Getting Worse

Nursing home lethargic patient with fever of 103, rhonchi, tachypnea. SAT 72% on room air. The nonrebreather got the SAT up to 100%. I had the patient on capnography and it was in the high 30's when all of a sudden it shot up to the 50's. His respiratory rate was also went up to the 50's. His SAT only went down to 96%, and he soon looked like he was having a harder time breathing. We were just pulling into the ER. At triage, they put him in the less severe wing. I told them the nurse was getting worse, but I think he already had it in his mind -- nursing home pneumonia. It took a little while for me to find a nurse in the wing we went to. I gave the report, but he's getting visibly worse, I said. Twenty minutes later he was intubated. I later read, in sepsis, you can expect a high respiratory rate and a high C02. I am still learning the capnography, but I was impressed with the sudden leap in C02 seeming to flag the oncoming change in condition.

Twenty Minutes Early

So I worked the high performance transfer car. There was no medic gear in it, so I asked if I could have some just in case they needed us for an emergency. You are only going to be doing transfers. You won't do any emergencies.

The deal again with the so called HP car is you do 8 transfers, you go home and get paid for eight hours. They promise to feed you calls -- all of short transport -- and if you are kept waiting or a call is cancelled when you get there, it still counts. If you do more than eight calls, you start getting paid overtime as soon as you've finished your eighth call. The car often is done with eight calls after six to six and a half hours.

My old partner's Arthur's favorite line whenever we were kept waiting was "That's okay, we get paid by the hour." By when you are paid by the call, well, its another thing. You hump. We had four calls banged out in the first three hours. No breaks, no lunch, just charging ahead with the stretcher. We were on our way to a fifth when we were sent on, you guessed it, an emergency. They were out of cars and someone was having trouble breathing. We pull up in front of the house and the fire department is there, and I just know they are thinking I am a slacker, when I only pull the stretcher and come in with a makeshift in-bag. No monitor or big house bag. The bad news is the lady has an MI history and is a diabetic. The good news is she has been having diarrhea and vomiting. My assessment is she is dehydrated. My partner asks me if I want to call a medic.

At the hospital I have to explain why I have no Blood sugar or 12 lead.

My partner tells me we should get credit for two calls, the cancelled call and the emergency, but since they never sent us the tag for the first call, it only counted as one.

So three calls to go and instead of short trips, it's from one side of town to the other, picking up someone and taking them out of town. To make matters worse, the staff at the places we go are slow. Talk about standing there, tapping your feet. Com'on, already.

We do our eight calls and punch out all of twenty minutes early.

It will be awhile before I work the HP car again.

CHF - Trend Summary

I am the tallest person in the company and today I worked with one of the shortest. The day started off slow, just sitting covering an area. Unfortunately, the area was close to the base. When a call came in for the bareatric ambulance, it went to us. So we had to drive back to the base, switch into the big ambulance and were sent off to pick up the 400-500 pound patient. Fortunately, they had to send another ambulance to back us up as is required by policy. My partner who has taken this guy before said he looked like he had gotten bigger. He was so big that when he got on the big stretcher, which is rated for up over 1000 pounds in the down position and 800 in the up position, he thought he was on the regular stretcher because he was hanging off both ends. Yeah, he's getting bigger, she said.

The problem with doing one big person run is you can never get back to the base to get in your regular ambulance. We were just about back when they sent us to another big person call. This lady was probably 500 with legs the size of an average person's torso. She could stand and pivot, but the stretcher in the medium position was too high, so we made the mistake of putting it all the way down so she could sit on it. My partner doesn't lift well, so we thought about calling for another person to have four strong lifters instead of three, but I said, I could take the end and the two guys from the other ambulance could take the head. I got down in squat position, squeezed the release and drove my legs up, but the stretcher stayed down. I had to stop or I would have ripped every muscle in my back. I was a little embarrassed. One of the other guys took the end then, he's younger than me by a good deal and very strong and squat. He got it up, although his head and throat turned purple. I think the stretcher was just too low for me. That and I haven't been as regular at the gym as I used to be, although that is changing. I was in the gym this morning for cardio.

Anyway, we finally got back to the base. While my back was slightly strained, I wasn't hurt. We got in our regular ambulance and went back out on post. We were sent priority into the city for a child struck by a car, but it just turned out to be a thirteen year old who had his foot run over. It hurt when I pressed against it, but he was very stoic. Thirteen year old wearing a do-rag, looking like Tu-Pac.

We were a half an hour from crew change when we cleared the hospital and instead of being told to come in, we got sent to the one area they send you too when they have no other cars available. Sure enough we got a priority one call. Difficulty breathing at the nursing home. It turned out to be a good one. CHF in a DNR patient. She was sucking when we got there. Altered mental status, cool, pale, clammy. As usual the staff didn't have much to say other than it came on very quickly. They said she was wheezing and they gave her a nebulizer by mask. I listened, but couldn't hear any wheezes. I did hear a lot of rhonchi and rales. I used the capnography and she had a decent wave form indicating no bronchospasm.

Her CO2 reading was in the 50's, which is high. Her respiratory rate was around 30. Her BP 180/115. Heart rate was 116. Her Sat was 80%. We switched her to a non-rebreather. I got a line and gave her three nitros, and her Sat was now 99%. Her heart rate and BP came down, and she was finally able to converse with me. Her capnography stayed on the 50s. Still she looked like a different person at the hospital. I printed out a trend summary afterwards.

It is amazing we had this feature on our monitors for some time and I at least never knew about. I have been trying to spread the word, and have only found one other medic who knew about it.

For any of you with Lifepack 12's out there, do the following:

Hit Options.

Hit Print on the options menu

Hit Report, which on ours is defaulted to Code summary.

You should get a trend summary option. Hit that.

Then hit print again on the options menu and the trend summary should print out.

I have found one monitor that doesn't have the trending software on it. Yours may or may not, but if it does, that's how to get it.

Looking at this trend summary, you can see the gradual reduction in heart rate (3rd graph), as well as the early SAT readings and later ones(4th graph). Next time I will try to get the capnography on in the room, rather than waiting to get out to the ambulance, as well as trying to keep the pulse SAT on.

When I got home, I tried to read more about capnography. The literature is so sparse, I can't always find the answers. This is about what I came up with. Her wave form shows no bronchospasm. Her high CO2 indicates tht she is getting tired and was in a hypoventilation state. Even though she is breathing at a higher than normal rate, she is not getting enough ventilation with each breath. She did look very tired. The literature I read said a sudden decline in her ETCO2 from the 60 area down to the 20s would let you know that in a few minutes or so you would find out she was completely flashing, fluid filling the lungs preventing poor CO2 diffusion. Fortunately we avoided that state. When I was done with my paperwork, I checked on her and we were able to have a good conversation. Unfortunately the hospital didn't have capnography as I would be curious to see what her numbers were.

Anyway, I am excited to learn about this all. I apologize if I am explaining any of it incorrectly as I am still a novice at it.

Tomorrow I am working 8 hours. All they had open was the so-called High Performance car, which is a transfer truck, where they let you go home after 8 calls and pay you for 8 hours even if you finish earlier. I wanted a regular shift, but told them if they could get my friend to work it, I'd work it, so they promised me that if I would come in. I don't particuarly like transfers, but I'll do them if I can hang out with someone I like working with.

Presentation

Went to the gym this morning -- I'm actually getting back into shape -- then in to work for six hours. Only did one call, a woman with a broken ankle. Tonight I gave my presentation at the hospital on the new AHA changes. It went over pretty well. A couple people asked me to email them my presentation. It was my first powerpoint attempt and I had no frills or anything in it. I think next time I could really liven it up.

I'm working eight hours tomorrow in the city.

Shark Fin

We had an eighty-year COPDer with Sats in the 80's not moving too much air. We gave her two back to back combi-nebs and monitored her with capnography. It was the first time I used capnography on a COPDer.

Here are the wave forms. Keep in mind a slanted "shark fin" wave form shows the person is struggling to exhale through resistance. A more box like wave form shows no resistance. Here's a normal wave form and a bronchospastic wave form:

And here's our patient's wave forms, initially, during the first treatment(combi-vent, which bronchodilates) and after two treatments:

Way cool, I thought. It really shows how effective our treatment was. The woman felt much better and was breathing easy. The nurse was impressed that we had capnography. She asked what the funny looking cannula was for. We tried to show her the wave forms, but she just nodded, and it seemed to me the wave forms meant nothing to her. A couple weeks ago, they would have meant nothing to me, too.

***

Only other call was for a woman with heartburn and a history of throat cancer.

***

For more information on capnography:

Capnography

Ow!

Just as we were arriving at a back pain, a cardiac arrest came in at the high school. They sent an ambulance from the city to that one, which was too bad because we heard later the teacher -- a substitute -- didn't make it. We were only a couple minutes away. Who knows if it would have made a difference? It was just bad timing.

The lady with back pain was a major pain herself. She yelled at the police officer for tracking a leaf onto her carpet. We couldn't do anything right. She had an alarm system and wouldn't tell the police officer how to set it. She insisted on doing it herself. She wouldn't tell her best friend either. It took us 40 minutes to get her out of bed and onto a stair chair, then we had to go through getting her off it, so she could set her alarm. She would say "Ow!" whenever we hit a bump. "Ow!" it seems to me is a sound that requires a mental decision to make as opposed to a true sound of pain. Anyway, I wanted to give her some morphine, but she said it made her sick. On the way to the hospital, she got upset about the direction we were going. We took the highway instead of going through the city which would have been far worse with all the rotten roads. We hit one bump on the highway and she said "I have news for you, this is the bumpier way." Not.

She liked me because I took care of her husband when he was alive. She said to me, "I know I'm such a bear." I felt like saying, "If you know your behavior is so bad, you need to correct it."

She had a mastectomy so she couldn't have a BP done in her left arm. She told it to me, she told it to the triage nurse, who wrote it down. We went to the room, and as I was giving my report to the nurse, she got out the automatic blood pressure cuff and took the woman's left arm, the woman said, "You haven't done your job, you haven't read what your supposed to. I can't have a blood pressure done on my left arm. What if I were unconsious?" She made the nurse make a sign, saying No BP or shots in the left arm.

***

We took in an old woman who refused to take her medicine because an aide was "forcing" it on her. Her presure was on the high side nd she had some increased water retention and some dementia. We were able to persuade her to go to the hospital with us.

Later we did a syncopal, who we couldn't get to go.

Alone in Back

Called to the group home for respiratory distress. Updated en route that the patient is choking and cyanotic. We arrive to find the thirty-year old with cerebral palsy agitated, but breathing quite fine. He is tube fed, and occasionally vomits and aspirates. His lungs sound clear. The aide has a machine BP cuff on his arm and is concerned because the reading is 280/230. I tell her it’s not an accurate reading. We retake it manually and its 130/70. There is no question but he is going to the hospital. That's just the way it is at a group home. They call us, we come, and the supervisor says transport. No matter what or how temporary the emergency. I don't mean to belittle what happened. I've taken this patient in many times before, often for this same thing. He is an aspiration risk so he goes. An aide comes with us. On the way I read his medical folder. There is a chart for his BMs. I easily decipher the code. LBM, MBM, and SBM, stand for large, medium and small BM respectively.

At the hospital, I get out of the back and my partner comes round and helps me pull the stretcher. At that same moment, the patient's parents arrive. The mother screams at the aide, who rode in the front "What you left him alone in the back by himself?"

"No," I say, "I was in the back with him."

I don't know what they told her, but she is frantic. She kisses her baby, and asks what happened.

I tell her he has been fine with us, very stable. It takes her awhile, but she finally starts to see that everything is okay. In triage, she asks the aide if he had a BM. She doesn't know. I consult the BM chart. "No," I say, "Not this morning."

Later, the mother thanks us.

***

It is a day for mothers. Our next call, on the radio a cop tells dispatch that he is with a motorist who says her son is having an asthma attack at home. We are sent to the home on a priority. The cops slow us down en route. The cop has driven the mother there and the boy is fine after having a treatment. Lungs clear. The mother thanks us for our response.

Awhile later we are sent for another child asthma, only to fine the boy is breathing fine. His lungs are clear. He says, it is not his breathing, but his chest hurts. He says he was rolling around and felt pain like someone stabbed him with a pin. His mother starts crying, "Is my boy having a heart attack?" "No," we say, "He isn't." We take him to the kid's hospital. I let the mom ride in back with him.

***

It was a busy morning. Five back to back calls. Also did a nursing home fall, possible pelvic fracture and a woman with a bad disc, who I had to give morphine too.

And then nothing for the rest of the shift.

Four Days

Worked another eight in the city. Other than working with an old friend, it was a boring day. Started out with a nursing home chest pain -- little old Spanish speaking lady was given a nitro for her chest pain and it dropped her pressure. The nurse who was Russian and was hard enough to inderstand, did not speak Spanish. The old Spanish lady told me she had the chest pain for four days. She seemed in no distress and her pressure had recovered by our arrival.

We did two transfers, which would have been okay, except twice we watched basic cars sit on-line while we were given the calls.

Last call was for a five week old who spit up his formula, but was fine.

A long rainy day.

Ambulance Dude

Worked eight hours in the city with my preceptee and we did three calls: a man with HIV who walked out of the hospital two days earlier AMA, a woman from a psych facility who had "EKG" changes, and an out of town transfer.

I've done a lot of jobs in my life, but I've been doing this full-time for eleven years now. One of the benefits of doing a job awhile is the things that you know cold. Like the streets -- directions, how to get from one place to another. Yesterday twice we were sent great distances that involved either going all the way through two cities or taking the highway in a choice of diameter versus half a circumference. Both times I chose the half circumference of the highway and both times I think I made the wrong choice because it seemed to take forever to get there. I guess I might have felt the same way if I'd made the diameter choice. We just had a long way to go in each case. Oh, yeah, and I did make an explicable wrong turn at one point, getting off the highway too earlier. Fortunately I knew another way. Still, I was embarrassed.

The last call was to a nursing home in a distance town. The patient's wife, who was very meddling, making certain we did this and that, asked me which way we were planning to go. I said over the mountain. Like a person waiting to trap me, she said "X mountain?" which is the way someone who didn't really know how to go, would go. I said no "Y Mountain." The nursing home where we were going was in the town I grew up in and was the home where my mother died, so I knew the way -- all the right back roads. It is always strange driving an ambulance in the town I grew up in. On the way back I thought of going an alternate way just to see what the old neighborhood looked like, but I didn't. That would have freaked me out, imagining me as a five year old boy playing in the street, looking up to see an ambulance -- my future forty-two years later driving past.

The "EKG" call posed an interesting dilemna. An asymptomatic patient in a mental facility has an ECG done on a regular basis because one of the drugs she is on can cause ECG changes. The doctor does and ECG and sees inverted T waves and then gives the patient ASA and calls for an ambulance. She shows us the ECGs. 1) the t waves are not particularly inverted and 2) the ECG looks just like the one done two months earlier. Do you point this out to the MD? who I don't assume working in a mental health facility does too many 12 leads or do you just say okay and transfer? We just said okay and transfered. We go to a busy ER -- they are all busy these days.

While at the facility one of the patients called to me "Hey, Hey, Ambulance Dude? Ambulance Dude?" Or should I say, "Ambulance Doctor? Ambulance Doctor?"

"Ambulance Dude works," I said.

"You going to have all green lights, all green lights. All the way to the hospital. You don't need to use your red lights. I'm going to take care of that for you. You going to have all green lights. You going to keep her safe for me. I'll take care of the lights for you."

Now, I can't say, I didn't have a red light on the way to the hospital. But I do recall it as a smooth easy ride.

-Ambulance Dude

Off

Two days off, hitting the gymn, cleaning the house, ignoring the lawn. back to work tomorrow for many days straight.

Small Sights

Two sights from the day:

1) Standing outside an old woman's house looking at the paint peeling on her back porch steps.

2) Sitting on the bench seat in the back of the ambulance, squirting cleaning spray on drops of blood on the floor, then cleaning them up with a towel.

Two small views. They are what I noticed today.

***

We took a chronic patient to the hospital with back pain. She'd been there a few days before for the same thing. Her belly was distended. She said she hadn't had a bowel movement for 13 days. Her vitals were fine.

The old woman's who's house I was standing outside of pushed her lifeline alarm because she wanted someone to check her out. She didn't want to go to the hospital. Little old lady. The house reeked of cigarettes. It was the worst I had ever smelled it. It was like she smoked four packs a day for fifty years and had never once opened the windows of her house. I told my preceptee I would be outside if he needed me or had any questions. I stood outside the house and looked at the peeling paint and thought about the tiny old lady laying in her bed who didn't want to go to the hospital, and I felt depressed about it.

The last call was for a manager who passed out at a Fast Food restaurant. I always am amazed at how dirty fast food restaurants are in the back. They were busy in there. It was at lunch time. They didn't stop for us. She was sitting in a chair in the narrow hallway by the walk-in freezer, but there was so much traffic, we just had to get her out into the ambulance. The blood on the floor was hers -- the results of my preceptee's IV.

I am not used to cleaning blood out of the back of the ambulance. One, I pride myself on leaving a clean back, but two, when I do make a mess, my partner cleans it up while I write the run form. Today, I wwas the partner who cleaned it up. My preceptee apologized. I told him, no problem.

Did another call for an elderly woman who tripped and cut her chin. We had to take her a half hour away to the fartherest hospital because that's where the retirement community's affiliated doctor's were -- not that they were going to be the one's sewing her up. I drove. My partner's complained about the long bumpy ride. I guess i have to take the blame for the bumpy part.

Dead

My partner later said she was taller laying down than she would have been standing up. An exaggeration, sure, but you get the point.

The call came in as a fall and not breathing from the police, who passed the call to the medical dispatcher who then updated us as a dead body, no attempts being made at CPR. The police when they arrived, relayed the same information.

I have to say it was a bit of a disappointment as I had my preceptee with me and he hasn't had a code yet.

When we entered the apartment we saw a police officer greeting us and pointing in the direction of the bathroom. There was a naked mountainous blob of flabby flesh crumpled and face down. A motorized lark and oxygen cannula were visible beyond the mound.

"Anyone see it happen?" I asked.

The officer shook her head. "The neighbor came over and found her."

It took two of us to roll her over on to her back. She was dead -- there was no question about that. It was just a matter of how long. She was asystole in all three leads. I touched her jaw and was relieved to feel the beginnings of rigor mortis. Her head was shaped like a giant bowling ball or the top snowball on giant snowman. No neck. Her tongue, which she had bitten, protruded from her mouth. I couldn't imagine getting an ET tube in there even if her jaw were limber. I looked at my preceptee.

We could probably make a stretched case to work her so he could get practice, but we could make a better case -- the right case -- not too. Besides -- it would have been a tough code to work for anyone, much less a new medic.

She had ever medical diagnosis there was -- diabetes to dialysis.

We put a sheet over her and later over the radio, we heard the funeral home was on the way to pick her up.

**

Did two other calls -- a high blood pressure vomiting and a dizzy woman.

Holiday Pay

Double time and a half for working on Easter. Started off with a chest pain at the Easter Sunrise Service. In the afternoon we did an old blind lady who tripped in the nursing home and needed some stitches. Just before shift change we had a call for a rectal bleed that went to the farthest possible hospital. Normally I would have been upset, but at holiday pay, the extra hours were appreciated.

Rerun

Worked ten hours in the city. Spent the first two and a half sitting around. It was a nice day. I studied Spanish.

The four calls we did were for an elderly woman who choked on some water and may have aspirated, a woman from a group home who had a routine colonostomy on Tuesday and now had a grossly distended, rigid abdomen, a college student with a turned ankle and a transfer.

I played around some more with the capnography, but I was having problems with it. The apnea alarm kept going off even though the patient was breathing.

I did another electronic run form -- I can only do them at one hospital because the printer doesn't work at the other hospital. It took me awhile to do it, even with the plug in keyboard I bought. Then after I turned it in, I noticed that somehow the patient's age was listed as one day old. I know I typed in her birthday, but I must have hit something to make it register as today's date. Oh well.

I went home and played some poker online while I watched the Red Sox game. They were losing 3-0. I was also surfing the internet and eventually I came upon an article about the Red Sox losing 3-0. I thought that was odd -- the game is only in the 6th inning, then I realized the game I was watching was being played in the daylight and it was dark out. I was watching a rerun.

I'm not as sharp as I used to be.

Trending

Four calls in the city today: a fall/weakness/dementia all in one, a homeless man alcoholic had a seizure, an unresponsive diabetic, and a minor motor vehicle.

We put the endtidal capnography on the weakness patient. I did it just to show my preceptee how it worked and to try out this feature the teacher told me about yesterday. It's called trending. He asked me if we had it on our Lifepack. I had never heard of it, so I said we didn't. The bottom line is so you go into the print menu and where it says code summary, you punch report and the trending option comes up. Hit that and then hit print. You get a minute by minute graph of whatever vitals signs you had programmed. In our case we got HR, RR, SP02, and Co2. I guess if you get into the programming, you can actually have the trending show up on the screen. The instuctor made the analogy of a stock markey screen -- not only does it tell you what the price is now, you can see where it has been over the last week (or in the patient's case the last thirty minutes).

Capnography

I took an awesome class today on capnography. We've had it for about a year, but with no training beyond being required to put it on all intubated patients and get a print out of a wave worm to verify the tube. This class covered intubated and non-intubated patients. Now I know what the numbers mean, what the waves forms mean, and how I can use that to help the patient. Hopefully I will be able to report about my experiences with it in coming days. I'm very anxious to try it on asthmatics and people in CHF.

Capnography article

Capnography.com

Eyes Closing

I taught a class tonight on the new AHA guidelines for the volunteer ambulance monthly training. It wasn't a recert class. It was just informational. I tried to talk about what the changes were and the science and research they were based on. You look out and see people's eyes closing and you know it can't be going too well. This is all I wanted to leave them with: Do good CPR and don't hyperventilate.

Diabetic Prisoner

We got called to the jail because they had a prisoner there who had diabetes and they wanted us to check him. There was nothing wrong with him and he had no complaints. We checked his sugar 200. He said he wanted to eat before he took his insulin so we left and they called us back and hour later after he'd eaten his Burger King breakfast. They handed him his insulin and syringe and he drew up his dose, injected himself and that was that. About once a year a sargent decides we have to be there when a prisoner injects himself.

We got called for an asthma. Old skinny guy we pick up all the time. he ran out of his albuterol. We gave him a treatment, and then he said he was fine and didn't want to go. We left him a couple treatments -- he said his meds were coming that day. An hour later he called us back and said he was having trouble breathing again so we took him in.

We did another diabetic. Guy got out of diaylsis went to a friend's house, became semi-concious. She gave him OJ. We found him cool and clammy sitting on the toilet. He had lost his bowels. His sugar was 90, so I thought maybe something else was going on, but he muttered he thought it was his sugar. His vitals were fine and he had no neuro deficits. I gave some D50, but he was slow to come around. We took him in. Only once he was in the hospital did he seem back to normal. He said he didn't eat as much as usual.

Last call was for a 95-year old lady with stomach CA and a rectal bleed.

Tomorrow I am teaching a class on the new CPR and AHA guidelines so I worked on my powerpoint presentation today. I have never done one before, but have really enjoyed putting it together.

I also signed up for a class in capnography being taught at a volunteer ambulance building in another town on Thursday. I'm excited about that.

My Town

3 calls today. All typical for this town. Day started off with the priority at the nursing home -- a pass from the commercial service for the extremity bleed -- but it turned out to be a transfer evaluation for hematuria on a stable nonverbal demented patient. The next call was at the insurance company for the employee with chest pain/anxiety. The last call was a diabetic with a blood sugar of less than 20, who ate breakfast at five in the morning, but was so caught up in making arrangements for her brother's funeral that she neglected to eat. We got the call at 4:30.

Nursing home calls, anxiety at the insurance company, and diabetics. That's my town.

The Juice

As soon as the 8:00 volunteers came in the tones went off and it was three back to back calls. Two syncopes and a rectal bleed. One of the volunteers who works with me Sunday morning is a nurse. She and her Sunday morning partner have been working Sunday mornings for over twenty years. Many years ago when I was a volunteer out here, I worked with them on my first shift. I like working with her because she is very competent and also knows somethings I don't which can come in handy when I don't know something. I have also taught her how to do 12-leads so all I need to say is do a 12-lead and it gets done. On one of the syncopes today -- an elderly man at home, who'd fallen and cut his head -- I did a quick assesment. He wasn't knocked out, he had no neck and back pain. He had a suturable lack on his forehead. While they bandaged him up, I took the gear outside and set up the stretcher. When I came back in, she said to me very nicely, he got dizzy before he fell. I thanked her. It was a not a question I usually forgot to ask, so it was nice to have someone watching my back. His lung sounds were decreased, and he was orthostatic. His ECG was okay.

My cold is still lingering, although I might say I am feeling a little better. Still after three calls, I was getting tired of lunging my gear and lifting people. Everything seems heavier than it should be when you aren't feeling 100%. On our last call, when we got there the cops were still trying to get into the house. I saw that a window screen was just barely open, so I climbed out on a ledge and jimmied it open, then I passed the flower pots that were on the window sill to a police officer and had called for my partner to boost me just a touch so I could get my arms into the window enough to pull me up. I love being a second story cat burgler man, but even as I was preparing to do it, I was thinking I was crazy. Maybe when I was feeling better. I think I was trying to prove something to myself. Fortunately, someone finally came to the door.

I have been reading this book about Barry Bonds and steroids called Game of Shadows. It is a pretty amazing book about more than just Bonds. It meticulously details the drugs these athletes were taking. Not just baseball players, but world class track and field athletes. They'd be over the hill athletes and then they'd get on this regime and start setting world records. They were taking up to 50 pills a day, but the main ones were steroids and human growth hormone. They'd also take insulin, clomide, a female fertility drug, and some stuff to make lean muscle in cattle.

I'm reading this and thinking, you know I've been feeling run down and over the hill, maybe I could use this stuff. Let's look at the public good here. Barry Bonds takes steroids to hit home runs, Marion Jones takes steroids to run fast, I would be taking to steroids to help people. And I could go for a world record, too. Instead of hitting 73 home runs, I could carry 73 millions pounds of patients and equipment in a year. And steroids would prolong my carrer. Of course, I wouldn't want to do all the pills and needles Bonds took. Forget about the female fertility and the cow stuff, just give me the the Clear and the Cream and HGB, along with the ZMA, zinc and magnesium.

Worry about getting caught? No, the state doesn't test medics for steroids. Not yet anyway. But, you know, I might be a standup guy anyway. What bugs me the most about these athletes is not that they took steroids, but that they lie about it. They deny what anyone with eyes can see. I wouldn't be like that. If someone asks me how I lifted that 400 pounder all by myself, I'll say, "It's the juice!"

Shunt

Started off the day with an unknown that turned out to be a diabetic. I have worked in this one town (3 days a week) for many years now and it seems half my patients are repeat customers. This lady has Parkinson's and a speech pattern that makes her sound retarded. We found her laying across the bed. After I gave her the D50, she gets up, but has the tremors. My partners thought she was either having a stroke or a seizure. In the ambulance afterwards, I told them she was very familiar to me and this was her norm.

The next call was also a repeat customer. It came in as a vomiting at a nursing home, but it was actually an intercept with a commercial crew outside the nursing home. The patient, whose norm was nonverbal, had vomited coffeee grounds blood and was hypotensive. The EMT asked me if this was a legitamate intercept call. I told her it was hard to say. I hated when I was in the position of having to call for an intercept. So I guess call when you are in doubt. They were probably going to call a medic alert at the hospital, but I really didn't think there was much I was going to do. I couldn't get a pressure or feel a pulse, and his nail beds were white, but he appeared in no distress and was in a sinus at 60 on the monitor. The only cardiac drug he was on was cardizem. No betablockers. Both his core and his extremities were warm. Even his fingertips were warm. He had a history of stomach CA. The nursing home had gotten a BP of 73/34. I got him out of his sweatshirt, by lifting it over his left arm and head, resting it on his right arm. I couldn't find a vein on his left arm, so I put an IV in his right hand and dumped in a couple hundred cc's on the way in (we went nonpriority). When I pulled his shirt the rest of the way off, I noticed he had a diaylsis shunt in his upper right arm. I had the IV in his right hand. You're not supposed to put an IV in the same arm as a diaylsis shunt. Oopps. I hadn't seen the diaylsis notation on his paperwork, but the crew told me he was in fact on his way to dialysis when they picked him up, and the nursing staff because he vomited and his pressure was low called the doctor, and instead ordered him to the ER. At the hospital, they got 76/44 on their machine in triage. While our oximeter didn't work, theirs read 98%. Because his pressure was low, they indeed called a medical alert.

In the medical room, the doctor was upset to hear the man was a full code. "Good, we'll do our best to ensure his quality of life." I hadn't seen this doctor before. He was a young guy. One of my crew members remarked later about how sarcastic the doctor was. One of the nurses noticed the shunt, and so they started looking for an IV on the other arm. When I came back with my paperwork, they had pulled my IV, but still hadn't gotten access. I felt bad about putting the IV in his shunt arm. I suppose I could make a case that with no blood pressure and no palpable pulse, it was justified, but the truth was I simply hadn't noticed the shunt. I did an internet search later to find out how bad putting an IV in an shunt arm is, but I couldn't find much. What I did find was that the main reason for not taking a blood pressure in that arm or doing an IV was not to damage the existing shunt or damage a possible future shunt site. Well, they aren't going to put one in his hand, so I suppose that was better than putting one in his forearm.

Just how emergently sick the man was I really don't know. His pressure was low, but as I said, he wasn't tachycardic, was Satting fine, was warm and seemed in no distress. Some people with chronic illness just have low pressures. I'm sure I'll pick him up again.

Last call of the day was for an old lady with Alzheimer's who vomited. Nothing else wrong.

Got back from the call in time to see the last of the Red Sox game. They won a nice 2-1 victory.

Three Days Off/Goals

I've had three days off. I've been waiting for my car to get out of the body shop, and when I finally went to get it today, they said the door still wasn't working. It should be ready on Monday. So I'm still in the rental. I've been working on cleaning my house. I've been going through papers, boxing up books, I'm trying to get everything neat so that I only have the essentials in my house with everything nonessential either given away or neatly put in rubber storage bins until I can decide what to do with it. Here are my goals for the coming months:

Physical Fitness: I've been battling this cold/cough so I have not been going to the gymn, opting for rest. I need to get back on a rigid schedule, aimed particuarly at strengthening my core.

Writing: I have two novels that I am almost done with, and I am putting together a nonfiction book (although I will know before the month is out whether my agent thinks this is a good idea, i.e whether the the publisher will be interested) and maintaing my blogs.

Spanish: I am going to the Dominican Republic late in May and I want my language to be way better than it is now, which isn't bad. I want to be fluent as possible. I have software, tapes, and plan to attack every spanish speaking nurse, tech, and aid at the hospital and demand they speak with me in Spanish.

Regional EMS-I need to work on new protocols, as well as the lights and sirens policy.

CMEs-I've agreed to teach two CMEs about the new AHA guidelines so I have to make certain my presentations are decent.

Money-I need to work a lot. I have been taking too many days off.

My house- I want everything in order before the month is out. I think I am going to buy a new bed. My back has been very stiff in the morning and I think maybe my ten year old bed is the cause.

My lawn- Forget it, I have already given up. I am considering just covering it with wood chips.

***

I'm doing a sixteen hour overtime shift tomorrow so I should have some EMS content.

Chatting

Started off the day with a minor motor vehicle accident. No real injuries. One patient wanted to go to one hospital, the other wanted to go to another hospital. Persuasion was completely uneffective. To top it off it was extremely cold out with the bitter wind and the accident was in an open space near tobacco fields so the wind had some serious momentum before it hit us. Pulling the stretcher the ambulance door slammed into my back. I gave my partner the choice, he could tech the call or wait with the other patient until the second ambulance arrived from the city. He chose to wait with the other patient. Bad move for him. He was freezing when they finally arrived. There is the EMS rule that once an EMT is on scene, the first ambulance can't leave until the next ambulance arrives, but it seems silly in many cases. This was one of them. We waited nearly thirty minutes. It wasn't a bad accident so the other ambulance wasn't using lights and sirens.

Next call was at a day care center where a two hundred and fifty pound twenty year old aide lay prone on the ground with back spasms unable to move. She got morphine.

We went to a doctor's office for dsypnea and found the patient on her cell phone chatting away, telling her friends she was going to the hospital. She hadn't been feeling well for a couple weeks and had been treated for pnemonia and she had a COPD/CHF history, her lungs were decreased, but to listen to her chat away while I was trying to assess her made it seem sort of silly that we were summoned lights and sirens.

We had a man with a syncopal episdoe in Dilbertville. He was sitting in his vcubilcle when he passed out, head into the keyboard. No history, a benign exam, he was just under stress, he said. This is a big company, who is all the time showing up at people's desks and telling them their services are no longer needed, even at times after thirty or more years of work. He was fifty and had been there only a year. "A guy has to work," he said, after telling me about the pressure to produce.

Last call was for a guy who dislocated his shoulder. He was in some serious pain. We could not get him to sit still nor could we find any way to splin the arm to ease the pain. I ended up giving him 12.5 of morphine. I gave 8.5 in increments on standing orders, then called for an additional 4. Big strong 23 year old guy. The morphine got the pain down to a 4 from a 10.

We got back to the base in time to watch American Idol. Amazingly, this was the fifth week in a row, we didn't have a call to interrupt our viewing. I like Mandisa, but thought they were all pretty lousy last night.

Opening Day

When I came in this morning the night medic told me he had problems with the med radio. I had serious problems with it yesterday. The interesting thing was we were in different ambulances.

I did a radio check in both ambulances this morning and everything was working fine. I think the problem may have been on the med end, instead of ours. When doing the radio check I turned the ignition on in the ambulance. I forgot to turn it off and when we went out for lunch, the ambulance was dead, so we had to use the other ambulance, while the town came and recharged tha battery. My bad.

Only one call today. An elderly woman who felt a pain in her chest when she was gardening. She said she thought she pulled a muscle. I agreed with her, but we still worked her up.

My partner brought me in a keyboard with a USB port that I can plug into the computer I'm using in the city to do my run forms. It beats using the hand recognition software or using the stylus to tap one letter at a time on the screen keyboard.

Watched some of the Red Sox game at work. Opening day. They were playing at Texas. They won! I'm going to Boston next week for the Fenway home opener.

The night medic came in for me early so I could go to a meeting for my Dominican Trip. I'm going back with the same group I went last year for eight days in May. I've got to go on a rigid spanish speaking regime now so I am in top form for the trip.

What EMS is About

I come into work and find a note posted on the door for me. "The only current lidocaine prefilled are in 280. There are none in reserve. 270's are expired." The note is from the medic who shares 270 with me. I have ordered more lidocaine, but the order is a couple weeks late. I am not that concerned because we have plenty of amiodarone, and under the new AHA guidelines, amiodarone is preferred to lidocaine anyway, and in the case of v-fib with pulse, lido has actually been removed from the algorithm.

I check my ambulance out, and then get in bed and sleep for two hours. At ten, the call comes in for the nursing home patient with the skin tear. We walk out to the ambulance and I hear on the radio the cops being sent to a chest pain. We should be going to that I say, and no sooner said, then the dispatcher calls us and reroutes us.

It turns out I know the son and daughter-in law of the eighty-year old man with the chest pressure that has now gone away. His twelve lead looks good, he's already had his aspirin, so I do routine ALS and take him in without lights and sirens. It is a good call, the kind of call EMS should be about. Helping a neighbor. The man was a little stubborn about the chest pressure, but his family finally convinced him to go, and we helped them negotiate the hospital. Afterwards, we all shake hands and wish each other the best.

The next call is for an elderly man not acting right. We arrive at a nice private home where a picnic is in progress. Uncle Morty is in the bathroom, cool, clammy and not recognizing his grandniece, who helps hold him up. He is an insulin dependent diabetic. His sugar is 36. We give him some D50, and he is back as good as new. His grandniece brings him a plate of food while he tells me he has been married to the same woman for 57 years. He refuses to go to the hospital. He neglected to eat because he was too busy talking to everyone and the food wasn't ready yet. He agrees to follow up with his doctor.

Later we get sent for a woman in her thirties not acting right according to her husband. The only history she has is lupus. When we arrive, the police officer tells us she can walk out. We leave the stretcher in the garage and walk in. She is sitting in a chair with a faraway look in her eyes. Her husband says this is not like her at all. Her skin is warm and dry. She has no facial droop, good equal grips and no arm drift. Her pupils are equal but not reactive. I have her get her shoes and we walk out to the garage where the stretcher is set up. I have a hand lightly on her arm because her balance looks a little bit off. Her husband has her meds. He tries to get in the back with us, but I tell him he needs to sit in the front seat. For a moment, I think about having him sit in the back, but since I have another crew member with me, I think its better he is in the front. After I have assessed her, I can stick my head into the front and interview him more thoroughly.

My partners are fairly new to EMS. Driving for the first time is the young man I wrote about in the story Compressions. In the back with me is another new EMT, who is very eager, but still needs more seasoning. I have him take the blood pressure while we start to the hospital on a nonpriority. I strap a tourniquet around the woman's arm and find a vein. He says the pressure is 160/100. Hmmm, I think.

I get a flash on the IV, and withdraw the needle, and start drawing blood. I have about half a tube, but it is drawing so slowly, I decide to just attach the saline lock. I detach the vacutainer, and while I am clamping down on the vein with my left hand, suddenly the patient starts to shake. She isn't just shaking, she is seizing violently.

"What's going on back there? What's going on?" the husband demands.

"She's having a seizure," I say. "It's okay; I have medicine to stop it."

"What's going on? What's going on! Is she all right?"

I am holding on to her arm, clamping the vein off for dear life. I can't reach my narcs, which are locked up in a cabinet behind the captain's chair. I'm not panicked because I'm thinking maybe she had a seizure earlier and was acting so weird because she was postictal. Besides, most seizures stop after a couple minutes. I manage to get the saline lock attacked to the catheter and taped down, just as she stops seizing. She sits there now, looking off to the left, and I don't think she is breathing. I look at her closely, but I can't see any movement. I do a sternal rub. No response. I don't feel a pulse, but we are bumping down the road.

The man in front is flipping out. "Shouldn't we be going faster? Shouldn't you have the lights on?"

I ask my partner to get out my airway kit, while I quickly put her on the monitor.

Here's what I see:

I cut off her shirt and slap the pads on.

"Step it up to a three," I say to the driver.

I am tempted to shock her, but I flash back to calls I have had in the past -- few with a good outcome. I shock them, they die. I have an IV. My med kit is on the bench next to me. I open it up and pull out a vial of amiodarone. I draw up 150 mg and push it in into the lock. I look at the monitor.

EMS is all about the action, but sometimes it’s about waiting.

She's in v-tack. I'm not certain if she is breathing. My old instinct would be to drop her down and tube her, but the new ACLS is saying you can delay the tube while you deal with the rhythm initially. What happened? I'm thinking. Did she seize because she was in v-tach or did she go into v-tack because of the seizure? It was a true gran mal seizure, not a hypoxic seizure. People stop breathing after a seizure sometimes, but then start up again. But she's in v-tack. What the ?

I do not want to shock her because if I do, the next minute I know I'm going to be doing CPR. But soon I am going to have to do something.

Should I have the driver pull over and grab a board out of the outside compartment so we can lay her down on it and start CPR? I look back at the monitor. She is out of v-tack. Thank the Lord. I'm not certain if it’s a sinus tack or a rapid afib. The rate runs from 140 to 170.

I have the ambu-bag in my hand, but now I tell my partner to get a nonrebreather out of the cabinet.

I have a pulse. There's some small chest rise. I get a blood pressure 170/120. She still doesn't respond to a sternal rub. We check her blood sugar. HI, which means it’s over 600.

I try to patch to the hospital, but all I can hear on the radio is a high-pitched whine.

"What's going on? What's going on back there?" the husband demands. The driver is trying to calm him down.

The whining stops on the radio and when I ask if the hospital is on, the operator tells me they are off now, but he will try to get them back on. They come back on, I give my patch, but get no acknowledgement.

I put in another IV and start running fluid in. She is still unresponsive. Her rhythm is looking better.

I think about tubing her, but she is satting at 98%, so I just watch her airway.

We park at the hospital, and the husband, comes around to the back and when we open the doors, he sees her laying there, her breasts hanging out in the open. I quickly grab a sheet and cover her up.

The husband wants to know what's going on. I tell him I'm not really certain. She had a lethal heart rhythm, but she's out of it now. Her sugar is high. He confirms she is not a diabetic and has never had seizures before.

We wheel her in. They never got our patch so they are not expecting us. They quickly get us a room. She is responding to the sternal rub now, and mutters a few words. I give my report while they get the rest of her clothes off.

When her lab results come back, her sugar is 1200, and most of her electrolytes are way out of whack.

The nurse tells me her husband kept saying how slow we drove to the hospital.

Here’s what her final rhythm looked like when we turned her over.

Last call of the day is for a dehydrated alcoholic.

Parking

When I went into work this morning, the supervisor told us we could no longer park in the lot of a drug store chain when we are posted in an area, because the manager had filed a complaint. This always amazes me. You would think they would be happy to have a ambulance so close by, not to mention all the business the crews bring in when they are posted there. Some places welcome out presence. A local dunkin doughnuts used to love us because when we parked there at night, they would never get robbed. Then we were told we couldn't park there anymore. I had a preacher once come out odfhis church and tell me we couldn't park in his empty church lot. The episode today made me think of the story a woman in Mississippi told me about how the Walmart there used to give them a hard time about parking in the fire lane, and then after the storm, they went down there and took pictures of themselves parked in the fire line in front of the empty Walmart that had its walls and most of its contents washed out to sea.

I was hoping I would have an interesting call to write about tonight, but it was more of the same. The 911s today were a woman hearing voices at a drug rehab center, a man having stomach pain while uundergoing diaylsis, and an old man in a nursing home who fell on his knees, but said he had no pain. Add to that two transfers and that was the day.

My back was very sore today. Yesterday I was boxing up books and stacking them in the garage. I'm trying to weed down my possessions. I have over 25 boxes of books I am going to get rid off(I'm donating to the library). I have another 25 boxes I am keeping stored in rubber containers in the garage(these books I may sell or donate at a later time), and that will leave a couple bookshelves worth in the house of my very favorite books.

I put in for vacation for July and turned in my pager that hasn't been working since I washed it with the laundry.

Tonight I am going to box up some more books, have a couple beers, and then get to bed because I lose an hour of sleep tonight due to the time change.