Bad decision

A middle-aged male calls 911 because he doesn’t feel well. We find him sitting in a chair in his bedroom, looking terrible. Pale, cool, diaphoretic, cyanotic, and in obvious distress.

What my father would call “looking like death eating a cracker.”

He had a CABG a few years ago, and has high blood pressure. His wife says he has never had a heart attack though, and only did the CABG after an abnormal stress test.

He’s having one today though.

The 12-lead shows a big anterior infarct, with lateral involvement, and with lots of ectopy on the continuous ECG. His blood pressure is low, too.

Lots of bad things are going on.

“Sir, let’s get you on to Local Hospital.”

“No, I want to go to Southside Hospital.”

Southside Hospital is thirty minutes and two counties away. And this guy doesn’t have thirty minutes.

“We really need to go to a closer hospital, and Local is only five minutes away.”

“I will not go to Local Hospital. Take me to Southside” he says between breaths.

“Sir, you are having a heart attack. Southside is half an hour away, and that is just too far. We need to go somewhere a lot closer.”

“I don’t care. I am NOT GOING to Local Hospital.”

Slimm was wise, as usual, and had the patient sign a refusal form on which Slimm wrote ‘Patient refused closest hospital.’

I hated to take a firefighter so far out of the county, but I really didn’t have a choice. We told the other guys on the engine that we would bring him back. I really don’t like to take riders, but I felt like something bad was going to happen, and I would need the help.

Something bad happened, and I needed the help.

About six minutes after passing Local Hospital, the patient went into v-fib. Even though my defibrillator pads were already on, and it took about 5 seconds to deliver the shock, it didn’t work. After Amiodarone and two more defibrillations, he was in asystole.

Slimm diverted us to Local Hospital, and the patient never came out of asystole.

If he would have gone to Local Hospital, the outcome would likely have been the same, but I can’t help to think that it might have been different. If he would have listened to the advice of the providers on scene, he might have survived. But he made a bad decision.

Someone once told me something very wise.

“People have the right to make bad decisions.”

It’s like a Hollywood script

Finally, Slimm and I are back together. This will be our first time back on a truck together in what feels like years, but has really only been about one year.

I have to wake up 5 hours earlier than I am used to, but I think it’s worth it.

We hugged in the parking lot. It was a brief hug, but it was a hug nonetheless.

Then we got breakfast.

And our breakfast was interrupted because some guy fell out of bed. Now my gravy is going to be cold, and nobody likes cold gravy on their biscuits.

“Radio Med One.”

“MmmmGohead” I reply sleepily.

“Caller is advising agonal respirations.”

“Mmmmkay.”

I turn to Slimm. “I hope the caller is just stupid.”

“Me too, bro. Me too.”

“Radio Med One”

WHAT?! “Gohead”

“Caller advises full arrest. They are starting CPR.”

Shit.

This sucks. The sun isn’t up yet, and neither am I.

Sure enough, it’s a full arrest. The fire guy recognizes me.

“What’s up, C?” he asks as he’s doing compressions. “You pick up an extra shift?”

“Naw, man, I’m back on the truck with Slimm again. Whatcha got?”

“Glad to hear you guys are back. Wife woke up and found him here about ten minutes ago. AED says ‘no shock,’ Bubba got the LMA in, and Chester is about to start the IO.”

I feel around this guy. I don’t see any obvious trauma, but his skin sure is cyanotic. And cold. I mean, remarkably cold. Most people I have felt this cold before have either had lividity or rigor, but he has neither. He is in asystole, and his pupils are dilated and fixed.

Basically, he’s dead. But not dead enough to stop working.

“C, you want us to stop, or keep going?”

“Nah, keep going, let’s move him out into the kitchen, and we’ll work him there. We have more room there.”

Somebody gets the IO, and I see Slimm putting together the bicarb and epi. He looks over at me. “We going to do the two rounds then call it?” he asks.

“Nah, buddy. We’re gonna get him back.”

I wink. Just joking, of course.

But we did.

Five minutes later he had a pulse, was breathing on his own about ten times a minute, and had a blood pressure of 130/90.

“We have to stop doing this.”

“What? Getting people back?”

“Not that. But doing it so easily.

“They should make a movie about us.”

Anemia

An unknown problem at a house. Which begs the question: how does the caller not know why they are calling?

Anyways.

We pull up right in front of the engine, and we all make our way towards the door. We can hear the gurgling from outside.

Inside, we find a lady who is obviously in the throes of death, laying in a hospital bed. She has that open-mouth look that healthy people don’t have.

Someone who looks like she might be a nurse of some sort is anxiously standing in the shadows, clutching what looks like a home-health folder.

“What’s going on?”

“She has anemia” says a guy who looks like he could be her husband.

Meanwhile, this lady has one foot through the pearly gates.

The fire dudes are doing their thing, getting vitals, and trying to put in an OPA, which is complicated by her wide-open mouth.

“Okay. She has anemia. What is going on today? How long has she been this sick?”
“She has anemia. That’s what’s going on.”

Obviously, I’m getting nowhere. “Okay then, why is she in the hospital bed?”

“Because she has anemia.”

Newguy has now decided to sink a tube. This lady has almost no blood pressure, and her heart rate is in the forties.

“Does she have any other problems besides anemia?”

“I don’t know.”

I gave up.

Stoned

A “person who needs to be checked out” at an apartment near the University. We are going by ourselves for once.

Today is Newguy’s day in the back, which means I get to carry this stupid jump bag up three flights of stairs. Great.

“What’s going on today?” he asks the college-aged male who answers the door.

We are doing Boston accents on this call, so I can’t help cracking a smile.

“Man, something is wrong with me, man” comes the reply.

“Okay. What’s wrong?”

“Man, I just don’t feel good.”

“Okay. What’s wrong?”

“Man, I’m telling you, I just don’t feel good.”

“You’re going to have to be a little more specific.”

“I dunno, man. Like, I just don’t feel good.”

“Okay.”

He gets quiet for a minute and looks down at the floor. “I think I smoked too much weed, man.”

“You smoked too much weed?”

“Yeah.”

“And now you’re really high?”

“Yeah.”

“Was the weed laced with anything? Did you do any other drugs? Anything like that?”

“Nah, man. Just the weed.”

“Are you sure the weed wasn’t laced with anything?”

“Yeah.”

“How are you sure?”

“’Cuz I know my weed.”

“But do you know the guy you bought it from well enough to know it wasn’t laced with anything?”

“I didn’t buy it.”

“Okay. How’d you get it? Did someone give it to you?”

“I grew it in my closet.”

“Interesting.”

“Man, I am so high. Something is wrong with me. Man, I don’t think I can read any more, MAN!

“Let me get this straight. You grow your own marijuana in your closet, and now you smoked so much that you can’t read, and you want to go to the hospital?”

“Do I need to go to the hospital?”

“I don’t know. I don’t think they can help you with reading comprehension.”

“I’ve never been this high before.”

 

We took him to the hospital.

Listen and learn

Newguy is out today. He and his wife are finding out the gender of their new baby, so he is going to the appointment. Well, Mrs. Newguy says they aren’t going to find out, but Newguy says he is going to cheat and sneak a peek at the ultrasound. He even has a plan and everything for how he is going to do it.

Nobody tell Mrs. Newguy, okay?

I’m working with a kid today. I did the math, and he was in diapers when I started in EMS. And he already has a bad attitude.

There is a difference between burned out and a bad attitude.

We get a call for a lady who is sick. It turns out the lady is visiting her daughter from Oregon, and has been confused, febrile, and weak for the past few days, and it is getting worse.

Daughter hands me an insurance card and says she needs to go to the hospital about 45 minutes away. While she is saying this, Babyface pipes in.

“Well, we could take her to Local Hospital, and they can just transfer her if needed, but they will probably just let her go if she just has a fever.”

Daughter looks excited, then goes on to explain that the sick lady is allergic to Tylenol and Penicillin, and has a diagnosis of primary biliary cirrhosis. No other medical problems though, which is good for a grandmother in her late seventies.

Finally we see the patient. She’s confused, sure enough. She’s pale, and the jaundice is pretty apparent in her sclera. (What is the plural of sclera? Is there one?) So, she’s sick, and probably needs to spend a day or two in the hospital for some IV antibiotics.

“Okay, we’ll take her to Westside Hospital. We are going to go bring our stretcher in here, and we’ll be out of the way.”

Babyface is absolutely apoplectic. “Why can’t we just take her to Local Hospital? It’s across the street. Westside is forty-five minutes away.”

I get stern with him. “I know where we are, and I know where the hospitals are, and we are going to take her to Westside Hospital.”

Later, at Westside, he decides to assert his position once again.

“Man, we should have just taken her to Local. This doesn’t make any sense.”

“What is primary biliary cirrohsis?”

“She’s probably an alcoholic, and she drank too much, and now her liver is shutting down.”

“Wrong. What is the first thing that comes to your mind when you hear that a person is confused, weak, and febrile?”

“Sepsis?”

“Fair enough. Does the diagnosis of primary biliary cirrhosis change that? You still thinking sepsis? What about her jaundice?”

“I don’t care about her cirrhosis, she just has a fever.”

“No, her ammonia levels are high, and she needs lactulose. She is very confused, and only responds to verbal stimuli, which suggests hepatic encephalopathy, and she needs an ICU. Taking her to Local Hospital would have been a bad decision, and a waste of time.”

He was still mad at me for the rest of the shift.

I don’t chase patients

A call for a person “out of their mind.” PD is already there.

“He’s crazy.”

“No joke. The dispatcher told us that. Why does he need to go to the hospital?”

“His mom wants him evaluated.”

“Why?”

“He’s crazy.”

I’m getting nowhere with this guy, so Newguy and I walk into the house and find the alleged patient and his mommy. The patient is in his mid-thirties, so I don’t know why he calls her “mommy” but who am I to judge?

“Ma’am, why does your son need to go to the hospital?”

“Because he’s crazy.”

I don’t even bother asking again. I just turn to the dude on the couch.

“You ready to go?”

“I guess.”

Cut to 10 minutes later, going down the road. The dude on the couch, who is now the dude on the stretcher, hasn’t said a word. He won’t answer my questions, or talk to me at all, so I’m just sitting in my chair catching up on paperwork.

The ambulance comes to a stop at a red light. Newguy is listening to a Handel on the Law podcast, and I’m kinda trying to pay attention to that.

‘Click click click.’

Before I look up, dude on the stretcher is now dude jumping out the back door. He takes off like an NFL running back with an open field in front of him.

I mean, he is gone.

“Med four radio.”

“Med four.”

“Show us ten-eight. Our patient left the ambulance and ran. Maybe PD might want to look for him.”

“Which direction did he go, med four?”

“I think north.”

“You think?”

“Yeah, I don’t chase people.”

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.”