"Where Are You Going?"

What a difference a good night's rest makes. Woke up feeling full of vim, vigor and vitality.

***

Went to a nursing home for a diabetic. We're chugging down the hall, my partner and I pushing a stretcher loaded with medic gear and a police office following right behind. A nurse standing by a pill cart asks us, "Where are you going?"

"Someone called 911 for a diabetic."

"Right there," she says pointing to the room.

"Well, okay," I say, "By the bed or by the window?" You always have to ask that. (I was sent to a room once where one person was in CHF, the other was recently deceased and the body just hadn't been moved. You can see the confusion possible.)

"By the window," she says.

I glance in the room. I would have guessed the patient was the one in the wheelchair by the door, who leans to the left drooling. The woman in the bed by the window, appears awake and not in visible distress. I recognize her as a patient I have treated before.

"And what's the story?"

"She's a diabetic. We found her unresponsive this morning with a blood sugar of Low. We gave her some oral glucose, then a shot of glucagon IM. Her sugar now is 40 and she won't eat."

"Did she eat this morning?"

"I don't know."

"Can we find out?"

"No, no one here knows. We had shift change. I just came in."

"Okay," I say. "Do you want me to just get an IV and give her some sugar and get her back to normal or do you want me to take her to the hospital?"

"The doctor wants her to go to the hospital."

"But if I get her back is he still going to want her to go to the hospital if the only thing you want is to restore her to her baseline." I point to the paperwork she has just handed me, which lists "Restore to baseline" as the reason for transport to the hospital.

I am trying to be helpful, as I often come to this same nursing home, get a line in a hypoglycemic patient, give them the D50, then have them consult with the doctor or I speak with the doctor and the person stays as there is no longer reason to transport unless there are other circumstances.

Another nurse who has come down takes the paperwork from me, crosses out "return to baseline" and writes "treat for hypoglycemia."

"Unless there is something else you want looked at, they are just going to turn around and send her right back."

"The doctor wants her at the hospital."

Fine. The patient is alert enough to follow me with her eyes, squeeze my hands on command and tell me her name. I notice all this red sugary drool on the pillow by her mouth where they tried to squirt sugar into her mouth. Not a smart move.

Her sugar is 55. I get a line and give her some dextrose IV. The first thing she says is "Can I get something to eat?'

"Did you eat this morning?"

"No," she says.

"Why not?"

She shruggs. "I was sleeping."

At the hospital, her family complains that she doesn't eat enough at the nursing home, they take her food whether she is done or not. The family says this is her fourth hypoglycemic episode in a month -- all because of not getting enough food to eat. I'm thinking now maybe it is a good thing I brought her in, maybe they will call social services or maybe try to find her a bed at another home that cares enough to see she eats.

***

Next call is for a tachycardia at a retirement community. The man is in rapid afib. I give him Cardizem and the rate slows from 160 down to 100. All the way in he complains of back pain. He has chronic back pain and has had it for twenty years. Every other minute he is asking me to help adjust his position on the stretcher. The ambulance ride is rather bumpy -- they still don't make ambulances for comfort.

At the hospital the triage nurse from the other day(hypothermia) is very concerned about the back pain. "Maybe he has a triple A," she says.

"He's had it for 20 years," I say. "Its chronic. Its old pain. The stretcher is uncomfortable. The road was bumpy."

She goes and asks him about ten questions about his back pain.

"The reason for the call was tachycardia," I say again. "The back pain is old. He was in rapid afib. He has no history of afib. I gave him Cardizem. His afib isn't so rapid anymore. He's feeling better, aside from his usual back pain."

When she finally looks at my before and after 12 leads, she says, "That's an awfully wide QRS. It looks like V-tach."

"Its a Left Bundle Branch," I say.

"But its very wide."

"Its a left bundle," I say again.

"Oh, that's right," she says.

***

I have been thinking about this journal and have thought about just writing about the most interesting calls or moments of the day, and not trying to record everything for fear it will get tiresome -- that it will get whinny. But if I were to do that, you would lose the truth and that is that this job is often mind-numbingly frustrating. Whether its nursing homes or triage nurses or stupid 911 calls -- it seems you are every day shaking your head, saying "Can you believe?"

Crew change everyday almost inevitably includes a "You wouldn't believe how stupid" story about something.

(I read a book a few years back called "Talking Trauma" written by a folklorist, who analyzes paramedic's stories. I am going to have to look at the book when I get home tonight and read what he has to say about storytelling and comment on it here.)

Now having said that, I will freely admit that there have been times when I have been the stupid one -- whether it has been calling for a paramedic when the patient didn't need one back when I was an EMT -- missing an easy diagnosis or doing something else dumb -- I do not exempt myself. We all have our stupid moments. I do try to get less stupid as I grow older.

I'm sure triage nurses have lots of stories about dumb EMTs and even nursing home nurses may have similar stories (I doubt it).

I just wish that there was more common sense in the world.

***

Couple hours later after I wrote the above, I am thinking about deleting it or else commenting on it more fully. I constantly rewrite my entries and I have deleted as much whining as I can. Because on one hand, the stupidness is a daily part of the job, on the other, it is not the noble part of the job, it is the small stuff that shouldn't be sweated, and maybe only bears only a minor mention. I should maybe focus on the bigger things, and if I don't have bigger things to write about, then maybe I ought to start looking. That's where I ought to be headed.

***

Ended the day with a CVA -- a seventy year old woman with facial droop and slurred speech since earlier in the day. Old black couple. House full of kids and grandkids. The husband was gruff. When I tried to question him about when the symptoms started, he answered impatiently, "She just ain't right. Take her down to the hospital. I'm coming too."

"I need to know exactly when the symptoms started."

"Well, I noticed about an hour ago, but the kids they say she ain't right this morning. I don't know. I was going to drive her, but she ain't steady."

It was pouring rain out, and he was busy trying to get a coat for her and for himself, and find himself a hat."

"You go to cover up that bald head, granpaw," one of the children said, "The rain going be splashing off you."

Out in the driveway, he tried to step up to get in the back. The step was high and he wasn't that limber at his age.

"You're going to have to ride in the front with me, sir," my partner said. "She'll be in good hands in the back."

We went to the hospital on a priority. I was going to patch in a stroke alert, but in going over the story again with the man, it was pretty apparent that the symptoms had begun at ten that morning, putting her well outside the three hour stroke window.

At the hospital, once they heard the symptoms were almost eleven hours old, they shrugged and put her in a room at the end of the hall. We made the bed up, disconnected her from our machines and slid her over.

"They got you guys doing everything," the man said. "I thank you for helping my wife."

When I asked him for insurance he said he had Blue Cross. I asked if she had Medicare, he said he didn't use it because he was still working.

When I left the room, he was in there alone with her, leaning over the rail, asking her how she was feeling, his hand brushing her hair.