Confrontation Averted

It was fathers day and we had a barbecue planned for mid afternoon. The pager opened up at noon for a patient with abdominal pain, located on the other end of our district, 20 minutes from my station. I went to station 73, fully expecting someone else to get to one of the other closer stations, but that didn’t happen. I went enroute. The dispatcher gave me additional information “28 year old female severe abdominal pain respond 30 alpha 4. Alpha responses typically mean no lights and sirens. Every time we ‘light it up’ we increase the chances we will get into an accident. Dispatchers ask callers key questions to determine the severity of the patient which dictates the urgency of our response. I wasn’t supposed to go lights and sirens, but I was looking at a 20 minute ride, and I wanted to take as much time off my response as I could. I light it up. “What took you so long” is what I hear as soon as I entered the trailer from an irate fiancé. The county was busy and even though I had a 20 minute ride, I even beat the county medic in, so this family waited for any kind of help to arrive for a while. 5 minutes feels like forever. 20 minutes is an eternity. I ignored the comment and went to work assessing the patient, who was in obvious pain. A female patient with severe abdominal pain, who looks sick could be bad, and I tried to rule out the most serious. Triple A or abdominal aortic aneurysm, and ectopic pregnancy. But the fiancé and the rest of the family wouldn’t let the protracted response time go, and I could hear comments through my stethoscope as I listened for bowel sounds. I was out numbered 5 to 1, and I checked to make sure I had a clear path to the door in case things got worse. I usually let these kind of comments go, but the attitude was getting worse so I needed to address it. “I am sorry it took me so long to get here. I am a volunteer and I left a barbeque to respond here. I would much rather be at home with my family on father’s day but chose to come here instead. The county is very busy and a county paramedic unit wasn’t available which is why it took so long to get help here. Now I need your help and cooperation to get the best care possible for your daughter.” I was pretty pissed but hoped my attitude didn’t show in my words. “Well it’s just not right” the father raised his voice. Oh Boy. Maybe my strategy back fired. Maybe my attitude was obvious. I thought about heading for the door. “But thanks for being here anyway” the patients mother said, and I continued with my assessment, relieved. I enlisted the help of the family to get the stretcher and get the patient on it. We had the patient assessed and packaged by the time Paramedic 4 arrived.

System Abuser

The tones woke me up at 1 am for a severe bleed at a nearby trailer park. I went to the station and responded solo in the ambulance. I pulled up to the trailer and was met at the front door by a 40 year old woman who directed me to the tiny bathroom in the back of the trailer. “I told him to take care of that….:” she squawked on and on about how her husband should have done this or that, but I really didn’t want to hear her yapping. I wanted to find her husband, and stop the bleed. I walked into the bathroom. The walls were sprayed with blood, and the floor was slick. He sat on the toilet, pale and sweaty. Blood flowed briskly from his lower leg. I wiped it away with a towel, found the exact spot where the blood came from, stuck one finger on the vein that was bleeding, and pushed, hard. Well focused direct pressure is the fix for severe bleeding. And I may have just fixed this guy, that simple. “Sir, how are you doing?” “I don’t feel so good. One of my veins ruptured.” “Yes it did. How old are you?” “45” “Any medical problems?” “No.” And I continued my assessment, while I kept my finger on that vein. The county paramedics arrived and we started a line. We ran some fluid into the patient and his color returned. We were called back to the same trailer 6 months later for respiratory arrest. I responded at 1 am alone again, walked into the trailer and found this mans wife lying on the couch, blue and snoring 2 or 3 times a minute. “Ma’am! “Hey!” I shouted as I shook her. No response. I nuggied her sternum. Still no response to even painful stimuli. I opened her airway, took out the bag valve mask and started to breathe for this lady. She had a good pulse. I took out a nasopharyngeal airway, lubed it and inserted it into her right nostril to help maintain the airway, and I breathed for her. There wasn’t much more I could do. Her pupils were constricted and that verified my suspicion that she was overdosed on pain medication. She has a history of drug seeking. Ruth, a county paramedic arrived also alone. I told her what I had, that I suspected an overdose. She agreed, took out a prefilled narcan syringe and gave a squirt of the atomized drug up her left nostril. The patient began to fight the bag valve mask and supported her own respirations. She came very close to death this morning. Had it not been for her husband finding her, and for me and Ruth making the response, she would be dead. A few months later we are called back to the same residence for back pain. It is the same patient complaining of back pain that has been going on for days, but she decided to wait till 1 am to call for assistance. She refused to go to the nearest hospital because “they don’t like her there” which I interpret to mean they won’t give her any more pain medication there. As I wait with the county paramedics for the ambulance to arrive this woman goes on about how if the short guy who wears Ravens stuff is on the ambulance I’m not going. “Last time he was here he was mean to me and said I was abusing the system. That we are volunteers coming out and she shouldn’t be calling 911 for non-emergencies.” Tim was good at doing that with frequent fliers. “I told him well if you are a volunteer then you don’t have to come out. If you don’t want to be bothered, don’t come out.” I was pissed. She looks up. “You saved my husband that night he was bleeding. “Saved you too, when you overdosed. But I’m a volunteer, so I guess I should have stayed home.” She got quiet, but I don’t think she got it. The ambulance arrived with Bill on it. I gave him a heads up on what was going on with this patient – really nothing, certainly nothing emergent. “You want to start a line?” I really wanted to. I wanted to start an IV on this lady just to inflict some pain, to give a little payback for abusing the system, and then bashing the people who work tirelessly to serve a leach on society like this. But she didn’t need one. I was grateful Bill was on the ambulance to handle the transport, because I had no patience for this lady. And I haven’t been back to her trailer since.

Stuck Pig

Holy shit, I thought. This lady should be pretty bad. There was blood squirted across the walls of the bathroom. “Hi ma’am. My name is Keith. I’m an EMT with the fire department are you ok?” “Oh, I am fine.” She said in a thick German accent. “But it looks like someone slaughtered a pig in there.” She laughed And it did. There was blood everywhere in her bathroom. “Where are you bleeding from?” “Just a little spot right here.” She points to her ankle. “It’s stopped now.” “Is it ok if I check your pulse and blood pressure?” “I am ok, but sure.” I checked her pulse and blood pressure. Both were normal. “Do you want to go to the hospital to get checked out?” “Oh no, I am fine.” “Ok.” Pretty different from my first varicose vein encounter. We were called to a residence at 4 am, down a long dirt road. Marty and I entered the residence and called out with no response. Marty looked in the bathroom “in here!” he shouted. Inside a woman lay in the bathtub, full of bloody water. I ran out to the medic to get a trauma pad, came back in handed Marty the trauma pad and left him. I was afraid of what I would see. He yelled for help, and I reentered the bathroom. The woman was beyond pale, and not responsive. We pulled her out of the tub and laid her on the bathroom floor. We started to wipe her down to try to find where the blood was coming from. It was a varicose vein on her lower right leg that was ruptured. We put direct pressure on it, then wrapped it tight with kling, put her on the stretcher and rushed her to the ambulance. She was in decompensated volume shock. She lost so much blood it was affecting her brain function. Marty started 2 large bore ivs and ran them wide open to replace fluid. I drove to the hospital. When we arrived and I opened the back doors, the woman who was pale, white and unresponsive on scene was sitting up, pink and talking. It was 5 am, the sun was just coming up, and I couldn’t think of a better way to start the day than knowing I played a role in saving this woman’s life, even if I initially was too cowardly to jump right in, I was ready to charge in first next time, and deal with it, which is just what I did tonight.

Quiet

The quiet after accidents is what often strikes me the most. It seems that a very chaotic scene should be really loud, but they always seem very quiet to me. We were alerted for a pedestrian struck on Route 1, in front of a bar. This section of route 1 has a bar on each side and people often run between them. They sometimes get hit. I went to the station and took the ambulance out by myself since no one else showed up. I could see the woman in the middle of the road as I approached. She was lying face up, like she just decided to lay down and take a nap. I pulled past her and parked the ambulance across the lane, to protect me from oncoming traffic, got out and walked back to the body. A small crowd had gathered, but I didn’t hear anything. The world was narrowed to just me and this lady. A man approached. “I am an EMT and she is dead. She was thrown at least 100 feet. I saw the whole thing.” “Ok” I knelt down beside this woman and felt for a pulse. There was none. She looked perfectly normal except for her grey color. There wasn’t any obvious deformity, but as I did a quick initial assessment I could feel that her skull was crushed through her long blond hair. She was a bag of goo. It felt like her body had no internal support left. I wanted to work her. She was so young, maybe 20, and beautiful. But I knew she was dead. “EMS lieutenant 73 dispatch. Priority 4” It was hard to pronounce her. Priority 4 is a designator that technically means no patient, but in my region it means the patient is dead prior to EMS arrival. There was nothing I or anyone else could do for this young woman. I knelt in the middle of route 1 with this dead young woman, and the world around me was silent. It was just the two of us, even though a group was gathered. “What is that lady doing out driving at 2 am anyway?” one of them said about the woman driving the car. Really? You are blaming the driver who struck this woman, who was out running between bars My patient now became the driver of the vehicle, and my concern became the crowd. I really don’t remember the driver much. I know she was upset, but she didn’t do anything wrong. Law enforcement arrived and helped secure the scene. I put a sheet over the body. The forensic investigator arrived. I didn’t have to, but I stuck around to assist with the forensic investigation. I felt I needed to for some reason. I had some kind of connection to this person I had only met in death. Maybe because I was the one to decide she was dead. Six years later, I met her husband. He had no idea I was on that call. He had no idea I was in EMS. As he described the scene, I knew instantly who he was talking about, and 6 years later he still blames himself for his wife’s death.

Naked Guy in Trailer Bathroom

Marty and I left the station for a person fallen call. Marty is a truck driver and EMT. He is an avid hunter and is always laughing and joking. He is a solid guy and I enjoy running with him. The call was to an age restricted community of double wide mobile homes. We were met by a concerned neighbor at the end of the driveway. “He is in the back bathroom. I think he is dead. He has been there a few days.” The neighbor tells us. Marty and I prepared ourselves for what we were about to see and smell. A body in a hot trailer decomposes rapidly. We cautiously entered the trailer, and saw a shotgun on the sofa of the living room. I didn’t smell the distinct odor of a decomposing body. We called out with no response, and slowly walked through the kitchen to the back hallway. The trailer was dark. There weren’t any lights on except for the light coming from the back bathroom. I could see a hand sticking out of the doorway. An elderly man laid on the floor of the bathroom next to a tipped over potty chair, and motorized wheelchair. He was covered in urine and feces and it looked like he was there for a while. He was large, tall, bald and naked, and he was an amputee with his left leg removed above the knee. His skin looked normal, not grey or purple like I expected. “Sir, can you hear me”? I shouted, afraid to get close to the mess on him and the floor. His eyes opened. “Help me!” he grunted. We were shocked. We expected this man to be dead. “Sir, what happened?” I asked as I squatted next to him to feel a pulse and start my assessment. He answered in unintelligible words. Marty started to get a bp as I checked pupils. “Can you tell me where you hurt?” “Help me” “We are trying but you need to tell me what is going on.” “What happened? Where do you hurt?” “My leg! my leg! Marty got a normal blood pressure and moved on to check a blood sugar. I went through a list of possibilities of what was wrong with this patient in my mind as I tried again to ask what happened. “My leg!” The blood sugar was normal. Bp normal. Rules out two likely reasons for this guy to be rolling around in his own feces. I stepped into the tiny bathroom to continue my assessment. The floor was slick with shit, and both Marty and I almost wiped out. “Go get a bunch of sheets we can lay down on the floor to give us some traction.” I couldn’t figure out what was wrong with this patient. He really wasn’t able to communicate, or follow commands, so I couldn’t rule out stroke. He had a good airway he was able to support, was breathing adequate and his pulse was strong and regular. I didn’t see any obvious life threats, but he did have an altered mental status. It didn’t look like anything was going to kill him in the next few minutes but we needed to start moving to the hospital now. Tracy arrived just as we were finishing our assessment. There wasn’t any room to work in the bathroom so we decided to slide the patient out into the hallway. There wasn’t anywhere to grab the patient; he was as slippery as the floor. Marty and I both got one hand under each arm and inched him out through the door and tried not to have our feet slide out from beneath us. Neither of us wanted to end up on this floor. He screamed with each move, but we really didn’t have any choice. Our physical exam didn’t reveal any injury, he couldn’t tell us what was causing his pain and we needed to get going. We placed a backboard next to the patient and rolled him onto it, mostly to get the patient from the floor to the stretcher. We wiped him off as much as we could. It was good his neighbor stopped by, but we weren’t sure why he described his neighbor as “dead by a few days” when we arrived. This patient was very much alive and was home the next day. Marty and I joked about with friends like that who needs enemies? But the truth was that man owed his life to a concerned neighbor. His potty chair tipped over when he was transferring to his motorized chair after using the bathroom. He fell to the floor and tried to pull himself back up into his chair. No one could hear his cries for help. He was there in his feces for two days before a neighbor came by to check on him. He was exhausted and dehydrated by the time we found him. We need to look out for each other. If his neighbor didn’t stop by to check on him, he probably would have died.

Bariatric

I responded to a call for a sick person in a local trailer park, and since it was close to my station, I knew I would be the first one there. I arrived and knocked on the door. I heard a faint voice say “Come in.” I opened the door and found a morbidly obese woman, 500 maybe 600 pounds, lying half on and half off the hospital bed in her cluttered living room. She was naked from the waist down and I could smell the diarrhea from the door. “Hi Ma’am. My name is Keith. I am an EMT. Are you hurt anywhere?” I asked as I walked into the trailer. She told me she wasn’t hurt, and that her problem was diarrhea that she has had for 3 days. Her husband died 6 months earlier. I had no idea about how we were going to move her. She enveloped the side of the bed. I called for a manpower assist and continued my assessment. I asked the usual questions about medical history and medicines, and tried not to gag from the overpowering smell of the diarrhea. Paramedic 1 arrived and I gave my report. Annie, a paid paramedic with the county and a volunteer with a neighboring fire department looked at the situation. Teresa arrived along with about a half dozen other people all standing there gawking at this poor half naked woman. I covered her up with an afghan that was folded on her couch. We figured we would try to move her back onto the bed, and get her cleaned up in the process, then transfer her to a stretcher specially designed for morbidly obese patients, which we didn’t have. I called dispatch to have a regional ambulance transport company respond with their bariatric unit, an ambulance specially outfitted to move and transport morbidly obese patients. Annie, Teresa and I decided that we could use the sheet already under her as a sling to roll her back onto the bed. We went over the plan with our patient, and told her that we would need her to grab onto the rail on the opposite side of the bed to help us pull her back up. When we had her up off the floor, we would clean the diarrhea off of her butt and legs. I asked everyone to leave the room except for the 5 people we would need to move this woman. She was humiliated enough and didn’t need any more gawkers standing around. We wriggled the sheet into position, and on three we moved her slowly back up onto the bed. Annie got onto her knees and wiped as much diarrhea away as she could. I left the living room gagging, got a few breaths of fresh air outside and returned. We noticed that she had a vertical bed sore on her hip, right where her skin enveloped a post on the safety rail of the bed. I couldn’t imagine the discomfort associated with laying in the same position, with the rail digging into my skin. The fire department chaplain came in and recognized this patient. He is a retired minister and is approaching 90. He often parks his car in the middle of accident and fire scenes, which makes operations more difficult, and he almost ran me over on the scene of a fire once. He is the photographer for the department and still uses film. But his heart is huge and he has dedicated his life to the fire service as much as he has dedicated his life to the Lord. “Do you remember me?’ he quietly asks. “I deliver meals to you on Mondays.” He adds. “Oh yeah, I remember you.” “How are you?” the chaplain asks and starts to chat with this woman. Which is exactly the treatment needed. We really couldn’t do anything until the bariatric unit arrived. The chaplain kept her spirits up as much as possible while some of the firefighters tried to determine if the rickety porch would collapse under the weight of her, the stretcher and the 6 people moving it. The bariatric unit finally arrived after a 45 minute wait. We placed a transfer board, basically a piece of thin slick plastic that makes shifting a patient from one bed to another much easier, between the patients bed and the stretcher able to carry 800 pounds, and with as many hands as we could fit around the bed, slid the patient onto the stretcher in one move. The porch creaked and sagged, and we worried about it collapsing so everyone was moved off except for two and they slowly moved the stretcher down the plywood covered ramp. We attached the cable to the stretcher and winched the patient up the ramps attached to the back of the ambulance, locked the stretcher into its bracket, closed the door and sent the ambulance on its way. This was the end of the call for us, and soon we would all return to our dinner tables, families and jobs. We did well with a significant challenge. But this wasn’t the end for the patient. Her ultimate problem won’t be solved. She would return home alone, dangerously obese. The chaplain would bring her dinners on Mondays, and we would be ready for the next call here.

Just a Little Dizzy

About 6 months later we were alerted for a patient feeling faint. The address sounded familiar, and sure enough it was the same trailer. I walked into the front door and the patient immediately recognized me. “How are you doing?” I said with a big grin, really happy to see her out of the hospital and home. “I am ok. I did break my hip but they pinned it together.” “Why did you call us today?” “I just feel a little funny, a little dizzy.” Her son barged through the front door, panicked. “What’s going on?!” “She is ok, just feeling a little faint.” I said. “Ma’am when was the last time you checked your sugar?” “Oh I don’t know. Yesterday maybe.” “Ok, can I check it now?” “Yes.” I swabbed her index finger with an alcohol prep, and waited for it to dry. Stings less that way. As I prepared the glucometer and lancet I spoke with her son. “Is she taking her medication as prescribed?” “I don’t know. She is becoming less reliable about those things. She fell twice last week.” His voice shook a little. “You know the drill Mrs Smith. On the count of three you will feel a little prick on your finger one two three.” click. The lancet pierced her skin and a small drop of blood formed. I placed the glucometer strip into the drop and waited for the machine to analyze the sample. I wasn’t sure what was causing Mrs Smith to feel dizzy. Her sugar was normal. Her blood pressure and pulse were good. I wanted a paramedic to do a 12 lead EKG to look for any cardiac problems. We placed Mrs Smith on our stretcher and put her in the back of the ambulance just as the county paramedics were arriving. I heard her son say “Mom you can’t live alone anymore” as I briefed the paramedic on what our assessment found. I was happy to see my patient out of the hospital, but sad to witness the beginnings of her loss of freedom.

Fallen and Can’t Get Up

I hoped I could find this address. Road drive ends in a series of 4 or five dirt lanes that wind through the woods. Picking the right one is always a crap shoot. I hoped I was on the right one as I drove down a potholed dirt lane barely wide enough for the ambulance. Finally a trailer emerged from the woods with its porch light on. We were here at 2 am for a person fallen, which could be anything from a fallen and I can’t get up call to a cardiac arrest. I turned on all of the scene lights to illuminate the front yard, walked to the front door and knocked. “Fire department!” I yelled. I didn’t hear any reply. Jeff brought the med bag and laid it on the rickety wooden front porch next to me. Kay arrived in her car. “I’ll check the back” she said. Soon I heard Kay’s voice “She’s back here!” Joe and I headed to the rear of the trailer where we found a 75 year old woman just inside the rear door lying on her left side, up against a wall. “Oh thank God! I didn’t think anyone was coming for me. I have been here for so long.” She quietly sobbed. “Its ok. We are here now. What happened?” I asked “I fell and I can’t get up. My left hip really hurts.” “How long have you been here?” “A few hours.” This means she is a candidate for compartment syndrome. When we are motionless for long periods of time, our circulation gets cut off. Kind of like when your leg falls asleep. If it stays that way for long enough, acidic metabolic wastes build up. When we move and restore circulation, those wastes can enter the circulation and send the patient into acidosis, which can be serious. I added this to my problem list, along with a possible fractured hip, and internal bleeding because of the fractured hip. The pelvis is very vascular and sharp bone ends of a fractured one can sever blood vessels. A pelvis can almost hold a persons entire blood volume which can cause hypovolemic (low blood volume) shock. I did a quick full body survey just to make sure she wasn’t hurt anywhere else. As I started my exam she quietly said “I wet myself. I just couldn’t wait any more.” obviously embarrassed. “That’s ok,” I said, “We will get you changed when we get you to the hospital.” We got a set of vital signs, and complete medical history. I asked why she fell, if she got dizzy, passed out, or tripped. She said she tripped. If she got dizzy before the fall, had chest pains, or passed out I would consider a cardiac problem, which we didn’t rule out yet. It just wasn’t a primary problem right now. Our biggest problem was stabilizing that hip and getting her into the ambulance, which wasn’t going to be pretty because of the cramped conditions in the back trailer hallway and the way she was crumpled against the wall. We decided the best way to go was to place a backboard behind her, between the patient and the wall. In order to effectively splint, we need to immobilize above and below the suspected fracture and above and below the adjacent joints, which for the hip means full body immobilization on a long back board. Her vital signs were good. We checked her blood sugar since she was a diabetic, and everything checked out normal except for her hip. We slid the board behind her, got everyone in position to do the move with as little movement to the right hip as possible, and went over the plan. “Ok Mrs Smith, we put a board between you and the wall. On the count of three we are going to slide you onto your back, and that board will be under you. We are going to try to move your right hip as little as possible. Just let us do all the work. I am going to tie your legs together to help keep your hip from moving” I placed a blanket between her legs and tied her legs together with three cravat bandages. The smell of urine was strong, and I could feel the pee seep through my pants onto my knee as I knelt beside her. On three everyone moved the board and the patient just right so that she wound up on her back, centered on the board. I was surprised at how well it went, and the patient felt instant relief once she was on her back, and the weight was off her hip. I noticed that her left foot was rotated outwardly, a sign of a hip fracture. That wasn’t a good sign since the outcome and quality of life for a 75 year old with a hip fracture are usually not good. We provided supportive care on the way to the hospital and turned her over to the emergency department staff. I wished her well, but knew that she may never make it out of the hospital.

Confused Dizziness

I was on my way home from the grocery store in a neighboring town when the tones for their ambulance went off. Medical box 800, station 8, 18, 28, paramedic 1. Sick person. I decided to go to the scene since I was only two blocks away. I could at least start care until Rising Suns ambulance and the county paramedic arrived. The house is plain, at the end of a cul de sac. I walk in through the open car port door and call out “Fire Department”. My voice echoes through the empty house. There is a kitchen table, and a couch in the living room, but that’s about it. There are a few bags of newspapers stacked on the hard wood floors. I hear a voice from one of the back bedrooms call out. “She’s back here.” A small elderly woman shuffles toward me and tries to explain what is going on, but her story is fragmented and I have a hard time piecing the incident together. I walk to the back bedroom and find Mrs Jones, who is the sister of the woman who led me to her, lying in bed looking like she is in obvious discomfort. “Hi Ma’am. My name is Keith. I am an EMT. What’s going on today?” “I was doing laundry and started to feel sick. I’m dizzy.” Her sister adds some information that doesn’t make sense and confuses my assessment. “Ok. When did you start to feel dizzy? “A while ago.” “Why did you call 911 today?” “It just got real bad.” Dizziness can be nothing or a sign of something serious, like a cardiac event or stroke, especially in elderly patients. I made a mental note that this lady may have a real problem. “Do you have any chest pain?” “No.” “Hold your arms out” She does and there is no drift. They stay straight. “Smile real big.” Her smile is equal. “Say Baltimore makes Dominoes sugar”, which she says without slurred speech. I explain that I wasn’t making her do silly things. That was a test called the Cincinnati stroke test, and while I can’t be certain, it doesn’t appear that you are having a stroke. “Do you have any medical problems?” She tells me she has hypertension, and vertigo. Bingo. “Does this feel the same way when you had vertigo before?” “Yes.” “Do you take any medicine?” “Yes.” “Do you know what it is?” Mrs. Jones tried to fumble through her medication list but had a hard time remembering it. Her sister tried to help, but really didn’t. Can I see the medicine you take? “I feel like I’m going to throw up.” Great. I don’t like vomit. I often feel like joining my patients who are vomiting. Why did I take this run? I didn’t have to. I was on the way home from the store, and now I am going to blow this beautiful afternoon in the back of an ambulance with a puking patient. Hopefully the county paramedic will think this is a critical patient and take it. Mrs. Jones sister shuffles down the hall with a plastic grocery bag full of medicine bottles. I sort through them to give me an idea of what she is taking, which will also help fill in some of the blanks in her history. Mostly they are blood pressure medication and vitamins. One full vial is for vertigo. “Mrs. Jones, have you seen a doctor about your vertigo?” “Yes” she says between wretches into another plastic grocery bag. “Did he give you medicine for it?” “Yes he gave me something, but I don’t have any.” I held a full bottle of Meclazine in my hand, filled a week ago. “Mrs Jones, you are vomiting because you are dizzy, and you are dizzy because you aren’t taking your medicine.” “I don’t have that medicine.” “Yes ma’am, you do. It is right here.” “That’s not mine.” “Yes it is. Your name is right on the label.” “No it’s not.” “She doesn’t have her dizzy medicine.” Her sister adds. “I am holding it right here. Here, look at the label.” I point to her name. “That’s not mine.” “That’s not hers.” Her sister reinforces. I stood there dumbfounded about how I can convince this patient that this meclizine was in fact hers, and it would fix her vertigo. The county paramedic unit arrived and I started to give my patient care report. “This is Mrs. Jones. She is complaining of dizziness that started a while ago but got worse today.” “I know Mrs. Jones.” the paramedic interrupted. She was obviously disgusted by being called to the same residence, for the same problem 4 times in the last 2 days. “The patient is non-compliant with her medication.” Yep. She was. And now I get to transport her to the hospital as she wretches into a grocery bag. We place her on the stretcher and wheel her out through the living room. I look around the barely furnished house. It doesn’t seem like these people are able to take care of themselves as hard as they may try. We load her into the ambulance, and I tell the driver to take it nice and easy to Union. This is a low priority patient. She is sick, but we know what is wrong, and it isn’t a life threat. As we ride to the hospital I try again to convince her that her problem is that she isn’t taking the medicine that would fix her dizziness. She gets agitated and tells me to stop calling her a liar. “No ma’am, I am not saying you are lying. I am just saying you are a little confused about your medicine. This is yours and it is for dizziness.” I point to the bottle. “No its not.” Ok. It’s not. I called social services when I got into the station, not as punishment, but for help. It was apparent to me that these folks were not able to care for themselves. They needed outside help, way beyond the scope of what I could offer. The best I could do was what I did…try to explain this was her medication and it would help, and call social services who hopefully could set up some kind of regular visits to check on the Jones sisters.

The Unlovable

Even on calls where I don’t think I can make a difference, like an obviously dead 90 year old woman who died in her sleep and was found at noon the next day, I can. The family members then become my patients, and how I act and what I say can have a big impact. There are a lot of lonely people out there who use EMS for companionship. And it gets frustrating to respond to the same address time and again, for really nothing medically. And so sometimes, patience wears thin on calls like this. But on those runs where I can show compassion for even the unlovable is where I can make the most difference. I pulled the diapers up on Mary, again. We usually found her on the floor, in a puddle of urine, depends around her knees. It was usual to respond for Mary two times a month while she was alive. She had a perfectly healthy able bodied niece living with her who was useless. She normally stood in the dining room, or sat with her arms folded, unconcerned that her aunt had been sitting in her own feces on the floor for a few hours, and never raised a finger to help us clean up her aunt. The calls to help Mary were often for a person fallen or unknown medical problem. We would arrive, walk in through the chronically open garage door, knock on the kitchen door. “Fire Department.” “Ok I’m in here. The door is open.” Would come the feeble response, and we would enter, find Mary on the floor, next to her potty chair, niece nearby bitching about how “she missed again” doing nothing to help. “Hello Ms. Mary. Are you hurt anywhere?” “Oh, no. I just can’t get up.” “Ok are you sure you aren’t hurt?” “Oh, yes. I don’t hurt anywhere.” “Ok what is the best way for us to help you up?” And the conversation would usually go the same every call, with Mary’s niece yapping in the background. We would get under each arm stand her up, pull her diaper up, or put a clean one on, and sit her in the chair of her choice, usually the one by the front window so she could look outside. This went on for years. Then we didn’t get calls to help Mary anymore, and I learned that she finally died at 89. The quality of her life in the last 5 years was horrible. I watched Mary deteriorate over the last 15 years. She was my first patient as a Maryland EMT. We were alerted for chest pains. I responded by myself and knew I would get there well ahead of the county paramedics since our station was just a mile away. I found Mary sitting in her chair at the front window. She was grey and sweaty and I knew she was sick. Hello ma’am. My name is Keith. I am an EMT. What is going on today? She told me that her chest hurt, and after a line of questions related to her pain, I learned that it started when she took the trash out, that it was sub sternal and radiating to her left arm, that she had a heart attack five years ago, and this felt just like that. I hoped the paramedics were close, because there wasn’t much more I could do for this patient besides give her high flow oxygen. I waited with her for the paramedics, and reassured her. I held her hand and rechecked her vital signs and pain. When they finally arrived, they confirmed that she was having a heart attack, gave her drugs to keep the arteries that feed her heart muscle alive as open as possible to keep the blood flowing to the heart, and we rushed to the hospital. And that would be the trend with Mary and I over the next ten years. There usually wasn’t much I could do for her, except be kind, even in the middle of the night when all she needed was a diaper change. It wasn’t always easy to show Mary compassion. But we always did. It was usually all I could do. I was saddened to hear that Mary died, but I was also relieved. That poor woman’s quality of life was crap for the last five years and at least now it was over. Her house was auctioned. At least it didn’t go to Mary’s niece. It seems that any trace or remembrance of Mary is gone. But I remember her.

Pediatric Arrest 2

John pulled into the station right behind me. He is a supervisor for a construction company, and he normally works nights. John is a solid guy, even keel and good under pressure. He is reliable and I was glad to see him. “This might not be good” I said as I climbed into the cab of the ambulance. “yeah” “793 enroute BLS” I said on the radio “793 echo response for an 8 day old in cardiac arrest. I reviewed the steps for infant CPR in my head and put my gloves on as we drove down the empty early morning roads. 8 day old kept repeating in my head. “I’ll grab the O2. You grab the med bag.” I said as John pulled into the driveway of an old small white farmhouse. I hopped out and hustled to the front door. An older woman met me. “I think she is ok now.” I walked into the living room where a young high school aged mother sat in a love seat and held her sleeping baby on her lap. Her sister sat on a couch and her mother, the woman who met me at the door, sat next to her. The baby was pink, and breathing. Ok. Good. For a minute I didn’t know what to do. I was so intent on infant CPR, that I forgot what to do for an infant not in arrest. Ok breathing, adequate. Pulse. I felt for a pulse on the brachial artery on her upper arm and after changing positions a few times finally felt the faint rapid tap on my fingers. I got the story from mom, and grandmom interrupted frequently. She was feeding her baby when the little girl suddenly projectile vomited. Her face turned deep red. “Did her face turn blue or purple?” I asked as I took my stethoscope from around my neck. “No.” “How long did this last?” “About a minute, then she started to cough and choke” “But her face stayed red, it didn’t get blue or violet?” “right” “EMS lieutenant 73 dispatch negative arrest.” I said over the radio to let other units to know they can reduce their rates, they can relax. I was still on edge. Something happened that scared the hell out of this family, and so I was scared too. I listened to this little girl breathe. The large head of my stethoscope covered almost her whole chest. I was listening for any abnormal noises in her lungs. She could have aspirated, or inhaled vomit into her lungs which would explain the coughing and choking mom described. All I could hear was the whisper of air moving into and out of her lungs unimpeded. It didn’t sound like she inhaled any vomit. We taped a pulse oximiter probe to her foot, to check how much oxygen was circulating in her blood…100%. She didn’t have any medical history, wasn’t taking any medications and was delivered at term without complications. She appeared to be a very healthy baby girl, who just scared the hell out of her mom, aunt, grandmother and about a dozen first responders. Paramedic 1, and our EMS chief arrived. I gave my report and they felt that I could transport the baby as a BLS patient, that she didn’t need any advanced life support measures, and I agreed. John drove non-emergency to the hospital, as I closely monitored the baby. I was afraid of the what ifs…what if this baby went into arrest enroute? What if she vomited again but aspirated this time? I was confident I would be able to handle any situation, but still I was afraid. I tried not to show my fear. I need to present confident and unshaken to my patients to gain trust. And I had a 16 year old EMT student riding with me. I explained what was going on as we drove to the hospital, explained that I was thinking of possibilities to the EMT student, and preparing for them mentally. I had the EMT student check vitals every 10 minutes, and I rechecked him until I knew I could trust that he was giving me accurate information. I kept the protocol book opened to the infant bradycardia and infant CPR algorithms, and anticipated problems. I usually don’t ride with the protocols open, I know them. But I don’t see many infants in my practice so the open book was a reassurance that I knew what to do. I was very attuned to this baby. When she fell deep asleep, her heart slowed, and oxygen levels dropped, but all stayed within the normal range. However I was ready. I knew where the infant BVM was, and I knew where we were and what ALS was available if I needed it, or if it just made more sense to run like hell to the hospital. I called the hospital on the radio to give them a report of our patient, so they were ready for our arrival. They waved us to room 19 where 2 nurses waited. I told them what we saw, what our exam found, and that transport was unremarkable. They took it from there and that was that. From complete terror to mundane. I met with the charge nurse and asked if there was something different I needed to do for my patient, if there was something I missed in my assessment or a treatment I should have implemented. She said no, you did everything great. We are calling this an ALTE (Apparent Life Threatening Event). I thanked her and we left after putting a clean sheet on the stretcher. My knees got weak when I went to climb into the cab to go home, when I realized the call was over, we are clear and we delivered this infant to the ED alive. It was ok to feel a little weak then. I got home at 5. I tried to sleep for an hour, got out of bed at 6 and went to work.

Pediatric Arrest 1

The pagers tones pierced the dark bedroom. Somehow Joyce ignores these. At least she doesn’t complain if they do wake her up. I listened for the dispatch “medical box 707, station 7 72 73 paramedic 1, cardiac arrest for an infant 0200 hours”. Oh God no. Please no. I laid in bed for a minute, eyes wide open and debated about going. I knew I would be the first one on scene, and that there was a very good chance I would need to make some critical decisions… I would need to quickly determine if the baby was in cardiac arrest or not, and if in arrest, was it workable, or was this baby dead beyond any help? I was afraid that my skills weren’t sharp and practiced. We don’t see a lot of pediatric cardiac arrests, thank God. I was afraid of what I might have to tell the parents. Infant cardiac arrests at 2 am don’t always turn out good. Any cardiac arrest at 2 am usually doesn’t turn out good. I knew that I would most likely be there by myself for a while. There are 6 people that run EMS out of station 73. I knew two of the 6 were working that night, and one was sick. I could feel my hands shake as I pulled my boots on and headed out the door. Images of the last pediatric arrest I was on shot through my mind as I drove to the station. I was the officer on the engine running an automatic alarm about 10 miles away from our station. We were two miles from the station when the cardiac arrest was alerted. I hit the lights and siren and called dispatch to let them know we were diverting to the medical box, that engine 7 could handle the alarm. Charlie responded in brush 73. We pulled up behind the brush truck to the front of a well kept rancher. I was directed to the back bedroom by an older man when I entered the front door. The 2 year old boy was on the floor and Charlie was doing compressions. I felt bad for the kid, for the family and for Charlie. He was here by himself for a few minutes. It’s a hard place to be, especially alone. The child reminded me of my son who was about the same age. He looked like he was sleeping. His skin was pale, but not ashen grey like many arrests. Most times you walk into a room on a cardiac arrest you can tell someone is dead just by looking, you don’t need to feel for a pulse. He didn’t look dead. His red hair and pale skin made him look like he was just sleeping. He had a red and white striped shirt on, like Waldo wears. I told Charlie to stop compressions and to set up the Bag valve mask with 25 lpm O2 attached. I felt for a pulse. His skin didn’t feel cold. It felt warm. I thought we had a chance. I opened his airway by gently tilting his head back and tried to get to get a breath in with the bag valve mask. I felt resistance and his chest didn’t rise. I repositioned his head and tried again. Again no air got in. Maybe that’s why this boy has no pulse. He choked on something. I looked into his mouth and didn’t see anything. I started back slaps. Nothing came out, and I had a hard time getting air in. I tried back slaps again, with the same result. I tossed the bag valve mask to the side and tried to blow into his mouth with mine and tasted sour vomit on his lips. I got some air in, but there was a lot of resistance. I didn’t understand but went back to chest compressions. I asked Charlie to take respirations, and each breath went in, but slowly and with a lot of resistance. “Sir, when was the last time you saw him?” “About 3 hours ago. We put him down for his nap and found him.” “Does he have any medical problems?” “No, not that we know.” “Any allergies.” “No.” “Was he on the floor on in the crib?” “He was in the crib. I put him on the floor to do CPR.” The grandfather stood behind me as he answered my questions. He put his hand on my shoulder as I did compressions, as if to say I appreciate all you are doing, but it was more than that. It was a prayer from grandfather through me, to give me what I needed to save his grandson. My compressions kept blood, and hopefully oxygen flowing to the brain and heart, buying time until advanced life support could get here. I heard paramedic 1 arrive on the radio. Jane came into the bedroom a minute later. “Last seen 3 hours ago. Grandfather came into the room to get him from his nap and found him in arrest. Started CPR. No history, no meds no allergies. I had a hard time getting an airway, and its still a struggle to get air in.” I gave my report to the paramedic. She put her airway bag on the floor and assembled her laryngoscope, a flashlight handle attached to a metal blade with a light on the end that allows paramedics to visualize the vocal cords which signify the entrance to the trachea. Air travels from the nose and mouth through the trachea into the lungs. Paramedics must pass endotracheal tubes through the vocal cords in order to successfully establish a secure airway. If they pass a tube without seeing the cords, or at least the arytenoid cartilage below the cords, they run the risk of tubing the esophagus which puts it into the stomach and does nothing for delivering oxygen to the lungs. Jane inserted the laryngoscope blade into the boys mouth and when she pulled up to move and hold the tongue out of the way she quietly said to me “How long has he been down?” so the grandfather couldn’t hear. ”Last seen three hours ago” “His jaw is rigored, I can’t get the tube. Oh Jeeze. We should call it” I felt like a fool for not recognizing that the boy had been dead long enough for rigor mortis to set into his jaw already. That explained why I had difficulty opening his airway and ventilating. We continued to work him, but I knew it was pointless. Still I kept at compressions with an acute focus. Everything was deliberate. The entire world existed in that room with me, Jane, Charlie, the grandfather and child. Station eights ambulance arrived and I asked Jane if she was ready to move. I told everyone what the plan was: I was going to carry the child to the ambulance. Everyone else was going to clear a path and hold doors. “Ready?” I asked, as I scooped him up and hurried towards the door. I heard a sobbing female voice come from a bedroom across the hall as I entered the living room. “Where are you taking him?” I climbed into the back doors of the ambulance that was parked in the driveway, placed the boy on the stretcher and started compressions again. Usually I would hand the patient off to the crew of the ambulance but not this time. The rear doors closed after Jane got in and we started to the hospital. She continued to attempt an airway with no luck, and I kept compressing his chest. Sweat dripped from my forehead onto the stretcher. We arrived at the Hospital and whisked the stretcher into a room packed with doctors, nurses and techs. They took over compressions and airway attempts. I watched as they transferred him from our stretcher to the hospital bed and got pushed further to the back of the crowd so that I wound up watching their resuscitative attempts through a window. I prayed that it would work, but knew in my heart it was too late. I tried not to cry. I tried to hide from other providers and ED staff. We don’t cry. Maybe we should, but we don’t. Kay saw and led me away past other firefighters, EMTs nurses. Kay is a 65 year old EMT and EMS captain at my station. She works in the Hospital ED as an ER tech and has been doing ems for decades. She knew everyone and everyone knew her, and she had a huge heart for sick and injured people. Sometimes her huge heart got her into trouble. So when I started to sob, she knew. She had been there. There isn’t really any private space in the ER, but we found a corner where she hugged me and let me cry and just said “Its ok.” We walked back to the room where the ED staff worked to resuscitate the boy. An ER tech said to me “can you believe his mother didn’t want him anyway?” I was too numb to let that idiotic comment register. Everyone responds to fear and stress different I guess. I was there when the doctor said “we’ve been at this for 45 minutes and there is no change. Can anyone think of anything we are missing?” Silence. “Can anyone think of any reason we should not stop?” More silence. “Time of death 1453.” I haven’t fully recovered from that yet. I don’t think we ever really do. I haven’t forgotten and don’t think I ever will. I don’t want to forget. I just hoped tonight wasn’t going to be a repeat.

Fear Control

Whether I think this is their worst day or not really doesn’t matter. They think it is and that’s what matters. And how I handle myself can have a big effect on the patient and family, regardless of severity. A big part of that is learning how to control my fear. I’m good at not outwardly showing my fear, at staying focused and on task and delivering good patient care through the fright. However, I’m not good at completely controlling fear and sometimes that means I let fear lessen my emotional control, which often manifests itself as anger. There are a lot of things to be afraid of in EMS. My biggest one is the fear of missing something big, of missing something that results in not doing the right thing for the patient, which results in a poor outcome for the patient. There is also the fear of not being perfect. In medicine we are expected to be 100% 100% of the time. It’s just not realistic. But the expectation remains There is always someone coming behind me. When I deliver a patient to the ED, a nurse checks my assessment and treatment, a doctor does the same. Most of my patients are not critical, and most times if I miss something it’s not life threatening. But it is pride threatening. My fear is that my assessment and treatment aren’t right, even on low priority, non-critical patients. I know my skills are good, but still there is that fear of missing something, that fear that results in the always present question will I be good enough, whatever the situation? I can’t hold myself to a standard of perfection, but I can hold myself to a standard of continuous improvement and learning. An instructor I had said he frequently will pull up an ER doctor after working on a puzzling or difficult patient and say “Doc, educate me”. I like that line and I use it. I am not too proud to learn. I don’t want to be that medic with a poor reputation. I want to be the medic people who know me would be happy to entrust the care of their loved ones to. My willingness to learn and be taught has lessened my fear of not being perfect. There is also the ever present fear of personal safety. We get hit by cars. We die in ambulance crashes. We can get the diseases our patients have. And more and more, we get assaulted by our patients, our patients’ families and bystanders. I am always looking around, and over my shoulder. I keep the door to my back, and never let anyone get between my partner and I and the door. Responding alone as I often do as a volunteer heightens all of these fears. I don’t always have a partner to rely on to catch things I miss, to watch the scene as I assess the patient.

Clueless Perception

I have the opportunity to enter people’s lives on what is often the worst day of their life, or at least they perceive it to be the worst day of their life. A lot of times its not, and while the patient, or family may think their world is collapsing, the patient, on the scale of patients I have encountered, is relatively healthy. That doesn’t mean they aren’t sick, or don’t need medical care. It just means that the patient isn’t as critical as the family or individual thinks. And sometimes the opposite is true. The family has no clue about how bad the situation is. I was on my way to the store when the pager opened up “Medical box 707, station 7, 72, 73. Paramedic 1, unresponsive overdose, 5555 Rock Road, utilize EMS ops, 1553.” I was less than a mile from the scene so I responded to the house. Unresponsive overdoes often turn into respiratory arrests, and I knew I would be the first one there. I reviewed CPR steps in my head. I pulled into the driveway of the run down cape cod at the same time as Paramedic Tom Higgins. The front screen door was hanging by one screw on one hinge, some of the windows were broken, and the lawn hadn’t been mowed in weeks. I entered the home cautiously, not really sure if this was a safe place to be. Tom and I came into the living room where a group of 6 people sat and watched tv. One of the 6 was a 20 something female seated on the couch. She was blue and non-responsive. Tom and I knew immediately that she was at least in respiratory arrest based on her color, if not in cardiac arrest. We moved her to the floor. I opened her airway, and got two breaths in with a bag valve mask which is a bag that squeezes air into the patients lungs through a mask that seals over the patients nose and mouth. I checked for a pulse and was relieved that her heart was beating, but slow. I inserted a nasopharyngeal airway, essentially a length of surgical tubing with a trumpet flair on one end and a beveled edge on the other that is inserted into the patients nostril. Nasopharyngeal airways help keep an open airway without causing a gag reflex. I continued to squeeze the bag valve mask once every 5 seconds as Tom started an IV and drew up narcan into a syringe. The family still didn’t realize how serious this patient was, how close to death she is. They continued to watch the price is right on the tv behind us as we worked frantically to restore her breathing. When asked how long she hadn’t been breathing, the mother said “Not breathing? We thought she was sleeping.” Narcan counteracts opiate overdoses, and not long after Tom administered the drug, our patient started to breathe on her own. I make assumptions about people a lot. I try not to, but experience usually proves right. The house was dilapidated, the living room dirty, the family clueless, and the patient overdosed on an opiate. I automatically assumed she had overdosed on heroin, either accidentally or intentionally. The reality was that this low income family can’t catch a break. Our patient was in a car accident one year prior that broke her back. She overdosed on prescribed pain pills because of a change in the dosage. There was nothing intentional about her condition. Nor was she abusing or taking illegal drugs. We often look down at overdose patients. I know one paramedic, Rob, who uses these episodes as teachable moments. He has an excellent calm, non-demeaning manner and gently says you came close to dying today. Maybe you can get the help you need now. He has a respect for these throw away addicts, that many don’t. Most people don’t look at addiction as a disease process. They look at it as a weakness, something people choose to do, and something that people can easily stop. Just say no for Christ’s sake. It’s not that easy. My perception changes depending on the mechanism of the overdose. Not breathing because of illegal drugs? Get what you deserve. Not breathing because of accidental od on prescribed pain meds? Poor thing. I wish I were more like that Paramedic, Rob. Maybe this is because I need a reason to deal with tragedy. When I see a dead 20 year old, I need a reason why. Overdose on illegal drugs is a preventable thing and it isn’t just some random act. It gives a sense of security I guess. It makes sense of the senseless. Don’t do drugs, and you don’t wind up like that. It’s a simple cause and effect thing that makes sense to me. You did that therefore, this happened to you. Sorry for your luck. Next patient please. It’s the ones that don’t make any sense that are the harder to deal with. Our patient was alert by the time we got her to the hospital, and had significant back pain since the narcan counteracted all of her pain medicine. She was near tears. As we waited in the hall for a room, she realized there was something in her nose, looked cross eyed and pulled out the nasopharyngeal airway, obviously puzzled. We placed the patient in bed 17 and wished her well. She didn’t care too much about that. Her back hurt bad, and she wanted medicine to fix it, the same medicine that almost killed her an hour ago.

About Volley

That’s a nick name for volunteer Firefighters and Emergency Medical Service workers. Its one of the nicer ones. Squirrel, tick are a few of the more derogatory. Regardless, I am proud to be a tick, squirrel or volley. I have been since I was 14. The majority of the emergency medical and fire protection provided to the citizens of this country are provided by volunteers. That dosn’t detract from the excellent work of the legions of paid fire and EMS professionals, but rather sets the stage for the stories that follow. Volunteers respond for most people in this country when they dial 911, and most people don’t know that. The majority of people providing protection to your families are just average neighbors who do so without compensation.

It seems that fewer and fewer people are volunteering. It seems this country is losing its volunteer spirit, and more people are asking what’s in it for me rather than asking how can I help. So part of the motivation for writing these accounts down is to document the amazing things ordinary citizens are doing to help strangers, and sometimes neighbors we know, under what at times can be very difficult circumstances. It’s also to show that EMS is not all blood, gore and vomit, nor is it all about saving lives. In fact all of these things are more rare than common. Yes we see blood and vomit, but that’s not in the majority of patients. I say this because the reality of EMS has often been portrayed as every run is a lifesaving run, and every patient bleeds or pukes. That’s just not the case. I once heard a speaker at an EMS conference say EMS is 90 percent boredom, 10 percent terror and in my experience, those statistics are spot on. I think everyone in EMS has heard time and again “I could never do what you do.” And the fact is that yes, you can. You just have to want to. Hopefully these stories will show that you could “do what we do” and may inspire some more people to volunteer. I don’t know what the draw of EMS was from such an early age. My parents were not involved. In fact they weren’t happy that I was. My great uncles were firefighters, but I wasn’t surrounded by fire and EMS. If anything I was discouraged. But still as soon as I was 14, I joined the local emergency squad. My involvement has waxed and waned over the last 30 years, and I have served as both a paid and volunteer provider. The incidents I respond to still continue to teach me significant lessons about life when I let them. These are just my stories. Every EMS worker out there has tons. Some call them war stories, but I hope you will see as you read these accounts that these are more than stories of gore and heroism. They are more about people dealing with life, and other people brought to help in some way. This doesn’t set me apart from the hundreds of thousands of other volunteers out there serving their communities, and I am anything but an expert. In fact I can think of many who are more qualified than I to write this. But these are my stories. These are the ones that inspire and motivate me. It is my hope that this collection of stories will inspire more people to get involved, and become volleys. This is dedicated to the EMS providers across the country who selflessly provide care to others, and their families who often get left alone as we respond.