We can all do better

This might be a long post, but there’s a lot of things I want to cover.

The crux of it revolves around our latest experience with the healthcare system: my wife and I had a baby yesterday. But we weren’t supposed to.

A few days ago, my wife noticed some dark red blood, and spoke to her obstetrician. After consult over the phone, she went to the doctor’s office, had an ultrasound performed, and was sent to our hospital for some longer monitoring. It was determined that everything was okay, and that the contractions she was experiencing were nothing abnormal, and she was sent home, and given instructions for some bed rest.

Nothing is wrong with any of this. This is what we expected, and we are grateful for the office and hospital staff. We were relieved there were no problems, and expected to wait another six weeks to meet our new daughter.

Until my wife woke me up.

It started at midnight. “This pain is different,” she told me. “And now the blood is bright red.” With her past pregnancies, there was a dramatic shift in the quality of her contractions, and this is what she was experiencing. My wife labored for four hours with our first child, and only two with our second one, and here she was telling me that she was in labor.

Six weeks early.

I’ve always prided myself on my ability to remain calm, and to reassure my patients, and their family members. Except in this case, my patient was my wife and unborn baby, and my patient’s family was myself and two small children. My wife is also a former paramedic, and hasn’t practiced in several years, but she was concerned as well.

After performing my own exam (probably against all recommendations, please don’t tell our obstetrician) her cervix was only minimally dilated, at one, but she was becoming effaced. And there was a lot of bright red blood. Her contractions were coming every five minutes, and lasted about 30 seconds. We both felt that delivery was imminent, unless we could stop it.

So we headed to the hospital, and called the obstetrician on the way. Luckily, the office had a physician in the hospital, and we were assured the doctor would come see us right away after we arrived.

But we got a midwife.

Now, listen. I have nothing against a midwife. Nothing at all. I fully understand how vital a role midwives play, and I am sure they are more than competent. But there were two exceptions in my case. First, this was a woman who was nowhere near full term, and second, we made it perfectly clear that we expected a physician in the room, as opposed to any midwives.

Let’s be realistic: when the shit hits the fan, the midwife is going to call a physician. So let’s just cut the crap, and have the physician in the room in case the shit hits the fan. Meanwhile, we have a woman in labor, with bright red bleeding, who is only 34 weeks along, with a documented history of short labors.

That fan was spinning pretty fast.

Of course, the midwife was upset when I specifically requested a physician. “I’m more than capable of delivering babies” she said.

“And so am I. I delivered a baby just last week in the camping section of a Wal-Mart. But we want a physician, specifically a perinatologist, and some terbutaline might be in order if we have any chance of stopping this preterm labor.”

I try really hard not to walk into situations with a chip on my shoulder, and I don’t volunteer that I am a paramedic unless it is called for. In this case, I felt it was called for. The midwife left the room, probably to soothe her hurt feelings, and we were moved to a delivery room quickly.

But I don’t care about her feelings. We had a situation which she could not handle, and it is my belief she should have called a physician on her own, instead of having to be prodded.

Our perinatologist was a fantastic doctor. Just all-around great. She was very reassuring, and explained everything that was going to happen. She ordered and administered the terbutaline, which gave my wife a lot of comfort, except the contractions didn’t stop. Their intensity decreased, but their frequency did not.

This perinatologist explained after a quick exam that my wife was 4 centimeters dilated, and 60 percent effaced. It didn’t look like we were going to be able to stop this labor. When I mentioned that I was concerned about a possible abruption, she assured us that delivery was the best option after all.

We didn’t see any abruption on the ultrasounds, but that didn’t mean there wasn’t one. The presentation was certainly indicative of placental abruption, instead of a bloody show, which is what the midwife called it.

My wife requested an epidural, and the anesthesiologist was called, and he came into the room only several minutes later. We were pleased with the alacrity the hospital staff was showing to our situation. In the meantime, a nurse and respiratory therapist from the NICU came to talk to us, and answered a few of our questions.

It was explained that everything looked just fine with the baby, and they weren’t expecting any complications, but that the baby might have to spend a little bit of time in the NICU if she was having any trouble. The NICU staff was very professional and reassuring, and they assured us they would be in the room for the delivery, as opposed to regular L&D nurses.

Once the anesthesiologist came in, we became somewhat concerned. Our nurse, who was very helpful and friendly, seemed a little too friendly with the doctor, and it seemed as if they were flirting, for lack of a better term, while he was performing the epidural.

As I was standing in front of my wife, with the anesthesiologist behind her performing the puncture, my wife looked at me and said “my head hurts and my toes feel warm.”

Of course, this caused the doctor pause, and after a few more questions, he removed the catheter, and applied a dressing to her back, then we laid my wife back on the bed. Only mere moments after the injection, my wife mentioned that she couldn’t feel her legs, which indicated to the anesthesiologist that he went too far, and administered a spinal block instead of an epidural.

This damned doctor was so busy flirting with our nurse that he went too far with his needle.

Right about now, I notice my wife looks terrible. She looks pale, complained of dizziness and nausea, and was beginning to sweat.

Her blood pressure was 70/30, and her heart rate was 160.

And I was noticing some late deceleration on the fetal monitor.

Our nurse quickly called the perinatologist, the NICU staff, and another anesthesiologist.

Our second anesthesiologist came into the room, and instead of talking to us, conversed with the nurses in the room, and talked about giving “neo.” Our nurse had already given my wife some ephedrine, with no change in the blood pressure.

The anesthesiologist looked at us and said “there’s nothing to worry about here, all this is normal, and we do this every day.”

Y’all, I about lost it. Just about.

“Don’t tell us there’s nothing to worry about. I’m the son of a physician, and I’ve been a paramedic for 17 years. My wife, your patient, is also a paramedic, and we generally act a little more concerned when we have a diaphoretic, hypotensive, tachycardic patient. And if that patient happened to be in preterm labor, and was having bright red bleeding, and we saw late deceleration on the monitor, we wouldn’t be all nonchalant.”

Of course, I hurt this anesthesiologist’s feelings. So now I’ve possibly made two people cry.

But we weren’t playing. This was a serious situation, and it seemed like there were three people who appreciated the seriousness of it: the perinatologist, the patient, and myself.

In the end, the anesthesiologist left, and the perinatologist and I (yes, she let me deliver) delivered a very, very tiny baby girl. She weighed 4 pounds, 3 ounces. Her apgar scores were 8 and 9, which were impressive and reassuring. The NICU staff determined our new baby girl could stay with us instead of going with them.

So we now have a premature, yet very healthy, baby girl. And we couldn’t be happier. Her mommy, daddy, big brother and big sister are very much in love with her, and we can’t wait to bring her home.

But we all need to do better.

Things should have been explained better to us. Granted, we aren’t typical patients, but we still should have things explained to us.

When you have a chest pain patient, do you tell them “I’m going to give you some aspirin, and I need you to chew them up, instead of swallowing them.”? That’s good, because you should. But you should also tell them “aspirin is going to work by making your blood clot slower. That way, in case you’re having a heart attack, the clot won’t be as big, and it will be easier to fix.”

Do you just administer a breathing treatment to an asthmatic, or do you tell them “this medicine might make more spit in your mouth, and might make you feel a little jittery, but that’s how the medicine works; it works by relaxing your lungs, making it easier for you to breathe, and it makes your heart beat a little faster, too.”

Do we do a good enough job explaining these things? When our patients are really sick, do we get in an ‘automatic mode’ and just do a lot of things quickly? Or do we take the time to explain to our STEMI patients that “you’re having a heart attack, and we are going to do a lot of things very quickly.” Do we tell them that they “are very sick, but I am going to take very good care of you, and not let anything bad happen to you.”

I think we owe that to our patients.

Most of us are very competent, capable providers. But that doesn’t reassure patients.

Touch your patients. Skin-to-skin if you can. I like to put my hand on their shoulder, just at the base of the neck. Look them in the eyes. Don’t tell them “everything is going to be okay” because that isn’t always the case. Tell them what is happening to them. Tell them what you are going to do for them, and tell them why.

Tell them you are going to take good care of them.

And mean it.

No! Bad Job!

Shaq and I are, as we call it, just chillin’ at post, tossing a football. Our magnanimous dispatcher raises us and sends us on our way to a local dialysis clinic, for a report of a “female with chest pain.” We make our way in that direction post-haste when we get an update:

“Med two, your patient is possibly coding, per the facility” comes the message from radio, while the MDT updates with “POSS FULL ARREST/CPR IP”

We have a hard time believing this, mainly because we haven’t run a legit call in at least six weeks, but maybe today is the day.

In the end, it was partially legit. No, the patient wasn’t in cardiac arrest. Yes, CPR was being done, but the patient never lost consciousness. At least the AED was applied correctly. Except there was a nurse doing CPR while the machine said to check for a pulse. And for some reason, she kept wanting to give nitro.

Instead of having a stroke, I decided we would just move the lady to our stretcher. In the process, I figured out what happened: the patient complained of chest pain, and the ‘nurse’ administered nitroglycerin, (probably too much at once, but maybe not) then the patient’s blood pressure bottomed out and the patient had a syncopal episode, at which time the staff panicked and began running around like chickens with their heads cut off.

Admit it, it’s plausible.

As we’re walking out, we hear one of the firemen talking to the ‘nurse.’ “Thanks a bunch, y’all. You guys did a great job.”


Doctor Jack Wagon

An ER physician cancelled my cath lab activation the other day. No, I didn’t save the 12-lead.  I should have, and maybe I will try to find it once I go back to work.

It was a male in his mid-forties. He had just gotten back home from a walk around the neighborhood, and couldn’t catch his breath, and kept sweating. It’s been a little warm around here for the past few days, but not that warm.

So, duh, he’s having an MI.

For some reason, the interpretation didn’t pick it up. He was in a sinus bradycardia with an (apparently new) left bundle branch block. He met all the Sgarbossa criteria. He was hypotensive. His skin was diaphoretic, even though it was 74 degrees outside.

We transmitted the ECG to the hospital, and I called the cath lab number on my phone, like we always do from the field. After loading up in the ambulance, I called the hospital to give them my ETA.

That’s when I was told my activation was cancelled.

“By who?”

“The ER doc.

It turns out that the nurse who receives the ECGs we transmit shows them to a physician. Not a specific physician, mind you, just any physician he or she can find in the hallway. And this time the physician cancelled my cath lab activation.


Wait for it.

Because my 12-lead didn’t say “STEMI” on the top.

No joke.


This jackass in a white coat cancelled my cath lab activation because the interpretive statement didn’t recognize an MI in the presence of a left bundle branch block. This isn’t a case of a false activation, either. I took the 12-lead upstairs to the cath lab to show a cardiologist friend of mine.

“Where’s this patient?” he asked me.

“Downstairs in the ED.”

“What the hell for? Why isn’t this patient up here?”

“Ask the jack wagon in Trauma 4. I activated you, but jack wagon cancelled the activation.”

Where was the patient?

In Trauma room 4. Twenty minutes after we walked in the doors, he arrested. He went into v-tach and tried to die. He was resuscitated, but now, several days later, he is upstairs in the ICU on a ventilator, with a balloon pump hooked up to him.

Because some jackass doctor can’t interpret 12-leads.


“Medic 4, caller reports a male in his twenties possibly overdosed. PD is en route with you.”

An overdose at the drug-treatment center. This seems ironic.

“Medic 4, update. Caller reports patient is unconscious but breathing. Caller advises come to the intake area.”

“Medic 4 received. Radio, show us on scene.”

Slimm and I make it inside with our equipment, walking with local fireguys. Slimm is still incredulous that Marshawn Lynch didn’t get the ball on those last plays from the goal line.

The scene looks like something out of a sketch comedy: fifteen people running around like chickens with their heads cut off, while some guy is lying unconscious on the floor. There’s two women in the corner, on a floral sofa, crying softly. One appears matronly, and the other could pass for a sister or girlfriend.

“Hey, y’all. What’s going on?” even though it is pretty obvious.

“He came in for <gasp> treatment, but then <pant, pant>, he acted like he was really high, and <gasp> then he went unconscious.”

Fire dudes are taking care of the supine gentleman on the floor. They say something about him breathing 6 times a minute. I see them get a BVM out. The chickens start to run faster.

Slimm looks exasperated. Not about the Lynch thing any more, but the current situation. He turns to the ladies on the sofa; “Ma’am, any idea what he could have taken, or how long ago it might have been?”

His mother tells us between light sobs “He does heroin and oxycontin. He probably took some pills on the way here or something, I don’t know.”

Well this should be easy enough.

“Okay, no big deal. We’ll give him some medicine, make him breathe a little faster, and we’ll get him over to the hospital next door, okay?”

One of the chickens says she will go get their Narcan.

This can’t take long, right?

5 minutes later, she’s still not back. It looks like fire dude’s hand is cramping.

“Any idea where the lady is with that narcan?”

“Oh, she had to go across campus. And then she probably had to get the key from the director”

“You keep the narcan somewhere else?”

“Yeah, we don’t keep it here.”

“You don’t keep narcan in the intake area of a drug treatment center, and instead you keep it more than five minutes away, under lock and key?”

If we had known that, we would have simply left a long time ago. And here I am, trying to save my boss a little money.

They give cops that stuff now days, and I’ve seen addicts with it. But the one place most likely to see an overdose and need the drug, is the one that makes it the most difficult to get to.

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.”