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.

Why?

Wait for it.

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

No joke.

Seriously.

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.

Brilliant!

“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.”

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.”

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.”

Psych eval

Emergency at the assisted-living facility. A little old lady “needs a psych eval” according to our dispatcher. Fire and PD are going with us as well.

Just like every other call.

Walking up to the door, we are met by a corpulent, thick-witted woman with a stack of paperwork and her singular entourage.

“What’s going on?” I ask.

“She in room two-oh-foh’” is her reply.

“Umm. Alright. Why did you call 911?” Perhaps asking the same question a different way will work.

“She been smokin’ in her room.”

Yes, ladies and gentlemen, 911 was called because a resident was smoking in her room. 3 paramedics, 3 EMTs, 2 police officers.

All for an octogenarian smoker. Who, as it turns out, was ‘smoking’ an electronic cigarette.

A long story, Part III: The Poignant Question

…continued again from the other day, and the other day’s other day…

 

So while we are all sitting in front of my friend’s garage, watching the big red truck and the small red truck pull up to the house, Bubba looks confused. I don’t have much to say, because things are going to get busy in a few seconds, and I’m trying to stay out of the way.

They unload their equipment and make their way up the driveway, introduce themselves, and begin to work on Bubba.

I’m standing somewhat back, ready to answer any questions they may have, but the situation is very well in hand. I’m not a paramedic right now, I’m just a guy standing with a patient.

I can see Bubba looking at their patches, and we all notice the ambulance’s arrival at the end of the drive.

“Y’all from the fire department?” he asks. It sounds more like “fur duhpurtment,” but we all are fluent in Southern drawl.

“Yessir, we are.”

“Well, what are y’all doing here?”

“Sir, you called nine-one-one. We come to all emergency calls.”

“Well that’s just stupid, ain’t it?”

“Why would you say that, mister Bubba?”

“I called for an ambulance, man, not a fire truck. Why did anyone send a fire truck when there wasn’t a fire?”

 

Later, I told him that I’ve been asking that same question for somewhere near fifteen years, and when he found the answer, to let me know.

A long story Part II: The Mix-up

…continued from the other day…

 

So I gave Bubba some aspirin, Vicki chilled the hell out, and we moved Bubba outside near the garage. Mainly to keep everyone away, but also to make it easier on the first responders.

Stairs and all, you know.

So the responders arrive, first the big red truck, followed by the small red truck, and then, a few minutes later, the ambulance. It was at this point that Bubba asked a very poignant, pertinent question, which I will save for tomorrow’s post.

These guys are doing the whole ALS thing to him. The guys in the small red truck leave seem anxious to leave, but the guys from the big red truck have their cardiac monitor, so they can’t go just yet.

Bubba’s getting a 12-lead.

One of the guys from the small red truck is looking at it, and he turns to one of the guys from the ambulance and says “looks like a real slow sinus brady with a real long first-degree block.”

“Hmmmm” says the ambulance man.

Mind you, I took Bubba’s pulse several minutes ago, and it was in the 80s. Bubba doesn’t look like a guy would have a “real slow sinus brady.”

“Can I see that real quick?” I ask.

One of the guys from the big red truck looks at me quizzically, as if to say “what the hell does this strange fellow want to see the EKG for?” but the ambulance guy hands it over to me, as they start to move Bubba onto the stretcher.

It’s pretty clear that it isn’t a sinus brady at all. And there isn’t a first-degree block anywhere.

I hand it back to the ambulance man. “That rate is somewhere near 80, and there isn’t a first-degree block.”

Before the ambulance man and the man from the small red truck can lecture me on how they know how to read an EKG, and I’m just some doofus with a party hat, I point out the answer printed right there on their paper.

“Your printer speed is set to fifty.”

He looks like I just explained string theory.

“Normal is twenty-five.”

“…Oh…”

 

A long story, Part I: The Freak-out

So, I’m visiting a friend’s house for a child’s birthday. I know what you’re thinking: I don’t have any friends. And you are right. Sort of. I have, like, three. And I was at the home of one of them.

His father-in-law was also there. A large, hulking man, built like a defensive lineman. Sort of like a big square with legs.

He comes up to me, and kind of hushed, says “my chest feels a little tight, C. What do you think I should do?”

I ask him about his medical history and all that good jazz. He’s 62, mildly overweight, hypertensive, with high cholesterol. He had a normal stress test a few months ago, and his EKG was “normal” according to the doctors. He’s never had a heart cath, or a heart attack, or anything major happen to him. He takes his medications regularly like he is supposed to, and everything is managed appropriately.

Our conversation is noticed, and his wife comes over and wants to know what’s going on. “My chest feels a little funny, I was just talking to C about what I should do” he tells her.

The next few minutes saw his wife almost have a syncopal episode, fan herself with a paper plate, say “lawdy jeezus” at least three times, and she summoned no fewer than two of her middle-aged concerned friends over. The next conversation went something like this:

“What should we do?”

“Probably put him in a car and take him to the hospital.”

“We should take him to an urgent care center!”

“Urgent care would be a waste of your time. Go to an Emergency Room.”

“Should we call 911?”

“No, just leave now and go to the hospital right up the-”

“I’m calling 911!”
“There isn’t really any need for that, he could be at the hospital before-”

“VICKI! CALL NINE-ONE-ONE! BUBBA’S HAVIN A HARTATTACK!”

“I really think that he would get there quicker if you just drove to the hospital yoursel-”

“BUT HE NEEDS PARAMEDICS! VICKI! WHERE’S THE AMBULANCE!”

“You do realize that I am a paramedic, right?”

“Yeah, but you aren’t working right now!”

 

I sighed, went off to find some aspirin, and sat down to wait.

 

To be continued…

These people got lights and siren responses

These are calls I have heard dispatched over the radio, or ran myself in the past few weeks or so since the implementation of the new policy that requires an “emergent response to all requests for services generated through the 911 system.”

  • A male with CHF who just got out of the hospital and wants to know how to take his meds.
  • A female with a swollen knuckle who can’t get her ring off (the ring isn’t stuck, her knuckle is just swollen.
  • A female who is depressed and ‘wants to talk to someone.’
  • A male in the waiting room of the emergency room who has been waiting too long and wants to go to another hospital.
  • A female who ‘has anxiety and witnessed an accident and is now having a panic attack.’
  • A male who ran out of gas on the interstate and is demanding PD drive him 40 miles home, but now PD wants EMS there.
  • A  very elderly male who is dead in bed, cold to the touch and stiff, with family refusing CPR instructions.*
  • A female who wants her blood pressure checked.
  • A school bus with 14 children on it was struck by the arm of an apartment complex gate. There are no injuries on the bus.
  • A male who was in a fight last week, and now has a swollen hand.
  • A male sitting behind a strip mall, dirty, and talking to himself.

There were others, but these are just the highlights.

But we want people to take us seriously.

*I sort of understand this one, but in reality, this family just needs a coroner.