the local mobile estate parks that we frequent quite a bit. So we mentally prepare ourselves for heavy lifting, bad smells, smoke, and low ceilings.
Upon arrival we discover that our mental preparation was 100% accurate. We find our pt lying in bed with the local BLS FD on scene providing O2 and getting a scattered history. Apparently this pt has a history of everything and was prescribed pain med for every disease she was diagnosed with. It was a pretty messy place and a side from all of the pill bottles with various levels of controlled substances, there were ash trays, beer cans, and other substances that I did not care to find the origins of. It was a bit gross to say the least.
So our pt does have a patent airway but is in and out of consciousness. She is cool to the touch despite being in bed for days and has an extremely weak radial pulse. And in case you could not guess, she was a very poor historian. She did say she didn't feel good. I would imagine so, her skin was highlighter yellow (LIVER FAILURE) and she just looked ill. Her vital signs agreed with my assessment. She was a bit hypotensive, SBP in the 70s but she was not tachycardic.
After some creative, out of the box thinking we get her out of her bed and on to our stretcher and into the ambulance. IV, O2, and monitor were initiated. However, she was a bit of a vascular challenge. Both my partner and I stuck her multiple times. I even tried for an EJ and that didn't work. My partner was a bit persistent in that we should go after the first stick. I told him I would try enroute. I did eventually get an IV in her. A small 22 in the wrist. I was hoping to try my awesome IV trick but I didn't have time or the luxury of smooth roads. But hey, a line is a line. Mean while "Mrs. Sharpee" is talking to people that are not in the truck, is a/o x toaster and keeps telling me that she is going to go smoke. Right...gotta love this job sometimes. So once vascular access has been achieved, I had my rider set up a make shift pressure bag which boils down to a BP cuff on a liter of NACL. I also had him try some Narcan to see if anything would have changed. It was more diagnostic than therapeutic since it didn't have an effect. But it was a good teaching moment. Just FYI, her pupils were dilated, not constricted. I am aware that narcs will constrict pupils, but with the amount and types of meds that were scattered around on scene, it was worth a shot.
The pt remained in the state that we found her in while enroute and upon arrival to the ER. I asked if they wanted to go to resus but apparently 70/30 is still acceptable for a regular room. After all, she was awake. However, she did get a central line later on. It was an interesting call. And it held us over for about an hour. I try to find the silver lining in things, so out of all of that we got an hour of over time thanks to the highlighter.
Recently I worked the second worst shift in the company. For the sake of anonymity I will keep the partners name and the shift we were working to myself. At any rate, It was just "one of those days". We did a few non-emergent BLS transfers and then the truck died. And just for the record, you can't use a defibrillator to jump start your car. The silver lining in that situation was that it gave us a hour or so of mandatory down time to do nothing. The rest of the day was pretty uneventful until the inevitable laws of EMS struck. I'm going to refer to this one as time to acuity ratio. This means that the smaller the amount of time you have left on your shift, the greater the acuity of the call you will receive. And of course this law applied itself to our truck about 30 minutes before we are set to clear. At least it was a priority one.
As we start rolling in glitter ball mode we get our update from dispatch for a 50ish year old female with AMS that has not been out of bed for the last few days. Could be nothing or it could be interesting. However, we won't know until we get there. It was in one of the local mobile estate parks that we frequent quite a bit. So we mentally prepare ourselves for heavy lifting, bad smells, smoke, and low ceilings.
Upon arrival we discover that our mental preparation was 100% accurate. We find our pt lying in bed with the local BLS FD on scene providing O2 and getting a scattered history. Apparently this pt has a history of everything and was prescribed pain med for every disease she was diagnosed with. It was a pretty messy place and a side from all of the pill bottles with various levels of controlled substances, there were ash trays, beer cans, and other substances that I did not care to find the origins of. It was a bit gross to say the least.
So our pt does have a patent airway but is in and out of consciousness. She is cool to the touch despite being in bed for days and has an extremely weak radial pulse. And in case you could not guess, she was a very poor historian. She did say she didn't feel good. I would imagine so, her skin was highlighter yellow (LIVER FAILURE) and she just looked ill. Her vital signs agreed with my assessment. She was a bit hypotensive, SBP in the 70s but she was not tachycardic.
After some creative, out of the box thinking we get her out of her bed and on to our stretcher and into the ambulance. IV, O2, and monitor were initiated. However, she was a bit of a vascular challenge. Both my partner and I stuck her multiple times. I even tried for an EJ and that didn't work. My partner was a bit persistent in that we should go after the first stick. I told him I would try enroute. I did eventually get an IV in her. A small 22 in the wrist. I was hoping to try my awesome IV trick but I didn't have time or the luxury of smooth roads. But hey, a line is a line. Mean while "Mrs. Sharpee" is talking to people that are not in the truck, is a/o x toaster and keeps telling me that she is going to go smoke. Right...gotta love this job sometimes. So once vascular access has been achieved, I had my rider set up a make shift pressure bag which boils down to a BP cuff on a liter of NACL. I also had him try some Narcan to see if anything would have changed. It was more diagnostic than therapeutic since it didn't have an effect. But it was a good teaching moment. Just FYI, her pupils were dilated, not constricted. I am aware that narcs will constrict pupils, but with the amount and types of meds that were scattered around on scene, it was worth a shot.
The pt remained in the state that we found her in while enroute and upon arrival to the ER. I asked if they wanted to go to resus but apparently 70/30 is still acceptable for a regular room. After all, she was awake. However, she did get a central line later on. It was an interesting call. And it held us over for about an hour. I try to find the silver lining in things, so out of all of that we got an hour of over time thanks to the highlighter.
Tuesday, June 14, 2011
A whole lot of strenght in a very small package
The other day I was "blessed" with the opportunity to work with one of our sister companies. This was thanks to my partner who called off that day. It was actually a good day. I ended up working about 45 minutes from where I am usually stationed, so it was a bit of a change. The calls for the day were nothing super exciting or very complicated. However, one pt encounter stuck with me.
We were called to do an inter-facility transfer from local hospital to super hospital for a young lady. I will try and keep this vague enough so I can tell the story and still get my point across. I don't want to break any HIPPA laws. Anyway, this little girl was in 2nd or 3rd grade and was at the hospital for a chronic medical condition complicated by pneumonia. She was one of those little girls that in the face of all the treatments, illness, and overall complications of life landing her behind the 8 ball; she was happy, bubbly, and very outgoing. She was also no stranger to medicine, ambulances, and hospitals. It was funny when she asked if we could go lights and sirens just because she thought it would be cool. Most of my regular partners would have probably done it for her, but mine that day stuck to the rules. She also had a few comments about the people driving behind us while we were enroute.
The transport was uneventful and when we got her to the super hospital, she asked us to sign a note book. She has all the nurses, docs, medics, and everyone else that takes care of her sign it and leave a little note. I put "I hope you feel better soon. Keep smiling and good Luck. Signed Paramedic Mike". It was the most routine of calls, but her infectious positivity and happy demeanor made it a bittersweet encounter. Unfortunately she still has along road ahead of her but who knows what will happen. Only time will tell.
We were called to do an inter-facility transfer from local hospital to super hospital for a young lady. I will try and keep this vague enough so I can tell the story and still get my point across. I don't want to break any HIPPA laws. Anyway, this little girl was in 2nd or 3rd grade and was at the hospital for a chronic medical condition complicated by pneumonia. She was one of those little girls that in the face of all the treatments, illness, and overall complications of life landing her behind the 8 ball; she was happy, bubbly, and very outgoing. She was also no stranger to medicine, ambulances, and hospitals. It was funny when she asked if we could go lights and sirens just because she thought it would be cool. Most of my regular partners would have probably done it for her, but mine that day stuck to the rules. She also had a few comments about the people driving behind us while we were enroute.
The transport was uneventful and when we got her to the super hospital, she asked us to sign a note book. She has all the nurses, docs, medics, and everyone else that takes care of her sign it and leave a little note. I put "I hope you feel better soon. Keep smiling and good Luck. Signed Paramedic Mike". It was the most routine of calls, but her infectious positivity and happy demeanor made it a bittersweet encounter. Unfortunately she still has along road ahead of her but who knows what will happen. Only time will tell.
Sunday, May 29, 2011
The bad boy chair
It's not a real weekend shift on the rescue truck if you aren't dispatched to someone with waaaay too much ETOH on board. It was a very busy day too. I think in 24 hours we did 10 calls. It was all a blur at the end of the shift. So much in fact that I forgot to punch out. Needless to say, I was very tired. But I digress...
So it's oh dark thirty and we get a call for a young woman at PD HQ having a seizure. We get there and there is a woman in her late 20's on the floor not responding to the ALELS or advance law enforcement life support. Which consists of making fun of the drunk person on the floor and then telling inappropriate jokes. Very effective, btw. The AHA should take heed. Anyway, this young lady did not respond much to verbal or painful stimuli. I was basically standing on her chest doing the sternal rub and didn't get much of a response. The fire officer that was on scene was a bit...um...excited. His exact words were "you need to load and go!". Pump the breaks there high speed. Lucky for us she was all of 100 lbs and was starting to come around. Apparently she went out with some friends and by the end of the night there was a big emotional explosion that I could only imagine that resulted in a pile of ripped out hair, broken containers of lip gloss, and a brush or two. Oh and when she finally came to, she told my partner that she was not going to talk to him or give him any information. I love it when people think Paramedics are figures of authority. I guess it's the uniforms (don't get me started...), the lights and sirens, and the fact that we can drive as fast as we want and park anywhere without getting in trouble.
This "load and go" situation turns into a battle royale with PD and the 80 lbs of crazy that is in cell one. This person just so happens to be the aggressor to our other pt and probably the reason why they were there in the first place. She was not cooperating and was screaming and was struggling with PD. They had enough of her and put her in what we have affectionately dubbed the "bad boy chair". It's basically a chair that you can put a handcuffed individual in and then further strap down their torso and legs. Little miss club scene was not happy about his. In my 28 years on this planet I have heard some bad things come out of peoples mouths, but this "lady" had a few new ones. She was a class act. I have to say I find it funny that once people are either painted into a corner or in this case strapped to a chair, they try and bluff and threaten their way out. She was threatening to sue everyone and was trying to give orders. Just because you are loud does not mean you are going to call the shots or get your way. Oh and little miss sanity then asked/told the cops to "!@#$'n taze" her. Whiskey, Tango, Foxtrot?
Once she was put in "time out", I called for a second unit because it was probably not safe to transport them in the same truck at the same time. My poor partner would not have known what hit him. But it probably would have consisted of the contents of a purse or two. We transport our less crazy pt to the local ER without further incident. Alcohol makes people do strange things. But most of the time it just makes you a hot mess.
So it's oh dark thirty and we get a call for a young woman at PD HQ having a seizure. We get there and there is a woman in her late 20's on the floor not responding to the ALELS or advance law enforcement life support. Which consists of making fun of the drunk person on the floor and then telling inappropriate jokes. Very effective, btw. The AHA should take heed. Anyway, this young lady did not respond much to verbal or painful stimuli. I was basically standing on her chest doing the sternal rub and didn't get much of a response. The fire officer that was on scene was a bit...um...excited. His exact words were "you need to load and go!". Pump the breaks there high speed. Lucky for us she was all of 100 lbs and was starting to come around. Apparently she went out with some friends and by the end of the night there was a big emotional explosion that I could only imagine that resulted in a pile of ripped out hair, broken containers of lip gloss, and a brush or two. Oh and when she finally came to, she told my partner that she was not going to talk to him or give him any information. I love it when people think Paramedics are figures of authority. I guess it's the uniforms (don't get me started...), the lights and sirens, and the fact that we can drive as fast as we want and park anywhere without getting in trouble.
This "load and go" situation turns into a battle royale with PD and the 80 lbs of crazy that is in cell one. This person just so happens to be the aggressor to our other pt and probably the reason why they were there in the first place. She was not cooperating and was screaming and was struggling with PD. They had enough of her and put her in what we have affectionately dubbed the "bad boy chair". It's basically a chair that you can put a handcuffed individual in and then further strap down their torso and legs. Little miss club scene was not happy about his. In my 28 years on this planet I have heard some bad things come out of peoples mouths, but this "lady" had a few new ones. She was a class act. I have to say I find it funny that once people are either painted into a corner or in this case strapped to a chair, they try and bluff and threaten their way out. She was threatening to sue everyone and was trying to give orders. Just because you are loud does not mean you are going to call the shots or get your way. Oh and little miss sanity then asked/told the cops to "!@#$'n taze" her. Whiskey, Tango, Foxtrot?
Once she was put in "time out", I called for a second unit because it was probably not safe to transport them in the same truck at the same time. My poor partner would not have known what hit him. But it probably would have consisted of the contents of a purse or two. We transport our less crazy pt to the local ER without further incident. Alcohol makes people do strange things. But most of the time it just makes you a hot mess.
Thursday, May 5, 2011
A block and a "blocker"
The last shift that I worked was a pretty easy shift if you only look at the sheer number of calls that we did. In 12 hours we only did 2 calls, but both of them were ALS calls. I told my partner that we are actually working real EMS today. I know that is not reality, but it was nice to only have to do rescue and ALS while on an ALS rescue truck. Just saying...
Anyway, our first call of the day was for acute mental status changes at a doctors office. We get there and find our pt who just looks like "one of those patients". They are lying on an exam table/bed in the doctors office and are awake but are not what you would call alert. This pt was unable to tell us where they where, what time of the day it was, the date, the president, who was recently shot in the face in Pakistan, or anything else. There was also talk of the pt possibly having menengitis because of neck and head pain with a fever. So we had to rely on bystanders, medical staff, and physical exam to get some answers. This pt had surgical scars everywhere, so I assumed that the medical history was extensive. But again the pt could not tell me anything other than "I dunnooo". At least there was a good looking family member there. Should have asked for her phone number, but that's another story in and of it's self.
Anyway, as I digress, the pt had fluctuating vitals signs but I am assuming that it was from them not being the most cooperative with the BP cuff and not sitting still. First it was low then it was high. They had a radial pulse the whole time so I wasn't too worried about hypotension. We had a new medic on scene with us from the local fire department and my partner and I decided to allow him to utilize some of his newly acquired ALS skills. So he started looking for an IV. I don't know if I was being impatient or he was taking too long, but I decided to look in the other arm. I was at the head of the stretcher in the truck and ended up finding one in the pt's hand. They were a bit of a vascular challenge but we got a line. Nothing big, but it did the job. Fluid and med access. We also did the stroke scale, which was inconclusive, and checked her pupils. As it turns out she had small pupils that were slow to react. This prompted me to look at the pt's medication list. This ended up showing a number of pain medications and also showed that the pt has a hx of medication abuse because she was prescribed Suboxone.
For those of you that don't know, Suboxone is a combination drug that is used to help people with their addiction to narcotics. It is a mix of Narcan, an opioid blocker (more on that drug later) and a narcotic, buprenorphin. The idea is that the mix of the blocker and the narc will help the pt ween off the meds and help them control their addiction. I personally think that it is a load of crap and this medicine is used as a crutch rather than a therapeutic modality. From what I have seen, it is an enabler in pill form.
Now then, back to the story. So our pt that is presenting with altered mentation, small pupils, and just not acting right is given some Narcan IVP. If we were wrong about the possibility of a narcotic overdose, there would be no effect from the medicine and would be benign otherwise. But the pt responded to the medicine well. They became a bit more coherent and not slurring their speech as much. I have to give props to my partner that day for doing a good assessment and immediately asking for the med bag to give some diagnostic/therapeutic Narcan. Way to go man.
Our second call of the day was for a fall. The gravity must be different in the area we run ALS because everyone falls down. It wouldn't be a normal shift if we were not dispatched to a fall once a day. So we get our call and get there to find a very old but talkative WWII vet. As it turns out, he had a bout of syncope or near syncope that brought him to the ground. CBG, ECG, V/S, and stroke scale are all completed along with a head to toe assessment. Everything checks out fine with the exception of his ECG/Heart rate. Via the pulse ox, it was 38-45. So we as we get him on the monitor we see an irregular rhythm that was not A-fib. We do a 12 lead and as it turns out this gentleman has a 2nd degree type one heart block. Also known as wenckebach. Hemodynamically, he was stable enough. So IV, O2, and constant monitoring and a trip to the ER was in order. No real change in status and the pt tolerated very well. The point here is that what the call comes in for and what you end up finding can be two very different things.
All and all a good shift on the rescue truck. Hopefully it will be my new full time position. We will know soon enough. By for now.
Anyway, our first call of the day was for acute mental status changes at a doctors office. We get there and find our pt who just looks like "one of those patients". They are lying on an exam table/bed in the doctors office and are awake but are not what you would call alert. This pt was unable to tell us where they where, what time of the day it was, the date, the president, who was recently shot in the face in Pakistan, or anything else. There was also talk of the pt possibly having menengitis because of neck and head pain with a fever. So we had to rely on bystanders, medical staff, and physical exam to get some answers. This pt had surgical scars everywhere, so I assumed that the medical history was extensive. But again the pt could not tell me anything other than "I dunnooo". At least there was a good looking family member there. Should have asked for her phone number, but that's another story in and of it's self.
Anyway, as I digress, the pt had fluctuating vitals signs but I am assuming that it was from them not being the most cooperative with the BP cuff and not sitting still. First it was low then it was high. They had a radial pulse the whole time so I wasn't too worried about hypotension. We had a new medic on scene with us from the local fire department and my partner and I decided to allow him to utilize some of his newly acquired ALS skills. So he started looking for an IV. I don't know if I was being impatient or he was taking too long, but I decided to look in the other arm. I was at the head of the stretcher in the truck and ended up finding one in the pt's hand. They were a bit of a vascular challenge but we got a line. Nothing big, but it did the job. Fluid and med access. We also did the stroke scale, which was inconclusive, and checked her pupils. As it turns out she had small pupils that were slow to react. This prompted me to look at the pt's medication list. This ended up showing a number of pain medications and also showed that the pt has a hx of medication abuse because she was prescribed Suboxone.
For those of you that don't know, Suboxone is a combination drug that is used to help people with their addiction to narcotics. It is a mix of Narcan, an opioid blocker (more on that drug later) and a narcotic, buprenorphin. The idea is that the mix of the blocker and the narc will help the pt ween off the meds and help them control their addiction. I personally think that it is a load of crap and this medicine is used as a crutch rather than a therapeutic modality. From what I have seen, it is an enabler in pill form.
Now then, back to the story. So our pt that is presenting with altered mentation, small pupils, and just not acting right is given some Narcan IVP. If we were wrong about the possibility of a narcotic overdose, there would be no effect from the medicine and would be benign otherwise. But the pt responded to the medicine well. They became a bit more coherent and not slurring their speech as much. I have to give props to my partner that day for doing a good assessment and immediately asking for the med bag to give some diagnostic/therapeutic Narcan. Way to go man.
Our second call of the day was for a fall. The gravity must be different in the area we run ALS because everyone falls down. It wouldn't be a normal shift if we were not dispatched to a fall once a day. So we get our call and get there to find a very old but talkative WWII vet. As it turns out, he had a bout of syncope or near syncope that brought him to the ground. CBG, ECG, V/S, and stroke scale are all completed along with a head to toe assessment. Everything checks out fine with the exception of his ECG/Heart rate. Via the pulse ox, it was 38-45. So we as we get him on the monitor we see an irregular rhythm that was not A-fib. We do a 12 lead and as it turns out this gentleman has a 2nd degree type one heart block. Also known as wenckebach. Hemodynamically, he was stable enough. So IV, O2, and constant monitoring and a trip to the ER was in order. No real change in status and the pt tolerated very well. The point here is that what the call comes in for and what you end up finding can be two very different things.
All and all a good shift on the rescue truck. Hopefully it will be my new full time position. We will know soon enough. By for now.
Thursday, April 28, 2011
The theraputic value of music...
Yes I know it has been a while, but I really have not had anything too exciting or at the very least interesting to talk about. Plus, this last semester was a beast and required way too much of my time. Now that I have gotten that off of my chest. Lets get to the meat of the blog...
So working a rescue shift with "Sebastian" when we get a 911 call for a fall. It's nothing too exciting. Just a LoL in NAD. That's little old lady in no acute distress. But she was on blood thinners so we treated accordingly. We package her up and take her to the area's only trauma center. After we get to our destination and get the truck 10-8 for our next call, we get a page stating that we, the rescue truck, have to do a transfer out of the ER to the Peds ER in one of the bigger hospitals in the area. Sebastian was immediately annoyed. Not so much that we had to do the transfer, but rather that we had to transfer a kid. A young kid. Like still had that new baby smell.
I don't know if I have a way with calming kids, but when I walked into the room this little girl stopped fussing and stared right at me. Smart kid. This little was originally brought in for DIB by the other ambulance company in the area. Originally this kid had a sat of "OMG" and received all of the breathing treatments. This helped a lot, so did the steroids, and fluids. So she was doing much better. We ended up having to transport her with out mom because of reasons I won't get into.
Anyway, while enroute to the super hospital, my new little buddy started to get fussy. I did all the usual things for babys to get them to calm down. She was not having any of it. She would calm down a little bit if I would talk to her but I couldn't do that the whole way. Mainly for my own sanity. So what can "talk" for me for 30 minutes? That's right! My iPhone. I looked through my play list for something soothing. You know, like a lullaby. Ah Ha! Bob Marley & the Wailers. She got through "Jammin" and "Redemtion song" and was out. Vitals stable. Just sleeping. I just played a few more songs off of the "Legend" album and wouldn't you know it, we were at the hospital. Kiddo did fine and did me a favor by pooping after we got out of the truck. Who would have thought rocking out or rather chilling out to some Bob Marley was the treatment of choice for this little one. I have to say she has good taste in music. I don't know who said it, but music is the language of the soul, and that little girl was very intent on hearing what had to be said.
So working a rescue shift with "Sebastian" when we get a 911 call for a fall. It's nothing too exciting. Just a LoL in NAD. That's little old lady in no acute distress. But she was on blood thinners so we treated accordingly. We package her up and take her to the area's only trauma center. After we get to our destination and get the truck 10-8 for our next call, we get a page stating that we, the rescue truck, have to do a transfer out of the ER to the Peds ER in one of the bigger hospitals in the area. Sebastian was immediately annoyed. Not so much that we had to do the transfer, but rather that we had to transfer a kid. A young kid. Like still had that new baby smell.
I don't know if I have a way with calming kids, but when I walked into the room this little girl stopped fussing and stared right at me. Smart kid. This little was originally brought in for DIB by the other ambulance company in the area. Originally this kid had a sat of "OMG" and received all of the breathing treatments. This helped a lot, so did the steroids, and fluids. So she was doing much better. We ended up having to transport her with out mom because of reasons I won't get into.
Anyway, while enroute to the super hospital, my new little buddy started to get fussy. I did all the usual things for babys to get them to calm down. She was not having any of it. She would calm down a little bit if I would talk to her but I couldn't do that the whole way. Mainly for my own sanity. So what can "talk" for me for 30 minutes? That's right! My iPhone. I looked through my play list for something soothing. You know, like a lullaby. Ah Ha! Bob Marley & the Wailers. She got through "Jammin" and "Redemtion song" and was out. Vitals stable. Just sleeping. I just played a few more songs off of the "Legend" album and wouldn't you know it, we were at the hospital. Kiddo did fine and did me a favor by pooping after we got out of the truck. Who would have thought rocking out or rather chilling out to some Bob Marley was the treatment of choice for this little one. I have to say she has good taste in music. I don't know who said it, but music is the language of the soul, and that little girl was very intent on hearing what had to be said.
Wednesday, March 30, 2011
Just can't get these right....
In EMS there is never a day or even a call that is exactly the same as another. They are like medicare sponsored snowflakes. At any rate, when you you think of combative and angry you usually do not think of a little old lady. However, this lady was pissed! Crazy, but pissed. So angry in fact that she tried to run me over with her walker. Calls like these always give me a funny feeling, and not in a good way. They are the 911 calls where no matter what I do, it seems that I can't ever get them right. Probably because they are no right or wrong answers to the questions at hand and that we do not have the adequate training to properly handle them. On the flip side to that, we do have the capability to give them a ride to the hospital. Now as much as I hate being call an "ambulance driver", it is a large part of what we do. Additionally, that is really all we have to do for this person. Take them to the hospital.
Saturday, March 12, 2011
Double trouble.
Recently I was working a 24 hour rescue shift at one of the company's out stations. At first it was the usual BLS type of calls and a lot of posting. It doesn't make the shift fly by, but you have to appreciate not working very hard and getting paid for it. So other than being bored out of my skull, it wasn't too bad for the first half of the shift. My partner even made dinner for us, but got a call just as she put our meal on the table. Murphy's law, I guess. Then we posted for a while and didn't actually get back to the station for another several hours.
Just when I thought we were finally all done and would be able to catch a few winks, we hear the tones go off for one of our sister stations for a cardiac arrest. My partner HAD to make the comment of "Haha! They have to do CPR". Thanks. Because probably 10 minutes after she said that we were dispatched to a cardiac arrest...and then another one after that. WTF?
To find a silver lining out of the two arrests that we were unable to save (presenting rhythms were both asystole) I was able to place the ET tube on both patients on the first try. The first one I did, I used the capnography cable, along with auscultation of lung sounds to confirm placement. The initial co2 was 28 but quickly dropped to 10-8 and stayed there for the remainder of the resuscitation. I didn't have a second electronic capnography adapter for the second code so we had to go "old school" and go with all the other stuff like watching the tube pass through the cords, lung sounds, chest rise, color change in the colormetric device, and so on. Although we were unable to save these two (unknown down times and advanced age) these type of scenarios always allow you to improve your practice as an ACLS provider and there is always something to take a way from the experience.
The thing I had to do is to talk to the family about termination of resuscitation and getting them to sign the paperwork. I always hate doing that. "Sorry for you loss, and please sign here so we can bill medicare" just doesn't sound very empathetic to me. But you gotta do what you gotta do.
I have to also give props to the fire department that helped us out on both codes. They rock and are truely a professional and competent bunch of fire fighters and medics. I know I write this blog with a bit of ambiguity, but they know who they are and they rock.
Just when I thought we were finally all done and would be able to catch a few winks, we hear the tones go off for one of our sister stations for a cardiac arrest. My partner HAD to make the comment of "Haha! They have to do CPR". Thanks. Because probably 10 minutes after she said that we were dispatched to a cardiac arrest...and then another one after that. WTF?
To find a silver lining out of the two arrests that we were unable to save (presenting rhythms were both asystole) I was able to place the ET tube on both patients on the first try. The first one I did, I used the capnography cable, along with auscultation of lung sounds to confirm placement. The initial co2 was 28 but quickly dropped to 10-8 and stayed there for the remainder of the resuscitation. I didn't have a second electronic capnography adapter for the second code so we had to go "old school" and go with all the other stuff like watching the tube pass through the cords, lung sounds, chest rise, color change in the colormetric device, and so on. Although we were unable to save these two (unknown down times and advanced age) these type of scenarios always allow you to improve your practice as an ACLS provider and there is always something to take a way from the experience.
The thing I had to do is to talk to the family about termination of resuscitation and getting them to sign the paperwork. I always hate doing that. "Sorry for you loss, and please sign here so we can bill medicare" just doesn't sound very empathetic to me. But you gotta do what you gotta do.
I have to also give props to the fire department that helped us out on both codes. They rock and are truely a professional and competent bunch of fire fighters and medics. I know I write this blog with a bit of ambiguity, but they know who they are and they rock.
Wednesday, February 23, 2011
A whole lot of ALS packed into 24 hours
Recently I had a very busy rescue shift. If I remember correctly, we did 9 calls in 24 hours. That may not seem like a very large number of calls, but it was more of when each call came in and what was involved. Still that is a call every 2 hours and 35 minutes. Our first call came in literally 8 minutes into our shift. So we hit the ground running. Our first call wasn't anything super exciting. Just the timing of it was bad.
Call number two was a simple yet fairly interesting call. We were dispatched to a physician's office for a diff breather. Upon arrival we come to find that our pt has a spontaneous pneumothorax and will require a chest tube to remove the trapped air. This pt didn't require much from me during transport. Just increasing his current O2 therapy from 2 to 4 litters to maintain sats above 95% was all that was required from me. However, I did have my thoracostomy needle ready in case he required emergent decompression. But just monitoring was all he required. Too bad we didn't have a student, it would have been a good teaching moment.
Now our most notable and invasive call of the day was for a cardiac arrest at a specialty nursing facility for someone who was not terribly old but had a laundry list of medical conditions. Getting dispatched to a "CPR in progress" is always a lot of work. So we get there and the staff that are providing BLS are not doing what I would call very effective CPR. So we have them swap out for someone with a bit more of an ability to push hard and fast. As far as our airway, breathing, circulation treatments go, this pt had a trach so the airway was being easily managed effectively by the staff. However, this pt was a vascular nightmare so my partner popped in an I/O in to the pts tibia and we started our ACLS drug therapy. The monitor showed asystole in 2 leads, but since this was a "fresh arrest" we worked it. Shortly after a few minutes of CPR and some epi and atropine (I know 2010 AHA guidelines say no more atropine in PEA, but our protocols are not up to date with those changes yet) the pt changed from asystole to PEA. It was confirmed PEA because pt had no pulses. So we continue our ALCS treatment and exhaust that particular algorithm to include a gram of calcium and an amp of NaHCO3 (sodium bicarbonate). All the while, one of the staff members keeps asking me when we are going to call it. The question kept getting avoided with strategic phrases like "Let's reassess after this round of CPR" or "We'll take a look after this round of drugs".
Then wouldn't you know it, we get a sinus tach on the monitor. We do our additional 2 minutes of CPR and check. My partner states this pt has a very weak pulse but it is there and correlating with the monitor. So I mix up a dopamine drip and calculate it with some down and dirty math tricks they taught us in school. And then wouldn't you know it, our pt goes into VT with a pulse. Sync cardio version at 100J is done and the pt goes from VT with a pulse to VT without a pulse. CPR is continued and we start our VT/VF algorithm. The pt is shocked and given 300 of amiodarone and we get a "gee wiz" blood sugar which ends up reading "HI". Nothing we can do about that except note it. The pt is still in VF and gets another does of DTE and an additional 150 of amiodarone. This then brings us back to asystole. And now that we have exhausted the drug box and our H's and T's, it was time to contact OLMC (Online medical control) for pronouncement orders. We get permission from the doc and call it. Since I am overly optimistic and try and find the silver lining in everything, I was happy to know that it was not my turn to do the paper work. I think the documentation took longer than the whole code. My partner and I were both mentally drained from that call and required supplies, lunch, and a cup of coffee.
Oh something interesting to not on that call was that we didn't have any EtCO2 readings. I am not sure what was going on with our detector, but it wasn't reading. It would have been a good predictor of resusitative efforts and good experience for my partner. Oh well.
The rest of the shift required a lot of posting and c-spine immobilization. We actually picked one pt up twice with in 4 hours. The first time we responded, it took what seemed like forever to find their location in the maze of an apartment complex they live in. The second response was much quicker and much more basic. Thankfully once we finally got back to the station, we were not called for the remainder of the shift. That means I got paid to sleep for about 5-6 hours. Gotta love a paid nap. All and all my partner during the day and I really earned our money.
Call number two was a simple yet fairly interesting call. We were dispatched to a physician's office for a diff breather. Upon arrival we come to find that our pt has a spontaneous pneumothorax and will require a chest tube to remove the trapped air. This pt didn't require much from me during transport. Just increasing his current O2 therapy from 2 to 4 litters to maintain sats above 95% was all that was required from me. However, I did have my thoracostomy needle ready in case he required emergent decompression. But just monitoring was all he required. Too bad we didn't have a student, it would have been a good teaching moment.
Now our most notable and invasive call of the day was for a cardiac arrest at a specialty nursing facility for someone who was not terribly old but had a laundry list of medical conditions. Getting dispatched to a "CPR in progress" is always a lot of work. So we get there and the staff that are providing BLS are not doing what I would call very effective CPR. So we have them swap out for someone with a bit more of an ability to push hard and fast. As far as our airway, breathing, circulation treatments go, this pt had a trach so the airway was being easily managed effectively by the staff. However, this pt was a vascular nightmare so my partner popped in an I/O in to the pts tibia and we started our ACLS drug therapy. The monitor showed asystole in 2 leads, but since this was a "fresh arrest" we worked it. Shortly after a few minutes of CPR and some epi and atropine (I know 2010 AHA guidelines say no more atropine in PEA, but our protocols are not up to date with those changes yet) the pt changed from asystole to PEA. It was confirmed PEA because pt had no pulses. So we continue our ALCS treatment and exhaust that particular algorithm to include a gram of calcium and an amp of NaHCO3 (sodium bicarbonate). All the while, one of the staff members keeps asking me when we are going to call it. The question kept getting avoided with strategic phrases like "Let's reassess after this round of CPR" or "We'll take a look after this round of drugs".
Then wouldn't you know it, we get a sinus tach on the monitor. We do our additional 2 minutes of CPR and check. My partner states this pt has a very weak pulse but it is there and correlating with the monitor. So I mix up a dopamine drip and calculate it with some down and dirty math tricks they taught us in school. And then wouldn't you know it, our pt goes into VT with a pulse. Sync cardio version at 100J is done and the pt goes from VT with a pulse to VT without a pulse. CPR is continued and we start our VT/VF algorithm. The pt is shocked and given 300 of amiodarone and we get a "gee wiz" blood sugar which ends up reading "HI". Nothing we can do about that except note it. The pt is still in VF and gets another does of DTE and an additional 150 of amiodarone. This then brings us back to asystole. And now that we have exhausted the drug box and our H's and T's, it was time to contact OLMC (Online medical control) for pronouncement orders. We get permission from the doc and call it. Since I am overly optimistic and try and find the silver lining in everything, I was happy to know that it was not my turn to do the paper work. I think the documentation took longer than the whole code. My partner and I were both mentally drained from that call and required supplies, lunch, and a cup of coffee.
Oh something interesting to not on that call was that we didn't have any EtCO2 readings. I am not sure what was going on with our detector, but it wasn't reading. It would have been a good predictor of resusitative efforts and good experience for my partner. Oh well.
The rest of the shift required a lot of posting and c-spine immobilization. We actually picked one pt up twice with in 4 hours. The first time we responded, it took what seemed like forever to find their location in the maze of an apartment complex they live in. The second response was much quicker and much more basic. Thankfully once we finally got back to the station, we were not called for the remainder of the shift. That means I got paid to sleep for about 5-6 hours. Gotta love a paid nap. All and all my partner during the day and I really earned our money.
Monday, February 14, 2011
Broken ankles and chest pain
So the last shift I worked literally consisted of about 7 or 8 calls with nothing but chest pain or broken ankles. First, our most critical pt of the shift was a gentleman with classic signs and symptoms of an MI before we even took vitals or put him on the monitor. He was gray, ashen, diaphragmatic, had nausea and vomiting, and actually passed out a few times. He was also hypotensive (even though the newbie basic that was there told me his pressure was 120/60...sure). Anyway, we throw him on the monitor and see a heart rate of 45, he had a pressure of 88/50, and just looked like crap. If nothing else, this guy was really sick. He did also mention that he had a "bacterial infection" and was taking meds for it but could not tell us what type of infection. So we start an IV and get him going to the area's only trauma center. Enroute my partner does a 12 lead. The 12 lead showed elevation of about 2mm in the inferior leads as well as V2, V5, and V6. So we then bump it up to a priority one and my partner starts the MONA regiment. Unfortunately, since our pt's pressure was still low, he was only able to do the "O" and the "A". The rest of the transport is without further incident.
Now, on to the ankles. It seemed as though everyone was breaking their ankles in our response area. One genius even thought it was a good idea to drink and rollerblade on an icy driveway. As the title of this blog entry suggests, it didn't end well. His ankle looked like a grapefruit and it was quite painful. The funny thing was that he kept saying "Shy-zah". He was German and didn't like the situation one bit. Sorry about the phonetic spelling, I didn't take German in high school or college. This gentleman had much ETOH on board and was still in a lot of pain. So we take him to the hospital and on the way there, he didn't want anyone to know he was drunk. Sure...we won't tell. Even if we didn't, it doesn't take a neurosurgeon to figure who is sober as a judge and who is drunk as a skunk.
Well, that was my most resent paid adventure in the world of prehospital medicine. It is never a dull moment in this job. Hopefully I can further my career along with obtaining my FP-C and get a kick ass flight job. Bye for now.
Now, on to the ankles. It seemed as though everyone was breaking their ankles in our response area. One genius even thought it was a good idea to drink and rollerblade on an icy driveway. As the title of this blog entry suggests, it didn't end well. His ankle looked like a grapefruit and it was quite painful. The funny thing was that he kept saying "Shy-zah". He was German and didn't like the situation one bit. Sorry about the phonetic spelling, I didn't take German in high school or college. This gentleman had much ETOH on board and was still in a lot of pain. So we take him to the hospital and on the way there, he didn't want anyone to know he was drunk. Sure...we won't tell. Even if we didn't, it doesn't take a neurosurgeon to figure who is sober as a judge and who is drunk as a skunk.
Well, that was my most resent paid adventure in the world of prehospital medicine. It is never a dull moment in this job. Hopefully I can further my career along with obtaining my FP-C and get a kick ass flight job. Bye for now.
Friday, February 4, 2011
A productive day...
Today actually turned out to be a fairly productive day. It did not start out that way though. When my partner and I got on shift, we checked the truck as usual and were just about to go on the air when the supervisor stops us and has us swap out trucks. Then after much flip flopping, we finally end up taking a very old "beater" truck down to another station to swap it out and take their truck. So that killed about 2 hours or so.
We finally get everything straightened out and get our first call. BLS Non-emergent. Fun. We did our fair share of the BLS stuff today. The interesting part about today was that on the way to the floor, as we are going through the required motions to gain access to the rest of the hospital, my partner and I hear "I need a crash cart over here!" coming form triage. We look at eachother and I figure I will give a quick look to see if I can lend a hand. As I turn the corner, I see about 6 nurses, a crash cart, defibrillator, and a guy lying on the floor not looking very good. They just started CPR and placed the pads to find course VFIB. POW! they send 200J through the guys chest and CPR is started again. I cut his clothes off and start looking for a line, so is another RN. 2 minutes later, they look at the moniter (Thanks AHA and ACLS) to find a sinus rhythm. Sweet. Even better we find ROSC, ROSV, and a conscious pt. The doc places an quick EJ and the pt gets 150mg of Amio. He is then swooped off by the staff to the resus room.
That was exciting and the best part was we didn't have to do any type of documentation. Woot! Otherwise today was just a priority 2 day at best. Still, most won't see it, but we acutally helped save a life today. Thanks local hospital for the opportunity to help.
We finally get everything straightened out and get our first call. BLS Non-emergent. Fun. We did our fair share of the BLS stuff today. The interesting part about today was that on the way to the floor, as we are going through the required motions to gain access to the rest of the hospital, my partner and I hear "I need a crash cart over here!" coming form triage. We look at eachother and I figure I will give a quick look to see if I can lend a hand. As I turn the corner, I see about 6 nurses, a crash cart, defibrillator, and a guy lying on the floor not looking very good. They just started CPR and placed the pads to find course VFIB. POW! they send 200J through the guys chest and CPR is started again. I cut his clothes off and start looking for a line, so is another RN. 2 minutes later, they look at the moniter (Thanks AHA and ACLS) to find a sinus rhythm. Sweet. Even better we find ROSC, ROSV, and a conscious pt. The doc places an quick EJ and the pt gets 150mg of Amio. He is then swooped off by the staff to the resus room.
That was exciting and the best part was we didn't have to do any type of documentation. Woot! Otherwise today was just a priority 2 day at best. Still, most won't see it, but we acutally helped save a life today. Thanks local hospital for the opportunity to help.
Thursday, January 27, 2011
Michigan: Home to the slickest ice in the world.
The other day I was working with a friend of mine when we recieved a 911 call not very far from our station and the hospital for that matter, for a person that fell c/o ankle pain. From the place (in the middle of the road) where this guy was lying to the hospital property was probably about 500 ft. However, to the ER was about a mile. At any rate, it is about 20 degrees outside and it was snowing lightly. My partner was not exactly enthusiastic about this call because it was late and she wanted to go to bed.
So we roll up to see just about ever vehile with lights on top of it in that town on scene. Just so we are all clear here, this guy was breathing, had a heart beat, and was totally conscious. However, he was lying on the ground with his knee pulled up to his chest yelling. It sounded very formiliar. Walking up I could hear all sorts of "y'alls" and "dag gums" and "do what nows". This was a good o'l boy from the deep south. Apparently "Bubba" as we will call him was visiting the Great Lakes State on business and decided to visit one of the local watering holes. This particular place has been known to attract the "biker crowd" and has the reputation for be a bit of a hole in the wall. Although in this particular area of the county, you get more of the "Wild Hogs" types than a hells angel. Anyway, as I digress...this poor fellow is lying on the ground, in the street, in the slush, and has a foot that is flopping around like wet noodle. I ask this gentleman what happened, and he proceeds to tell me in what sounded like something out of a Larry the cable guy bit. He says things like "I'm not from here" and "I been drinkin'" and "Man, you yankees got some slippery ass roads! I mean your ice is slippery!" ... ok...
Nothing for nothing, but I am not about to start treatment in the middle of the road while it is snowing and it is 20 degrees out. So we get him in the back of the truck and get his history, vitals, and so on. And then we are off to the ER. I call ahead just for a quick heads up. Mean while, Bubba proceeds to tell me how awesome he is and that how he is not used to "nice yankees" and that his wake boarding skills boarder on legendary. Oh yeah, he also keeps mentioning that Michigan has some "Slippery ass ice". Thank god for him, because I would have totally forgot. He also proceeds to tell me that he has great insurance but they won't cover his visit if they know he has smoked pot. Well what he actually said was something to the effect of "Buddy, I gots great insurance. Don't you worry meow. But they won't pay if they know I's was [makes hand gestures pertaining to smoking something illegal]". I respond with a very professional "totally...". And then his looped and very drunk story starts again.
Once we get to the hospital and roll by the nursing station, he promply gives a very southern fried "Hello ladies. How you derrin" and tells me you have to give'em a little some'em some'em. I'm sure everyone within earshot rolled their eyes. I give report to the RN and immediately appologize for any misbehaving he will do and turn over care.
I have to say that taking care of drunk people is a pain in the ass. Especially the ones that are mean, rude, or covered with vomit. This guy was the kind of drunk person that you want to respond to. Alert, quirky, funny, and other than the pain of his injury, in good spirits. You just gotta look out for that slippery ass Michgain ice.
So we roll up to see just about ever vehile with lights on top of it in that town on scene. Just so we are all clear here, this guy was breathing, had a heart beat, and was totally conscious. However, he was lying on the ground with his knee pulled up to his chest yelling. It sounded very formiliar. Walking up I could hear all sorts of "y'alls" and "dag gums" and "do what nows". This was a good o'l boy from the deep south. Apparently "Bubba" as we will call him was visiting the Great Lakes State on business and decided to visit one of the local watering holes. This particular place has been known to attract the "biker crowd" and has the reputation for be a bit of a hole in the wall. Although in this particular area of the county, you get more of the "Wild Hogs" types than a hells angel. Anyway, as I digress...this poor fellow is lying on the ground, in the street, in the slush, and has a foot that is flopping around like wet noodle. I ask this gentleman what happened, and he proceeds to tell me in what sounded like something out of a Larry the cable guy bit. He says things like "I'm not from here" and "I been drinkin'" and "Man, you yankees got some slippery ass roads! I mean your ice is slippery!" ... ok...
Nothing for nothing, but I am not about to start treatment in the middle of the road while it is snowing and it is 20 degrees out. So we get him in the back of the truck and get his history, vitals, and so on. And then we are off to the ER. I call ahead just for a quick heads up. Mean while, Bubba proceeds to tell me how awesome he is and that how he is not used to "nice yankees" and that his wake boarding skills boarder on legendary. Oh yeah, he also keeps mentioning that Michigan has some "Slippery ass ice". Thank god for him, because I would have totally forgot. He also proceeds to tell me that he has great insurance but they won't cover his visit if they know he has smoked pot. Well what he actually said was something to the effect of "Buddy, I gots great insurance. Don't you worry meow. But they won't pay if they know I's was [makes hand gestures pertaining to smoking something illegal]". I respond with a very professional "totally...". And then his looped and very drunk story starts again.
Once we get to the hospital and roll by the nursing station, he promply gives a very southern fried "Hello ladies. How you derrin" and tells me you have to give'em a little some'em some'em. I'm sure everyone within earshot rolled their eyes. I give report to the RN and immediately appologize for any misbehaving he will do and turn over care.
I have to say that taking care of drunk people is a pain in the ass. Especially the ones that are mean, rude, or covered with vomit. This guy was the kind of drunk person that you want to respond to. Alert, quirky, funny, and other than the pain of his injury, in good spirits. You just gotta look out for that slippery ass Michgain ice.
Wednesday, January 12, 2011
Preemptive Karma...
Just the other day I was working a rescue shift. Nothing too exciting so far that morning. Just a chest painer and a dead guy. So we get sent to go to post because everyone else was busy. Well, except for one of the MICU trucks which was at the same post. As my partner and I drive up, we notice that both people in the vehicle are asleep. Obviously, the first thing that pops into my head was "how can I mess with these two"?
So I do the logical/mature/smart thing and decide to drive right up next to them and blast the siren. This apparently was more of a problem than I thought it would be. Now before I go any further, let me paint you a better picture of the area. The other (larger) ambulance is parked in a small parking lot next to a curb and a tree with enough space to drive my ambulance between the two. I obviously miss judged the turning radius of my vehicle and as I am pulling next to the other truck I look in my mirrors just in time to have the back bumper of their vehicle "kiss" my left rear wheel well. This promptly wakes up the other crew who for some reason decide to back up their truck. Don't ask me. I was driving the other truck. So I actually have to get over the PA system and tell them to stop moving. From all the grinding, rubbing, and all around bad sounds that came from the contact of these two mobile infirmaries, I thought the damage would be pretty bad.
Much to my surprise, the larger ambulance didn't have a scratch on its bumper ( the area I came into contact with). However, my vehicle now as a 9 inch by 3 inch "beauty mark" on the rear driver side wheel well. Every one was OK and after much moaning and groaning I give the supervisor a call to tell him what happened. He wasn't exactly enthusiastic about what I had just told him, but he was professional and gave me clear instructions on what to do from there. Basically it involved me not driving for a week and everyone writing an incident report.
Moral of the story? Being a smart ass can be fun, but it can and will bite you in the ass. Am I still going to be a smart ass? Am I still going to try and pull a prank or two from time to time. Absolutely. However, I not going to do so with company equipment. Now I have to take CEVO...again. For the third time in less than a year. This is why I need a flight job.
So I do the logical/mature/smart thing and decide to drive right up next to them and blast the siren. This apparently was more of a problem than I thought it would be. Now before I go any further, let me paint you a better picture of the area. The other (larger) ambulance is parked in a small parking lot next to a curb and a tree with enough space to drive my ambulance between the two. I obviously miss judged the turning radius of my vehicle and as I am pulling next to the other truck I look in my mirrors just in time to have the back bumper of their vehicle "kiss" my left rear wheel well. This promptly wakes up the other crew who for some reason decide to back up their truck. Don't ask me. I was driving the other truck. So I actually have to get over the PA system and tell them to stop moving. From all the grinding, rubbing, and all around bad sounds that came from the contact of these two mobile infirmaries, I thought the damage would be pretty bad.
Much to my surprise, the larger ambulance didn't have a scratch on its bumper ( the area I came into contact with). However, my vehicle now as a 9 inch by 3 inch "beauty mark" on the rear driver side wheel well. Every one was OK and after much moaning and groaning I give the supervisor a call to tell him what happened. He wasn't exactly enthusiastic about what I had just told him, but he was professional and gave me clear instructions on what to do from there. Basically it involved me not driving for a week and everyone writing an incident report.
Moral of the story? Being a smart ass can be fun, but it can and will bite you in the ass. Am I still going to be a smart ass? Am I still going to try and pull a prank or two from time to time. Absolutely. However, I not going to do so with company equipment. Now I have to take CEVO...again. For the third time in less than a year. This is why I need a flight job.
Friday, January 7, 2011
96 hours, an I/O, and a full arrest. What could be more fun?
This week was a very busy [EMS] week for me. Meaning that we had a ton of calls. I worked new years eve day and new years followed by 4-6 12 hour shifts after that...I think. It has been kind of a blur. Either way, we were hammered with calls. On the "holidays" we did 16 calls, and up until today every shift had an average of 7 calls. Ugh. Busy stuff.
Most of the past week has been stuck in what I am sure have mentioned before as "priority 3 purgatory". However, today we recieved a call for pt in their 60s who was having trouble breating. So much trouble in fact that this person's heart stopped beating. So it's a CPR in progress kind of day. It was a bit of a unique code situation. Our patient had a trach which made the "A" part of airway, breathing, and circulation much easier. The staff at this menagerie of tirtiary care was performing good compressions but bagging like hyperventilation was going to bring them back. The first few things we did was confirm the arrest, place the defib pads, and check a rhythm which turned out to be PEA. The staff was told to slow their bagging down to about 12 times a minute and we then looked to gain vascular access. This particular pt was a...um...vascular challenge to say the very least. My partner and I didn't even try to start an IV. We just popped in an IO in the right tibia. It was super easy and was the first state side IO I have done in a while.
Then the strangest thing happend. Before we gave any drugs, fluid, or electrical therapy, we achieved ROSC (return of spontaneous cirulation). The pt had a pulse again. So we took the opportunity to switch the pt on to our ventilator and transported priority one to the area's only trauma center for further care. The BP was still low, but the pt was perfusing.
On our way to the ER, the pt decides to throw me a curve ball and codes again. Just so everyone is aware, doing CPR in the back of an ambulance is not easy, fun, or comfortable. Plus, its very traumatic to the pt. In this case, I am pretty sure the pt had a floating sternum, meaning the sternum detatched from the ribs and was basiclly floating around the chest. Not a very nice feeling or sound. So I start CPR again and reach for an amp of epi, since the pt was still in PEA (sinus tach was the underlying rhythm). I push the meds just as we roll up to the ER.
As we roll through the doors of the resusitation room, I give my report. One of the ER residents was ready and very willing to intubate this pt, but I kind of stole her thunder when I told her she has a trach in place. She looked alittle disappointed. Oh well, so we get the pt over to the bed and again we get ROSC.
Once that whole tornado of ACLS is brought under control, the doctor mixes a neosynepherine drip. That's right, the doctor. You don't see that very often. He said he wanted to make sure we kept this pt alive until family can show up to say "good bye". So we clean up, do our paperwork, and clear. Before I leave, I ask one of the nurses if the new registration girl is single or not. Haha.
Several hours later, we return to the area's only trauma center to find that our pt is still with us. Surviving the night is another story. But as much work as we did this week, it was good to use our skills and critical thinking again. Gotta love life on the MICU.
Most of the past week has been stuck in what I am sure have mentioned before as "priority 3 purgatory". However, today we recieved a call for pt in their 60s who was having trouble breating. So much trouble in fact that this person's heart stopped beating. So it's a CPR in progress kind of day. It was a bit of a unique code situation. Our patient had a trach which made the "A" part of airway, breathing, and circulation much easier. The staff at this menagerie of tirtiary care was performing good compressions but bagging like hyperventilation was going to bring them back. The first few things we did was confirm the arrest, place the defib pads, and check a rhythm which turned out to be PEA. The staff was told to slow their bagging down to about 12 times a minute and we then looked to gain vascular access. This particular pt was a...um...vascular challenge to say the very least. My partner and I didn't even try to start an IV. We just popped in an IO in the right tibia. It was super easy and was the first state side IO I have done in a while.
Then the strangest thing happend. Before we gave any drugs, fluid, or electrical therapy, we achieved ROSC (return of spontaneous cirulation). The pt had a pulse again. So we took the opportunity to switch the pt on to our ventilator and transported priority one to the area's only trauma center for further care. The BP was still low, but the pt was perfusing.
On our way to the ER, the pt decides to throw me a curve ball and codes again. Just so everyone is aware, doing CPR in the back of an ambulance is not easy, fun, or comfortable. Plus, its very traumatic to the pt. In this case, I am pretty sure the pt had a floating sternum, meaning the sternum detatched from the ribs and was basiclly floating around the chest. Not a very nice feeling or sound. So I start CPR again and reach for an amp of epi, since the pt was still in PEA (sinus tach was the underlying rhythm). I push the meds just as we roll up to the ER.
As we roll through the doors of the resusitation room, I give my report. One of the ER residents was ready and very willing to intubate this pt, but I kind of stole her thunder when I told her she has a trach in place. She looked alittle disappointed. Oh well, so we get the pt over to the bed and again we get ROSC.
Once that whole tornado of ACLS is brought under control, the doctor mixes a neosynepherine drip. That's right, the doctor. You don't see that very often. He said he wanted to make sure we kept this pt alive until family can show up to say "good bye". So we clean up, do our paperwork, and clear. Before I leave, I ask one of the nurses if the new registration girl is single or not. Haha.
Several hours later, we return to the area's only trauma center to find that our pt is still with us. Surviving the night is another story. But as much work as we did this week, it was good to use our skills and critical thinking again. Gotta love life on the MICU.
Monday, January 3, 2011
The "hype-no-tensive" pirate!
So in the not so distant past, I was working a MICU shift where we responded to a 911 call for a pt with low blood pressure. This is also known as hypotension. Hypo meaning low in relation to blood pressure, as hyper means high in relation to the same function. With that being said, we will return to the story at hand.
Now my partner and I arrive on scene to a "handy man special" single floor ranch style house in an area that is occupied by people that are taking full advantage of that certain government program that is located between sections 7 and 9. As I am sure you are already aware, this place was about as clean as gas station bathroom and probably smelled similar to one. So we walk in with the local fire department who was actually very helpful. We find two men, on in a wheel chair and one who looks like someone just pissed in his Wheaties. Our pt was actually the one in the wheel chair. The obvious questions are asked first. What happened, what type of medical problems do you have, any allergies, and are you always in that wheel chair. The pt's brother was not happy with that last question. He immediately threw what we in the medical field call a "hissy fit" and proceeded to tell us in a very high pitched manor of the events that transpired. Apparently his brother suffers from "hype-no-tension". They will remind us of this several times over the next 30 minutes. This act of replacing the "o" in what should have been hypotension with a "no" totally threw my partner for a loop. So I had to translate white trash pirate for him into terms he could actually use.
Oh yeah! The whole pirate thing. Let me paint you a better picture. Our pt, the one in the wheel chair is something of a miracle of modern medicine. You see, he sort of drank himself into his current condition and is kept alive by medicines, medicare, and certain family members being enablers. This gentleman was probably a buck thirty soaking wet with change in his pockets, had a fairly thick beard and mustache and to top it off, had a black "pirate-esque" eye patch that he wears due to an unfortunate incident at a certain hospital with a medication he is unsure of. As you can see, he was prime material for being captain of the football team.
So we ask black beard about his medical problems and what brought us to his lovely home to assist him with. He proceeds to tell us the story of how when he stands up he gets dizzy, "hype-no-tensive" and falls down. After my eyes stopped rolling, we took him to the area's only trauma center for further care.
As we are loading him into the truck, he is still talking about his mispronounced condition. For some reason, I felt it was necessary, nay my duty to correct this one eyed pirate citizen. I tell him "Sir, you mean hypotension. Low blood pressure." He yells at me and says, "NO! Hype-no-tension! Like Hype-no-dermic needle!" I just look at him and say "Actually no. But it doesn't matter. As long as we are both on the same page that you have low blood pressure, then it will all work out". We then load the pt up and I let my partner take the call. The pt was very very done with me and what I had to say/offer. So we bring captain hook to the ER and continue back out into priority 3 purgatory.
An interesting thing to note on this call is the correlation between the amount of DVDs one owns to the total amount of productive work days in a year. I think I will deem this "Blue Rays Law". If your DVD collection exceeds either the amount of days you work per year or is greater than the number of days in a year, than you are not exactly a very productive member of society. Call it jaded, but when I came up with it, I was pretty damn proud of myself. Ha ha! That's all for now.
Now my partner and I arrive on scene to a "handy man special" single floor ranch style house in an area that is occupied by people that are taking full advantage of that certain government program that is located between sections 7 and 9. As I am sure you are already aware, this place was about as clean as gas station bathroom and probably smelled similar to one. So we walk in with the local fire department who was actually very helpful. We find two men, on in a wheel chair and one who looks like someone just pissed in his Wheaties. Our pt was actually the one in the wheel chair. The obvious questions are asked first. What happened, what type of medical problems do you have, any allergies, and are you always in that wheel chair. The pt's brother was not happy with that last question. He immediately threw what we in the medical field call a "hissy fit" and proceeded to tell us in a very high pitched manor of the events that transpired. Apparently his brother suffers from "hype-no-tension". They will remind us of this several times over the next 30 minutes. This act of replacing the "o" in what should have been hypotension with a "no" totally threw my partner for a loop. So I had to translate white trash pirate for him into terms he could actually use.
Oh yeah! The whole pirate thing. Let me paint you a better picture. Our pt, the one in the wheel chair is something of a miracle of modern medicine. You see, he sort of drank himself into his current condition and is kept alive by medicines, medicare, and certain family members being enablers. This gentleman was probably a buck thirty soaking wet with change in his pockets, had a fairly thick beard and mustache and to top it off, had a black "pirate-esque" eye patch that he wears due to an unfortunate incident at a certain hospital with a medication he is unsure of. As you can see, he was prime material for being captain of the football team.
So we ask black beard about his medical problems and what brought us to his lovely home to assist him with. He proceeds to tell us the story of how when he stands up he gets dizzy, "hype-no-tensive" and falls down. After my eyes stopped rolling, we took him to the area's only trauma center for further care.
As we are loading him into the truck, he is still talking about his mispronounced condition. For some reason, I felt it was necessary, nay my duty to correct this one eyed pirate citizen. I tell him "Sir, you mean hypotension. Low blood pressure." He yells at me and says, "NO! Hype-no-tension! Like Hype-no-dermic needle!" I just look at him and say "Actually no. But it doesn't matter. As long as we are both on the same page that you have low blood pressure, then it will all work out". We then load the pt up and I let my partner take the call. The pt was very very done with me and what I had to say/offer. So we bring captain hook to the ER and continue back out into priority 3 purgatory.
An interesting thing to note on this call is the correlation between the amount of DVDs one owns to the total amount of productive work days in a year. I think I will deem this "Blue Rays Law". If your DVD collection exceeds either the amount of days you work per year or is greater than the number of days in a year, than you are not exactly a very productive member of society. Call it jaded, but when I came up with it, I was pretty damn proud of myself. Ha ha! That's all for now.
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