Fake Code

Three year-old vomiting copius amounts of blood. Lights and sirens response. I'm thinking. No way. We get there, the kid is okay. Alert, good color. Has a bloody nose. Has a history of bloody noses. The blood in the sink isn't a whole lot. Bright red -- just spit up from blood from the nose. The mom doesn't want to go to the hospital. She says she'll take the kid to the pediatrician.

We had our paramedic student/ veteran nurse riding with us today. We set up our fake code in the back room. It was interestiung to see her go through it. She is very smart, very experienced, runs codes in the ER, knows her stuff, but having to run a chaotic street code, was frustrating for her.

The way we do it is I start out as a patient having chest pain. One of members -- a seventy six year old Italian lady -- plays my mother, and she harrasses the medic student as she tries to treat me. "Help him, can't you help him!"

My chest pain quickly deteriorates. I keel over -- in arrest. The patient then becomes the two maniquins we have on the floor -- an Intubation head and a CPR mannequin. She gets CPR started, then goes for the tube.

After a few minutes, my "mother" brings over the heart monitor and says "What's this machine for? Can't you help my son? he doesn't look very good."

The patient has to be treated, loaded on the stretcher, extricated to the ambulance bay, loaded in the ambulance, driven around the block with CPR, a patch made to the hospital, then unloaded again.

She was very embarrassed she forgot the monitor/defibrillation. Hey I told her -- that's why we're doing the drill. You know ACLS cold, I told her later, you just need to learn the coreography of an EMS code. I wish I'd had more practice before my first one on my own years ago. What a disaster that was.

I went over with her, how to lay out your equipment, how to see the big picture, how to order people about, how to get the code run and the scene controlled and to extricate the patient and not forget to bring your equipment along. We'll do it again next time she comes in. She will be very good once she gets some calls under her belt.

The only call we did was for a guy who drank, shot up some heroin, went to pick his sister up, then passed out in the car. She called 911, by the time we got there he was awake and alert, though sluggish. With the persuasion of an officer, we took him to the hospital -- he really didn't want to go -- and once there he walked out before we had even finished our paperwork.

Alerts

We're called for a stabbing. The teenage girl says she doesn't want to go to the hospital, just give her a band-aid. The firefighter tells her she might need some stiches. She doesn't want to go. I look at the wound. There is a 1" puncture/incision wound under her left shoulder blade. The bleeding has stopped. I ask her what she was stabbed with. She doesn't know. She said she was just sitting there and some girls came over and then was a fight. She doesn't know anything. If she does she isn't telling.

We lead her to the stretcher anyway telling her she needs to go. I have no idea how deep the wound is. When I try to lay her down on the stretcher, she screams. Her rib hurts. I have my partner go on a priority. Her lungs are clear and equal, but she is breathing shallowly. I give her some oxygen and put in an IV, while my partner calls the hospital. She is sweating now and getting more short of breath. She is crying. I'm starting to get a little worried about her.

In the trauma room, they give her the workover. When they lay her down her heart rate goes up to 140. They sit her back up, it goes back to 112.

Later, they list her in stable condition.

***

There are basically three places patients go when they are taken to an ER. They get an alert, they get a bed -- either in a room/alcove or the hallway, or they go to the waiting room. An alert is either the trauma room, a code room, or just a doctor and a bunch of staff piling in the room to see what is up with the patient. If I think someone needs an alert, I call the hospital and notify them. There is a general feeling that if you call an alert, the patient should merit one. You don't want to cry wolf, but you want to be a good advocate for your patient. Sometimes, like with the stabbing, we just lay out the facts and let the hospital call the alert. Other times we request the trauma room or a stroke alert, etc.

The stabbing you just don't know. You can never tell. Some calls are obvious. Others -- particuarly traumas -- you do your best, use your best judgement. You head to the hospital as fast as you can and hope they are okay. I've had a lot of traumas where I started on a priority, then came to realize as I did my assessment the patient wasn't really that bad off. This girl, I was starting to worry about her. Our scene time was five minutes. Total call time ten.


***

I had two medical alerts today. One was an asthma from a doctor's office. She was very tight, and hacking up yellow phlegm. I gave her a breathing treatment, some fluid, and called for orders for solumedrol, which they granted me. She was doing better by the time we got to the ER, but she needed attention. She was coughing up a storm so a respiratory therapist gave her some nebulized lidociane and that worked pretty well. I had never heard of that treatment before.

The other call was for a mentally disabled person from a group home not feeling well. She had a history of frequent UTI's, and they said she tended to get hypothermic whenever she got sick. She was in no distress with good vitals. I didn't even tech the call. She didn't even feel that cold. Her core was warm. She had good capillary refill. I drove. We got to triage and because her temp was low, the nurse called a medical alert. I was surprised. The doctors and the staff wanted to know why we were bringing the patient into an alert room. We just looked at the triage nurse, who explained to the others her temperature was 93-something by their stick it in the ear thermometer. Hospital protocol. So they wrapped her in a thermal blanket. I didn't think she needed an alert. But what do I know.

I never found out the final disposition of any of the patients.

My job is to just get them to the hospital.

***

Did three other calls. An elderly man who tripped in the parking lot, and bystanders called 911. His wife was a little Italian lady and she was giving the cops the business. "He's fine. Why are you bothering us. We're law-abbiding citizens. You can't have him. You're not taking him from me. he's okay. leave us alone."

The cop was laughing. "I haven't argued with a bad man as much as I am arguing with you," he told her.

I checked the man out and he was okay. He signed a refusal.

***

Took someone home from diaylsis.

Did another respiratory distress. I gave her a combivent and was calling to get her some Solumedrol too, but I couldn't hear the hospital on the radio. That sometimes happens with one of the hospitals.

Overtime Pay

Eight hour shift. Did three calls. Nothing too serious.

A pregnant woman feeling dizzy who went to her doctor's for an ultrasound. He called because she was dizzy and short of breath. She said she has been dizzy and short of breath during the entire course of her pregnancy. Saw her regular doctor the other day and he said she should just deal with it.

A lady with cancer who had a near syncopal episode on visiting her doctor for a regular appointment.

A nursing home patient with heavyness in her left arm. She said she has had the heaviness for years, and the doctor's haven't been able to figure out why. What was different today? I asked. I had a new nurse she said.

I worked them up. Did I make a difference today? No. But I did my job.

***

I was thinking today when I started I looked around and saw all these other medics working six and seven days a week(in those days there wasn't the overtime available, but there were more companies to work for, so many medics worked for two or three different companies), and told myself I would never get in the position where I had to work overtime or two jobs to make my payments.

Back then I was living in a one bedroom apartment paying $550 a month. I was living on maybe $32,000 a year, working only three days a week.

Now look at me. I make way more than that now, but I've got a morgage and bills to pay. I need to work. Not that I don't like it. I love the work. I was just thinking this morning when I was at the gym. I wouldn't mind spending more time there. I've been studying to be a fitness trainer. It'd be nice to have a part-time job as a trainer. I think I'd be good at that. It doesn't pay what paramedic overtime pays though.

Some One Else's Name

Last night I went to a going away party for an old partner of mine. I was glad there was a good turnout.

In EMS people work at a place for years. They come in to work everyday, work long hours, and give it their bes. They become a part of the life, of the city they serve. Then they quit or they get hurt, or in rare cases retire. The next day the work goes on, and it is if they were never there.

My old partner worked the city for 14 years. We were full-time partners for maybe two or three, but over the last six worked together occassionally on overtime shifts. We have many stories between us. Many of which we retold last night.

Life hasn't been the greatest for my friend in recent years -- he an MI, and has been going through a divorce, which is almost final. As soon as it is, he is leaving for Florida. He wants to work an ambulance job, but says he'll get a Home Depot job if neccessary. He likes the sun down in Florida and knows some people there.

Like I said, I was glad a lot of people came out to pay their respects.

At work they'll cross his name off the books and write in someone elses.

***

We did four calls: blurred vision with a headache, fall with a possibility of a seizure, a rectal bleed, and a nursing home patient with hallucinations according to the staff. The nurse said the patient was trying to get out of bed because mice were after her. The patient denied seeing any mice.

We had to break in to the fall house. I've been there many times before, so I told the cops how to get in. I reached up and pried opened one of the bedroom windows, then boosted a female cop up through the window, and she she went sliding in, legs up in the air, then went around and opened the door for us.

Bullet in My Brain

The Terry Shiavo case has been all over the news. Shiavo is the forty-one year old woman who has been in a vegetative state for the last fifteen years. Her husband is ready to have her disconnected from her feeding tube. Her parents want to keep her alive.

I understand it is hard for people to let go of loved ones. We see it all the time in patients of advanced age without mental capcity and multiple medical illnesses, who are still full codes.

And I understand that Terry Shiavo is a relatively young person, but I would not want to live like she lives. I know few people in EMS who would.

We walk out of a nursing home after bringing a vegetative patient back from the hospital trip. "Just put a bullet in my brain,” my partner says.

***

Three calls: an elderly insulin dependent diabetic who forgot to eat and was unconcious until I gave her some D50 and woke her up, an MVA with no injuries, and an old man with an injured hand from smacking it against the bed rail.

Routine

When I first started in EMS I remembered everything that happened, every patient's name, face, details of the life and home. Now here I am at the end of the day, struggling to remember the calls I just did.

There is a tedium to the job. The calls I did today didn't challenge me at all -- I went through them on autopilot, eyeballing the patient, feeling their forehead and pulse, putting them in a johnny, listening to their lungs, getting the patient on the stretcher, asking the neccessary questions of people on the scene, getting them in the back of the ambulance, taking their blood pressure, telling my partner to head for the hospital non-priority, putting in an IV line, drawing blood, putting them on the cardiac monitor all while continuing to assess them and get the history, writing the run form as I talk, labeling the bloods with the patient's name and time of draw plus my initials, cleaning up the wrappers, neating up the back, writing the triage form for the hospital, making the radio patch, switching from the onboard back to the portable o2, getting everything done so when we hit the hospital, I'm ready to jump out, wheel the patient in, hand the triage slip to the nurse, get assigned a room, find a bed for the room, get the patient over, find them a pillow or use bath blankets as a makeshift pillow, hand the bloods to the nurse, give her the report, say good bye to the patient, call and get times, drop off the run form, wash my hands, make a little small talk with the people I see everyday, grab something to drink, then get back in the ambulance and do it all over again.

The benefit of the tedium -- of the regular, the ordinary -- is you get in the routine so that when you have the call where you have to hurry, you are so conditioned to get everything done that you can actually maybe make a difference.

Here's the calls I did today (after consulting my run forms):

An Alzheimer's patient with a bruised hip, who babbled all the way to the hospital. The hospital gave her a cocktail of drugs not for her pain, which she didn't have, but to shut her up.

A woman with COPD coughing up green phlegm and running a low grade fever.A man coughing up green phlegm running a low grade fever. The guy's wife wanted us to wait there with them at the hospital until he was seen so we could take them back. No.

And a lady with gross hematuria, who the doctor thought might also be having an MI based on her ECG, which showed a slight ST depression. She was having no symptoms other than an episode of chest pressure the previous day. I asked for a copy of the old MI. They had to go find it. Looked the same. The doctor wanted a cardiologist paged stat as soon as we got to the hospital. I dutifully relayed the message to the triage nurse. We'll let the ER doctor make the call on the that she said.

They had patients up and down the hallways. Some very sick people, others not so sick.I punched out and will back tomorrow.

Morbidly Obese

Back to work after a week hiatus-- my longest time off in over a year. Was actually able to swap shifts so I only had to take one vacation day.

How did it feel to be back at work after a week? Like I never left.

Did seven calls, including two extremely heavy patients. One morbidly obese woman -- 40 years old -- with multiple medical problems, CHF, HTN, IDDM, MI, osteomyletis, MRSA, pnemonia, having trouble breathingI just gave her some oxygen by cannula – I didn’t know what was causing her dsypnea other than being overweight and sick.

When we finally got her comfortable on the hospital bed -- it took forever, because she was so hard to manuever on the sheet -- you just could not lift her up, I asked if we could do anything more for her, she gasped, "Get me someting to eat. I'm hungry."

They ended up intubating her.

Stripped

Worked in the city today. They gave me the same old car they always give me. It is the oldest car in the fleet. I get it because it has more leg room than the new cars, but it is noisy and often in need of repair.

When I come in at the start of the week the scenario is not uncommon: Get a mechanic to jump the car, rebuild the ambulance -- it always gets stripped by other crews -- then finally get on the road.

Today, we got the ambulance jumped, then I had to find a monitor, then find monitor batteries, then find a glucometer, and rebuild the IV shelf. Took us an hour to get ready.

Then they sent us on a BLS wait and return. Then another one. All we did was BLS.

Fingertip

Two calls again, and again both in the morning. I am liking this. One flu and a degloved finger tip that the hospital was able to sew back on. I gave the guy some morphine and put his fingertip in a bag and put the bag on ice.

Like a Dead Man

Did two calls in the morning -- a headache and a flu from a nursing home, then nothing the rest of the shift. I slept on the couch like a dead man.

MI-Inferior Posterior

MI-Inferior Posterior

MI-Right Sided MCR4

MI

A guy passed out driving, had severe chest pain in his right arm. He was awake when we got there, but he looked like crap. Pale, grey, like death. He was holding his chest. He was only forty, but he looked sixty. Some hard miles on him.

I put him on the monitor. Massive Tombstone ST elevation in the inferior leads with the characteristic depression inverse elevation in VII and III that suggests posetrior involvement. I did a quick MCR4 to look at his right ventricle. Tombstone there as well.

02, ASA, double lines( a 14 and a 16) all on the way to the hospital. I called ahead to tell them I was coming in with an acute MI.

They were ready -- not a free pass to the cath lab, but at least they had a room and nurse waiting with their 12 lead machine and she called the doctor over as soon as I came in. He was on the phone to the cath lab shortly after that -- he didn't even wait for their ECG-- and they were getting ready to wheel the patient up to the cath lab as I was leaving.

Someday they will let us go right to the cath lab, but in the meantime, I think having the doctor nurse and room ready works okay.

I heard later they cleared the blockage and put in a stent. He’s in intensive care, but doing all right.


***

Gave morphine to a lady with kidney stones. Did another abd pain and an MVA

Dirty Wet Day

Arranged with my relief to come in two hours late this morning in return I would stay two hours later this evening. It is now past six. There were no calls during what would have been the first two hours of my shift. I'm hoping for none now. In the meantime we did four calls.

A broken wrist, a fall with a head lac, a motor vehicle where the driver fell asleep and took out a telephone pole, earning a trip to the trauma room for his chest pain and sore ribs, and a fall on the ice that hurt all over.

Another dirty wet day. I need to go wash the ambulance again.

Forty Minutes to Go

Today started off busy. A possible heart, a muscle pull, a fall with multiple skin tears from a nursing/residential community, and a diabetic whose blood sugar was 30 from not eating, and who signed a refusal after I gave him an amp of D50. Then nothing.

I went in the back bedroom and crashed for over an hour.

I feel like I could still use a day of sleep.

Got up, washed the ambulance which was brown from all the dirt on the road kicked up from the melting snow and ice.

Ten hour shifts

Today was one of those long days. Cold windy. The sun made you squint. At least it melted some of the ice away from yesterday's storm.

Ten hour shifts suck. The eights go quickly, the twelves you are there knowing you're working for the haul, the tens, just suck it out of you.

We did seven calls, nothing really interesting, but all sort of wearing.A cut finger, a difficulty breathing, a diabetic, a vomiting depressed person, an MVA, a return from a doctor's office, and a flu.

Command

Busy day in the city, but a good day. It was one of those days where I just felt in command of my job and work. Whether is was calming down a pscyh, treating a chest pain, handling an asthma, or for that matter just knowing the best way to get from one part of town to the next, everything went well. I have days where I fumble all day long. Today was just smooth.

We went to the lockup for a psycho junkie who was bouncing off the wall. She was simultaneously in withdrawl and in a rage against the officer who had arrested her. She was fighting and punching and spitting, but it was like her punches weren't landing on me nor her spit, and I was able to get her down on the stretcher easily and held her almost with my voice while the cops shackled her. Then she started going nuts again. This one cop was really pissing her off. I don’t know what it was between the two of them other than he had arrested her.

In the ambulance, she was trying to pull her hand out of the cuff and was trying to bit herself. I gave her some Ativan and Haldol IM so she wouldn't hurt herself, and she calmed right down.

We went into the ER and they had five or six security guards along with the cop there. Everyone was like “where's the psych?” There was just a quiet girl on the stretcher, but then she saw them, roused quickly and started going nuts again. I tried to talk her down some, and got most of the guards away.

Then once we got her in the room, and restrained on the the ER bed, and the cop out of the room, she slept like a baby.

Later we got called for a girl with post traumatic stress disorder, who was flipping out over an incident that reminded eher of when she was raped. The cop said she didn't want to talk to anyone. Some bystander had taken to her aid and wasn't letting anyone talk to her. I went right in and calmed her down, explained how going to the ER was the best thing, and I could get her help there. Worked like a charm. She told me how nice I was and thanked me.

Seven calls all told, a seizure, a chest pain, an asthma, three anxieties and a detox.

Stroke Protocol

Working a Sunday and it gratefully has been as slow as Saturday. I got in a nice nap this morning, brought in a patient with the flu, and had just fallen asleep again in the early afternoon when we got a call for a stroke at a nursing home.

The lady was flaccid on the right side, and although she had some dementia, was a full code. The nurse told me that she was summoned by nursing aides at 1:45 and found her leaning to the left. The aides said she was fine, then they noticed her leaning to the left. So 1:45 is the onset time? I repeat. That's right, the nurse says.

The time of onset is critical in order for the patient to recieve a therapy called TPA, a drug which can bust the clot causing the stroke if administered within three hours of the onset.

Here's a link with the guidelines for use of TPA and one about its benefits:

www.stroke-site.org/guidelines/tpa_guidelines.html

href="http://www.medicinenet.com/script/main/art.asp?articlekey=38883"


We go to the hospital on a priority and I notify the hospital of a stroke alert. I tell them on the radio that onset is 1:45. After I finish my report, they ask what time the onset was. One forty-five, I say, quarter to two. When was she last seen? they ask. She was seen at 1 forty-five by people in the room who said she was fine before. What is her normal baseline they ask. Dementia, but alert, This is a new event. One forty-five onset. She is a full code. No history of stroke.

I am a little aggravated because as sometimes happens they don’t listen to you, forcing you to repeat yourself when you are busy trying to take care of the patient. It didn't matter so much with this patient, as I have done everything I need to -- Ecg, IV, blood sugar, 02, neuro tests, the works -- and she is stable.

At triage, the nurse asks me when it began. One-forty-five, I say.

But when was she last seen before then? At one-forty-five, I say. A nurse was summoned to the room because the aides noticed she was leaning to the left. The aides had been in the room with her and said she was normal, and then they noticed she was leaning to the left, and they summoned the nurse. So the onset is 1:45 or maybe a couple of minutes before.

We could call the nursing home, the nurse says.

1:45, I say, Quarter to two. Onset. She was alert, then she was not. The stroke clock begins at 1:45.

I have to then go over all the rest of my findings with the nurse, who finally calls the stroke alert, and we take the patient down to the room.

A doctor who I have never seen before comes in and I give my report. Onset 1:45, I say. She was noticed leaning to the left. She had been fine.

What was she before, when was she last seen? One forty five onset, I say. The aides were in the room with her. She was fine, then she was leaning to the left. Time of onset 1:45.

We have to be certain, the doctor says, it is critical.

I know I say, that's why I called in the stroke alert. 1:45 onset. I went thorough this on the radio twice, and in triage three times. I want to be clear, one-forty-five. I glance at the clock. That means you have two hours left on the stroke clock.

Jeesh.

And then my partner tells me they go ahead and call the nursing home anyway, and guess what they tell them. The same thing that is written on the paperwork I also showed them. 1:45 onset.

So I am maybe a little cranky. Maybe I still need a little more sleep time to laugh about it rather than feel testy.

Stroke is an interesting issue, but there is a great deal of politics involved with it. Only a few patients meet the criteria for TPA and in only helps a small few. I have heard people from some of the smaller hospitals say the stroke center hype business is just a gimmick to get stroke patients brought to the bigger hospitals. But I hear some other people say it can be life-saving. I just do what they tell me. When the patient is with-in the wthree hour window, I go lights and sirens and call the alert. When they ask time of onset, I tell them:

One-Forty-Five.

Next time I will draw a big sign and hang it around the patient's neck.

Prayer

Slow day today. Only did two calls.

Went to a church where a womanin the lobby had a blood sugar of 40. She was a hard stick, especially with about twenty members of the congregation looking on. It took me about five minutes to find the vein and get up the confidence to hit it, but i got it, a little 22 on a hard angle in her hand. Gave her an amp and half -- took forever to push -- and she was back smiling a multiple missing tooth grin.

The woman, her husband and the minister thanked us, then all joined hands with the other members of the congregation and said a prayer, as we loaded our gear back up on the stretcher and headed out the doors.

The other call was a lady with the flu.

Escaped Mental Patient

A guy escapes from a mental hospital, hitchhikes to his friend's house, then sits on the porch waiting for the friend to get home. Suddenly, he starts to feel his neck tighten up, and his face and arms. he can't move them. Panicking, he staggers out into the road, lurching in and out of traffic, trying to get someone to help him. He thinks he is dying.

Finally someone calls 911 and reports a crazy man wandering in and out of traffic who appears sick or deranged.

When we get there he is very scared and anxious. I ask him what meds he is on, and he says he has been on Haldol for the last four days.

That's the answer right there. Haldol can cause dystonic reactions, which produce symptoms just like the man is having.

Here's a link that explains them in depth:

http://www.drugintel.com/drugs/reglan/acute_dystonic_reactions.htm

I give him 50 mg of Benedryl IV and within minutes he can move his neck and face and arms.

"I thought I was dying," he says. "I can't believe no one stopped to help me. Aren't people supposed to help others in distress."

"They probably thought you were an escaped mental patient," I say.

"I thought I was going to die," he says.

***

Did three other calls. A nursing home patient vomiting blood, a lady who tripped on the conrete and broke her nose, and a lady who may have had a seizue in the supermarket.

I'm still dog tired.

Long Day

Had a nurse riding with me today for part of the day. The medic program always sends me their nurses instead of making them do ER time. She was good. She is an experienced nurse, who just needs to learn the choreography of the street call.

We did two nursing home calls when she was with us -- a pnemonia and an HIV type flu.

Later in the day we did a jaundiced bed-ridden patient.

Even though I only did three calls, it seemed like a long day. Each call was to the farthest possible hospital.

First Name

At first I thought the woman laying on the Persian carpet was a teenage girl. Turns out she was in her sixties -- the wife of a rich man. Well cared for, pampered, probably some surgery too.

She lay down because she was feeling lightheaded. Her heart rate was 170.

Out in the ambulance I explained to her that I was going to give her some adenosine and what the side effects were: Although lasting only 6 seconds, she might feel chest pain, short of breath, headache or a slightly other-worldly feeling.

She got very nervous and asked for her husband. I talked it over with him and decided to give her Cardizem instead while he held her hand. It worked like a charm. Slowed her right down to the 70's. She felt much better.

At the hospital her husband asked for my name and shook my hand, and introduced himself, using his first name.


We took care of an adorable six year old with Down's who used sign language and signed energetically all the way to the hospital with her mom interpreting. She wanted to know everything from mine and my partner's names to what the buttons on the wall did. Very cute.

Took a nursing home patient in for a bone scan and went to another nursing home for the ankle fracture.

Difficult to be in Closet

We get called for a woman in a retirement home with diarreha. We go down the dim carpeted hallway after coming out of the narrow dim elevator, and the smell hits us. It smells like a dead body. Provided there is not a dead body on the floor, I can tell you what we will encounter. A patient with c-dif. C-dif is a bacterial infection that causes diarrhea. Let's go to the experts on this one.

"Clostridium difficile is a Gram-positive, spore-forming, toxin-producing, obligate anaerobe that is ubiquitous in nature. Over the past decade, it has become a very prominent nosocomial infection worldwide. It is notable that C. difficile infection caused ward closures in 5% of UK hospitals in 1993, and by 1996 this figure had risen to 16% [1]. However, the available epidemiological data may not be accurate. Diagnosis depends on stool culture and testing for toxin, but wide variation in practices for stool collection and in laboratory methods for diagnosis make it difficult to know the true incidence.

It was first recognized as a potential pathogen in 1935 when it was described as ‘Bacillus difficile’ [2]. However, its identification as a normal bowel commensal and subsequent association with pseudo-membranous colitis in relation to broad spectrum antibiotics was only established in the late 1970s [3,4].

Renal, oncology, haematology, geriatric, intensive care and surgical patients are particularly prone to infection with this microbe, emphasizing its potential threat to patients with depressed immunity. Infection has been noted to be of a greater severity and to cause higher mortality among patients with chronic renal failure, more so than can be accounted for by age differences alone [5]. The increasing use of broad spectrum antibiotics and the expanding population of patients with depressed immunity has resulted in an increase in the frequency of outbreaks of infection which may be prolonged and difficult to control [6].

Clinical presentation

Patient presentation can range from asymptomatic colonization or self-limiting diarrhoea through to severe diarrhoea, pseudomembranous colitis, megacolon, colonic perforation and death [6]. Most patients, however, present with passage of large volumes of watery stool which experienced healthcare workers can often recognize from its characteristic smell [7,8]."


The key line "Which experienced health care workers can recognize from its characteristic smell."

It smells bad.

Here are some other descriptions of its smell:

"characteristic horse-dung smell"

"The smell is disgusting."

"a distinctly foul smell."

"he has C diff, short for Clostridium difficile. I can’t think of a worse type of diarrhea. There is nothing else that equals the foul smell of that, nothing. Nurses are unanimously in agreement on this;"

A web site called medical memonimcs teaches people to remebemer C-dif, by the memmonic "Difficult to be in the Closet:"

"Difficult to be in a Closet with someone having explosive foul smelling diarrhea, because it would smell and there would be no air in there.
Clostridium Difficile causes explosive foul smelling diarrhea and is an anaeorbe (no air)."


I had my partner tech the call. I drove to the hospital with my head out the window like a dog.

***

Did three other calls -- all BLS. A demented lady from home not feeling well, a nursing home patient who refused to go to diaylsis, and another call I forget.