No comprende’

A call for a “person choking” at the nursing home, in the “Memory Care Unit.”

Caring for something that isn’t there any more.

On the way in, we walk through the obligatory keyed-entry door, and Newguy points out a sign just inside the unit.

“New Memories Made Here!”

Kinda ironic.

A crowd of people is gathered around an old feller in a wheelchair at a dining table. Sure enough, he’s choking. As in, not breathing. He’s blue, but looking around. Close to death.

Newguy springs into action like some sort of caped superhero, sans cape, and performs a few abdominal thrusts. Our patient becomes unresponsive, and we move him to the floor, when I swoop in like the superhero’s sidekick with my trusty laryngoscope.

“What the hell is that? Bro, hand me the forceps real quick.”

There’s something in the airway, sho’ nuff. And I’m about to get that junk out.

The forceps go in, grab the food bolus, and I withdraw it slowly. As the food comes into his mouth, the patient starts to gag, cough, and miraculously, his skin changes color. This guy might be a chameleon.

I look at Newguy. “Just who is the sidekick NOW?”

Somebody examines the food bolus, and quickly deduces that it is roughly two-thirds of a lightly chewed Nutter Butter bar.

“Who gave him the cookie?”

“I did.”

“His arm band says ‘Nectar-thick liquids only’.”

“Oh. I didn’t know. I don’t read English.”

“Narc-what?”

“Person choking” is what the dispatcher says. A young person, too.

We skedaddle on over there, to find the nice fire crew already on scene. From what the friend says, the unconscious guy on the floor took a bite of a chicken sandwich then passed out and turned blue.

Somebody is bagging this guy, but “his sat is good with the bag, so I didn’t tube him.”

His vitals are okay, except for the unconscious part. He is breathing on his own, about 10 times a minute. Sugar’s normal. Heart rate is normal. Pressure is better than mine. Something about pinpoint pupils, but whatever. Everything is going smoothly so far.

While I’m thinking of the logistics of how to get this unconscious fellow up two flights of stairs, I hear some wonderkid say “Narcan.”

My ears immediately perk up, and my head turns as I say “dowhatnow?” But they don’t hear me. They are too busy talking amongst themselves.

“Yeah, we might as well.”

“It ain’t gonna hurt nuthin.”

“Yeah, it can’t hurt.”

“How much you want me to give?”*

“Give half of it.”**

“Okay.”

I interject. “Uh, if we’re gonna give naloxone, how about we go with point-four milligrams instead of one?”

“So you want me to give a fourth of the vial?”***

“Uh…”

The other guy speaks up: “Just eyeball half of it, it’ll be alright.”****

Before I can begin to process the shit show of patient care that just occurred right in front of my eyes and ears, someone gives ‘about half the vial’ of naloxone.

You know what happens next, don’t you?

Homey promptly awakens, retches, and coughs up a humongous piece of a chicken sandwich, which was obviously lodged somewhere north of his vocal cords.***** (It was just too big to go past the cords. Imagine you took a huge bite of a sandwich, and decided to inhale it without chewing. Yeah.)

My head is literally about to explode at this point.

 

* Personally, I don’t want you to give any, but the question wasn’t being asked of me.

** ”Half?” Is your partner not intelligent enough to read the numbers on the side of the little cute glass tube?

*** Okay, now we know you can’t read, and you suck at math. For the record, zero-point-four is one-fifth of 2 milligrams. Or twenty percent.

**** Seriously, I heard a paramedic say this. In the company of 4 other paramedics. Have you no shame, mustachioed dude?

***** Seriously, what the hell is going on here? The call was for “choking” and you arrived on scene to find an unconscious guy lying on the floor with a fucking chicken sandwich in his hand missing a bite. Did nobody think to look in his airway? A blade and a set of forceps would have done fixed this problem a long time ago, but now this guy’s going to have to sit in a hospital for a few hours.

 

Newguy and I are left to try to pick up what remains of our jaws from the floors. We literally can’t believe the serious shit-show we just saw happen. And meanwhile, these yahoos are patting themselves on the back.

What the hell is wrong with people?

TBD: Think Before Denying

Newguy and I are inside the home of a delightful lady who was complaining of chest pain, at least according to our dispatchers.

Our intrepid local first responders are huddled around the patient, in a mad dash to save her from the throes of death.

They seem to be succeeding at preventing her imminent demise, and also are sucessful in their attempts to create a large pool of blood all over the patient’s hardwood floors.

It’s a win/win situation so far.

One of the patch-wearing heroes rattles off some vital signs, and they are all better than mine, with the exception of her blood sugar: 331. Alas, she is a diabetic.

I really enjoy when the pieces of the puzzle assemble themselves.

Our infirm female has said several times now that she needs to “tinkle,” and asks if she can go. Newguy wants to get the 12-lead first, so he asks her to wait just a minute or so. It’s normal, by the way.

“Okay then, can I have a glass of water while I wait? I’m really thirsty.”

“Nothing to eat or drink until you see the doctor” the intrepid hero reflexively replies.

Newguy is nonplussed. “Why can’t she have anything to drink?” he asks.

“I don’t know” is his reply. Clearly, he has no idea.

“Were you guys going to put saline in that IV over there?”

“Well, yeah…”

 

Why don’t we think about these things? Don’t we all recognize what is going on here? This lady is hyperglycemic, and polydipsic and polyuric. Because her blood sugar is ridiculous. Granted, I’ve seen higher, but she’s going to get a large amount of fluids in her IV on the way to the hospital, so is there really any harm in giving her a glass of ice water?

The Curious Case of the Bumbling Buglers

“Hey man, wake up.” urges our bantam hero from the driver’s seat of the ambulance, “we’ve got a call.”

Arising from his light slumber, our second, slightly more portly hero reads the information on the MDT and presses ‘RESPONDING’ with an undaunted confidence that is rarely seen.

Then mumbles “bullshit.”

Over the radio crackles updates from dispatch: “PD-related call…male says he overdosed on cocaine about an hour ago and feels light-headed…requests EMS and Fire to check him out…PD is also enroute…”

Slimm deftly maneuvers the ambulance through traffic, never making contact, nor spilling his coffee.

The heroes with the big tank of water and fireproof clothing announce their arrival at the home of the cocaine-sniffing dipshit over the radio, making sure to establish command and set up a landing zone. No need to launch the water rescue though, this is on dry land.

Returning to our ambulance, we find the first two heroes moving in the direction of the distressed person with an alacrity only seen in nursing homes. Shortly, they arrive on scene, making sure to check in with the incident commander.

“Med 4 on scene with two personnel.”

As they deftly maneuver across the barren land, interspersed with pine cones and the remnants of a despair-filled, low-class life, they are intercepted by a first responder; Slimm executes a spin move but is still stopped in his tracks, just short of the goal line. Even Slimm can’t get past a man with bugles on his collar.

“This guy in here snorted some cocaine a little over an hour ago and says he feels funny.” he informs our altruistic, polyester-clad heroes. “His vitals are fine. He wants to go get checked out. No LOC, no medical problems, nothing like that.”

Slimm finally speaks since arousing his best friend in the world from his slumber earlier “you mean he don’t want to go to jail” he says, as we are granted access to the rust-streaked home that is easily moved.

The bugle-collared gentleman has associates, two of which are standing around what appears to be a dude afraid of the Iron Bar Motel. Local law enforcement stands back a little bit, contemplating his impending lunch hour, and the laborious task of deciding where to drive his cruiser. The third associate, who looks more like a nefarious cohort, wields a metal clipboard with an expertise rarely seen in the field, his ballpoint pen perfectly poised to write down any information at a moment’s notice.

Slimm notices one of the Bugler’s friends has established access for intermittent needle therapy on the Sniffer. The Bugler’s friend proudly turns and proclaims, loud enough for the neighbors to hear, “I gotchew an ate-teen in his raht arm.”

The Bugler interjects: “we gave him 2 of Narcan right before you pulled up.”

A look of perplexed bewilderment crosses the faces of our heroes. Slimm’s head instinctively cambers a few degrees while his brow furrows “WHY?”

“Well, cause he overdosed on cocaine. DUH.” is the reply from the Bugler.

Slimm turns to C: “I can’t man, I just…I…man, I gotta go…I’ll be in the truck” he stammers, as he turns and walks back to the ambulance with a mixture of incredulousness, disdain, and sadness.

“We got it from here, fellas” our portly hero informs the Bugler and his Nomex-clad cohorts. Turning to the Sniffer, “come on man, we better get out of here before that Narcan wears off.”

 

 

Cath lab

I’m running a call with Joe again. A little old lady fell down.

Literally.

Fire is on scene. We all mosey into the house.

“Hey, guys. Whatchagot?”

“Hey, this is Maude*. She fell right here walking to the kitchen. She has a complete heart block.”

“Okay. Is she hurting anywhere?” to Maude, “Hi. Are you hurting anywhere-”

“Dude, she has a complete heart block.”

Joe and I both notice the leads are on Maude, but not the combo pads. That, along with the fact that Maude looks like she feels better than 50 percent of us on scene, don’t worry us too much.

“Yeah, I heard you. How about we get her on the stretcher and out to the truck?”

“Man, I don’t think you understand. She has a complete heart block.

“Okay, okay. I get it. Let’s get her on the stretcher and move her to the ambulance.” Joe is good at hiding his annoyance. Very good. But someone has a point to make, apparently.

“Dude! Listen to me! You aren’t hearing me! She has a COMPLETE HEART BLOCK!”

Joe turns to the Captain on the engine, who, up to this point, has been expertly wielding the clipboard.

“Hey, man. Can y’all run out to the truck and grab the cath lab? We forgot to bring it in.”
“Dowhatnow?”

“The cath lab. I left it in the truck. Can someone run out there and get it for us? Oh, that’s right, we don’t have a cath lab in the truck. Maybe we should take her to one?”

 

*obviously I made that name up.

Sometimes we should refuse transfers

Almost once a month, I see in my Facebook feed a link to the article from several years ago in which a Florida ambulance service was ordered to pay a 10 million dollar settlement to the mother of a baby that was born in the back of one of the service’s ambulances. The mother was being transferred from one hospital to another, due to the patient’s (apparently) precipitous labor. The mother’s water broke, and the baby was delivered (and heroically resuscitated) in the back of the ambulance. Unfortunately, the baby suffers from cerebral palsy, and a jury in Florida found that the ambulance service was liable for the injuries to the baby, because they did not have the appropriate equipment on board.

I trust that the story is easy to find, and has been read by the majority of us already, so I won’t link to it here.

I’ve argued that the service never should have taken that transfer in the first place, and that the service is most certainly liable.

Most of the Facebook comments on these threads follow a common pattern; that: 1) the paramedic performed a heroic thing by resuscitating a 25-week fetus, 2) the ambulance crew should have called their supervisor or medical direction prior to taking the call, 3) shock that an ambulance service would be held liable when they saved a very difficult patient, 4) the plaintiff must be money-hungry, and 5) the ambulance service should have demanded that a hospital employee ride in the back of the ambulance with the patient.

I will never argue with anyone on the first point. I know several people who work for EVAC, though not this particular paramedic. I can only imagine the difficulty this paramedic encountered when faced with having to resuscitate a pulseless, apneic 25-week fetus with only the help of their EMT partner. This was very strong work by an EMS crew, with a much better outcome than would have occurred in a lot of other situations.

I don’t agree with calling a supervisor or medical direction. Calling a supervisor for guidance would be only minimally helpful, and a medical director phone call does nothing to remove liability from the providers. This ambulance service was most certainly liable, from the actions of the call-taker to the paramedic who accepted the transfer.

All too often, if the paramedic had refused to take this patient (as some would), they would be viewed as a “problem” employee who was “refusing to run a call.”

To address point number four, I don’t believe the mother of the baby is “money-hungry” in the least, but that she is now faced with paying for a lifetime of care for a baby who suffered injury at the hands of the ambulance service.

And to address the final point, asking for a rider from the hospital only provides the paramedic with another pair of hands. Hospitals (in my experience) are hesitant to send riders for several reasons. First, because they lose the nurse for several hours, and staffing levels are affected negatively. Second, many nurses are not protected from liability when they leave the hospital grounds. Nurses operate under a physician while in the hospital, much like paramedics operate under a physician while in the ambulance, which begs the question; which physician does a nurse riding along operate under?

Several years ago, I was called in the middle of the night to a small, rural hospital to transfer a patient to a very large hospital that was more capable of taking care of him. The patient was incredibly sick, with a PaCO2 in the 90s, with a PaO2 in the 70s. This patient was on BiPAP, and the sending hospital was absolutely bouncing off the walls to get him out of their hospital. While I was working on a critical care truck, my ventilator at the time did not have the capability to provide BiPAP. I informed the sending physician that I wasn’t able to transfer this patient in this condition, and he was apoplectic. The sending hospital was not in the position to send their BiPAP machine with me in the back of my ambulance, as it was the only one they had, and they couldn’t be without it for the 5 hour round trip.

While the physician was incredibly mad at me, I stood my ground, and he finally asked what needed to be done to have the patient transferred, and we discussed the case. The patient was sedated, paralyzed, intubated, then placed on my ventilator for the transport, which was uneventful.

When I got back to the station in the morning, my supervisor called me into the manager’s office to discuss the call. The phone call they received from the sending physician led them to believe that I did not want to run the call, and that I was rude, and incapable of handling a patient on BiPAP. After explaining the potential liability that the company would face had I transported that patient as he was, everyone agreed that I did the right thing.

I was fully prepared to walk out of that hospital that morning without a patient. I act in the patient’s best interest first, as we all should, but I also keep in mind the company’s position. Those two don’t have to be in contrast to each other. If we act for the company first, by taking the call because it is a paying patient, then that is not always in the patient’s best interest. If we do the right thing for the patient, then the company will, more often than not, be okay.

MCI review

When at an MCI, assignments are given to you. For example “take those three patients from that car right there to Local Hospital.” But we all knew that already.

When those instructions are given, it isn’t necessary for you to hang around and give scene reports to the arriving units, directing them to where their patients are.

Incident Command is the one with that responsibility.

When informed that you are to “transport them to Local Hospital,” that doesn’t mean you hang around for another 15 minutes with your thumb up your butt then ask the IC “hey, is it cool if we leave now?”

“Your ambulance should have left 15 minutes ago!”

MCIs work much, much smoother with just a tad bit of cooperation.

Phone calls

FEM/22YO/BLEEDING FROM MOUTH” says the MDT.

We arrive on scene to find a pleasant looking female, approximately the age stated on our mobile dispatch terminal thingie. We don’t notice any obvious trauma or distress, but we haven’t made it to the apartment door yet.

Slimm takes point.

Good morning, ma’am. What seems to be the problem today?” he asks.

I’ve got this thing on my mouth and it burns.”

And then we see it.

A cold sore.

I bet that burns and hurts. How long have you had it there?”

I woke up with it this morning.” (and decided that a call to 911 was in order, apparently…)

Have you tried putting anything on it?” Slimm asks, knowing full well the answer will be a resounding ‘duh, of course not.’

I don’t know what it is! Shouldn’t I see a doctor or something?!”

Well, ma’am,” Slimm replies, being the consumate professional that he is “it appears to be a cold sore. There are lots of treatment options at the pharmacy.”

What is a ‘cold sore’?”

It is a type of herpes infection. They are pretty common, actually. They usually go away in a few days, but they can come back at any time really.”

Sometime in the past few days, Slimm has become a dermatologist.

I HAVE HERPES?! ON MY FACE!?”

It really isn’t that big of a deal. Most people get them…”

OhmygodIhaveherpesonmyface!”

We are sliding quickly down the slope towards an anxiety attack.

Am I, like, contagious?

Well, yes ma’am. If you share utensils, or drinking glasses or straws, or kiss, or have oral sex, you can pass the virus to the other person.”

A gasp audible from ten yards escapes her mouth.

I need to make some phone calls…”

We make our way back to our ambulance and climb in. Slimm turns to me. “I wonder who she is going to call?”

My friend Lilly

Lilly* has schizophrenia. As if that isn’t enough, she was also born early, to a cocaine-addicted mother, with hydrocephalus. She also has bi-polar disorder, diabetes, and is legally blind. Her growth was severely stunted by all of her problems, and even though she is in her mid thirties, she is barely 4 feet tall. Lilly’s mother and her crack-dealing boyfriends abused her as a child.

Lilly’s aunt “takes care” of her. What she actually does is provide a place for Lilly to live. Auntie tries, and she tries hard. But she can’t do it. Auntie says Lilly is family, and family takes care of family. Auntie makes sure Lilly gets all of her medications every day, and makes sure she is well-fed and clothed.

Auntie doesn’t have much. She lives on a paltry disability check she gets, and her son contributes some of his earnings he makes selling drugs in the neighborhood. I can’t imagine how they manage to eat, much less afford their home. Auntie inherited the home from her mother when she died a few years ago, and somehow makes the mortgage payment.

Lilly doesn’t want for love. Her cousin, her Auntie, their extended family, and even the neighbors all care about Lilly. But Lilly is sick.

Lilly has psychotic breaks about three times a week, and has been for several years. She throws things in the house, punches walls, scratches cars with keys, screams, swings at people, and does all the things to be expected.

She can’t help it.

So the police go to the scene to make sure she doesn’t physically hurt anyone, and to try to stop Lilly from causing more property damage. They don’t arrest her, because she doesn’t need to be arrested. They call for an ambulance, because she needs mental help, and there is no such thing as a mental health house call where Lilly is. The call for the ambulance invariably triggers a call for a fire crew in their engine.

But the loud noise from the engine makes Lilly agitated, and the crew doesn’t really know what to do. They just know they aren’t needed there, but they have to be there until we can get there.

So we show up, and we spend the next thirty minutes doing everything we can to talk Lilly down.

I like Lilly, and I would like to think she feels the same way about me. We have a routine: I kneel down and remove my sunglasses so we can make eye contact, I touch her shoulder and introduce myself, and she screams at me. I tell her that I am here to take her away from what is making her upset, so she can go talk to someone if she wants to, or so she can be alone for a little while.

Lilly always agrees. Sometimes it takes longer to talk with her, but she always agrees.

Then we take her to the hospital her Auntie chooses, since Auntie has power of attorney.

The hospital staff is incredibly nice to her. They all say hello, and they smile. They allow her to keep her clothes on, and they give her a soda and saltine crackers.

Sometimes, a physician will sign an involuntary hold order, and Lilly has to go to an inpatient center for several days. But that doesn’t fix the problem.

I really don’t know what Lilly needs. I think she needs a nursing home of some sort, or at least an assisted-living facility. But I don’t know how that would help.

I just know the current situation isn’t working.

Poor Lilly is a horrible victim of a horrible situation, and she can’t help it.

 

*Not her real name, of course.

That duck can pull a truck

The call is for a middle-aged man with “altered mental status not breathing normally.” I’m responding with the ambulance crew and a fire crew to the apartment complex address listed on the MDT.

I arrive on scene as the ambulance crew is making their way inside. I know the medic fairly well. He did all of his intern rides with Slimm and I, and he is good at his job. I know he won’t need me, but I would like to see him working on his own. The fire crew has been there several minutes.

I walk in to see the fire crew taping down an IV in the patient’s arm. “It’s a white-out, C” says Ashley the medic, with his thick drawl. “Suggah is thutty.”

(Think Kevin Bacon in JFK. Not Costner, because his attempt at a southern accent was piss-poor.)

I see Ashley and his partner spiking a bag of saline while a fire crew member is reaching into his bag for the D50.

“Hey, b’fore y’all go ‘head and push that dee-fifty, let’s mix it up in this bag right here.”

“But he needs the sugar. His glucose is really-”

“I know, I know, but we should mix it up in this right here bag instead’a givin’ it straight in the vein.”

“That doesn’t make any sense-”

“Look, now. If I tell you that duck can pull a truck, then hook that duck up! Lemme show ya’ ” Ashley replies, grabbing the syringe, attaching a needle, and mixing it into the bag of saline.

“Now, what we got here is dee-ten. It’ll wake’em up just tha same, but it’s just less shockin’ to tha system” he explains.

I know exactly what he is doing, because that is my preferred method of dextrose administration.

The patient wakes up quickly, and I glance at the bag. About 100ml are in so far. Somebody repeats the glucose stick. “Eighty-nine.”

“Now see, he’s had a hunnid of dee-ten, and he’s already awake. Ain’t that suggah better’n givin’ tha whole amp and jackin’ it up to tha three hunnids?”

Apparently, when a Southerner tells you that a duck can pull a truck, you are supposed to shut up and hook that duck up.

Learn something every day.