The Plan/Nothing

Lady falls coming down the front steps, carrying her baby. She twists suddenly as she falls so she will land on her back, and protect the baby. She does, but she hears a snap in her ankle and is in severe pain -- lying there on the front lawn.

I don't need an X-Ray to see it is broken. 10 out of 10 on the pain scale. No allergies. Medication time. She weighs 200 pounds. I give her 5 of Morphine. It takes the pain down to a 7, but she is considerably calmer. My routine has always been to give 5, wait a few minutes, then move the patient, and then give them more if they need it in the ambulance. Today I decide to give her another 3 before we move her. I can do that now under the new weight-based protocols. I give it to her. We wait. She has been having a conversation with the neighbors. All of sudden she says something about not buying ice cream sandwiches, when she starts laughing. The laugh does not end. It goes on and on. She is laughing so hard I am worried she is going to pee herself.

"Looks like the Morphine is working," her neighbor says.

In the ambulance, I give her the last milligram allowable under standing orders. She is still cracking herself up. She isn't thinking about the pain. And that was the plan.

***

An hour to go before crew change and we hear a basic unit call for a medic for the diabetic. The dispatcher tries to rouse the precepting crew, but they are in the hospital. They call us.

When we arrive, the fire department says the BLS crew is bringing the guy down on a stair chair. The fire fighter says the man doesn't have a diabetic problem, but is on meth. I get my first glimpse of the patient as the crew say he is on methadone, not meth-ampedamine. They also say he is a diabetic who did heroin today. His pupils are constricted. His brow is warm and dry, but his hands are cool. He answers me, but I can't understand what he is saying. He has some white foam on his lips.

I get him in the back of the ambulance. I can't get a BP, but then use the monitor's BP and it says 109/54 and he is chugging along in a sinus tack at 120. I'm not certain if I trust the BP, but with a sinus tack, it seems reasonable that he has a BP.

I have my partner start toward the hospital on a non-priority. We are not that far from the hospital -- maybe four or five minutes out -- and I figure it will give me time to check his sugar and give him D50 or narcan or both if needed, along with some fluid. I prick his finger, and he starts waving his finger, and I have to tell him to hold still so I can touch the glucometer to the blood on his finger to check the sugar.

It is 224. No problem there.

I look for an IV, but he has no veins. I jab him in the AC, and fish around, and get nothing, then look up at because I am concerned he is not really reacting to my fishing around with the needle. I look at the monitor and am confused that his rate is down to 60. His respiratory rate is down to about 6. I draw up some narcan, and hit him with it, but he does not react.

I tell the rider I have with me to drop him down and start bagging him. I tell my partner to step it up to a one and call the hospital to patch for me. His heart rate is dropping. I quick get out my intubation kit, and tell the rider to switch places with me.

By the time I have my blade out he is down to 20. The man has buck teeth, but some cric pressure from the rider, puts the chords into view and I sink the tube. I am expecting his rate to pick up by now, and it does briefly. We're pulling into the hospital now. "Start CPR," I say. He has no pulses.

I push some epi and atropine down the tube, and that picks the rate up back into the 60's, but still no pulses.

In the ER, they try get a central line and try everything. Epi, Atropine, Bicarb, Calcium, Narcan, D50.

Nothing.

Dead.

***

Did five calls. Besides the above two, did a seizure, a diaylsis transfer, and a COPDer.