15 Times, The Gift, No One Home

15 Times

Woman with asthma at the doctor's office down the street from the hospital. Has gotten two Xopenex treatments with minor relief and a shot of Xolair. She was tight.

I know what Xopenex is -- the single albuterol isomer (Levalbuterol, it supposedly works better than plain albuterol, but is more expensive. I have noticed a lot of primary care docs are using it in treatments for their patients, while a few ER doctors have still not heard of it)-- I went to a CME on it, but I had never heard of Xolair. I asked the nurse what Xolair's mechanism was. She said it for asthma. Yeah, I said, but how does it work? It makes them better, she said. She didn't know.

Imagine my impression if she rattled out the following:

http://www.rxlist.com/cgi/generic3/xolair_cp.htm

Here's some info on Xopenex:

http://www.rxlist.com/cgi/generic2/leval_ids.htm

We got the woman out to the ambulance, and she volunteered that she had been tubed 15 times. We were two blocks from the hospital. She was starting to wheeze worse. I told my partner to drive and call the hospital. I banged in a line, and started a combivent. As soon as we pulled her out of the back, the wheezing amplified yet again. Wheeling her down the hall caused everyone to take notice. By the time we got her into the room, people were running over. The doctor asked if she'd gotten epi or solumedrol. "She came from across the street," I said. "She's getting worse with each breath." I wasn't disputing that she could have used both drugs, but a) she just started plummeting as we hit the hospital and 2) you have to call for orders for both interventions, and if I had called, I'd still be in the ambulance. As it was, I was in the hospital 10 minutes after we arrived outside the medical building where the patient was seeing her doctor.

He gave her both meds and some ativan and then shortly declared she was doing better. She wasn't. I was standing right there shaking my head. She'd getting worse, I said to the RT. They tried heliox and she was sucking the nonbrebreather bag empty with each breath. She got tubed for the 16th time.

While we're at it, here's a good article on asthma:

http://www.emedicine.com/med/topic177.htm

***

The Gift

A forty-five year old man lays slumped against the storefront of the Erotic Palace. He is out cold, drooling. He clearly has done some drinking from the smell of his breath. Doesn't respond to sternal rub. We take his jacket off so we can get access to his arms. No track marks. He is clutching a small box in one hand. We get him up on the stretcher and then into the back of the ambulance, and get him stripped down on the top. His pupils look pinpoint, but he doesn't respond to narcan, which I give him in two doses, .8mg, then 1.2mg IV. His blood sugar is 244. He is tachycardic at 120. His blood pressure is fine. His respirations are snoring so I put in a nasal trumpet that slides in easily and helps with his breathing. In his wallet there is a non- driver's ID card, and a mental health clinic appointment notice.

I'm trying to piece it all together. I glance at the box, which sits by my clipboard now. There is a gift bow around it. I open the box.

In the ER, I give my report, running down what I have done. The doctor and nurses ask many questions.

"The answer," I say, "is in the box." I open the box and show it around.

A small diamond ring.

"He has a broken heart."

***

No One Home

A seventeen year old mother called 911, saying her one year old had fallen and was bleeding. When we got there no one would answer when we buzzed the apartment from outside the security door. We had a callback put in, but they just got the answering machine.

We got in the apartment building, went up and knocked on the door. "EMS!" my partner said.

The door opened after a second and third knock. She said she didn't hear the buzzer, the phone or the first two knocks.

The child was fine, a small cut, maybe a stitch needed. Nothing suspicious, according the cops who had come up with us. Just an honest accident.

On the way to the hospital, the mother told my partner she called 911, then called her mother, and once her mother calmed down enough to see the child wasn't hurt, she warned her not to answer the door. The police would come she said, and think you hurt your child, then DCF would come and take your child away.

***

Also did a chest pain, a TIA and a seizure.