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Routine

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Most of EMS is routine. You punch in. You check your vehicle and equipment. You respond to calls. You drive cautiously, look both ways at the intersections. When you get to your patient, you ask the same questions. How are you feeling? When did it start? Have you ever felt this way before? What kind of medical problems do you have? You take vitals. You do your head to toe. Your IV, 02, monitor. At the hospital you give your report. Write your paperwork, and get ready to do it all again.

“Any good calls lately?” others ask.

“No, just routine,” you answer.

But every once in a while, you have a story.

So the other day about noon time we get a call for a stroke. Woman with right sided weakness. The first question I always try to answer is when did it start. If it started within the last three hours, we go lights and sirens to the hospital and call in a Stroke alert. If it started longer than three hours ago, we go speed of traffic. Less than 3 hours the hospital can give thrombolyitics to try to bust up the clot causing the CVA if they determine the cause of the stroke is a clot and the patient meets a host of other criteria. If it is over three hours, they generally cannot. (I realize there are some regional variations on the three hour time, but three seems to be the most commonly used.)

I find the woman sitting in a chair leaning against the wall. She has clear right-sided facial droop, but her speech is still understandable. She says she had a bad headache last night, and woke up weak this morning, and this weakness has been progressive. She had to use her husband’s walker to go to the bathroom. Her grip strengths aren’t too bad, and there is no pronator drift. Her BP is 130/70. Her heart rate is 56 and a little irregular. No prior CVA history. She has Hypertension and has had a cardiac stent placed. She is in no pain.

I reconfirm that she woke up this morning with the facial droop and weakness. We’re talking six hours ago. So we get her on the stretcher and start to the hospital, routine post-clock CVA going with flow of traffic. Unless I need to, I usually do most of my care in the ambulance. En route to the hospital, I put the woman on a cannula, pop in an IV, put her on the monitor. I apply electrodes to the chest leads and then put them on the patient’s chest. Every CVA gets a 12-lead. Routine. I ask her age – 75, and then hit the button.

What I see catches my attention. That can’t be right. Maybe we hit a bump at just the right moment.

I repeat the 12-lead. I repeat it again just to be sure.

I stare at it. Elevation in I, V5 and V6 with reciprocal changes in V2 and V3. It looks like the patient is having a STEMI – a ST-Elevation MI – a heart attack.

“You sure you are not having any chest pain?” I ask the patient.

“Well, I am having some,” she says, “but it’s not too bad.”

“Jim,” I call up to my partner. “You can hit the lights on.”

I call the hospital and ask for medical control. “I have a bit of an odd call here,” I say. “I have a STEMI/STROKE Alert. Patient woke up with right sided weakness. While her grips are strong and equal, she has clear new onset facial droop. I also just did a 12-lead that looks as if the patient is having a STEMI. She is now admitting some chest pain.” I describe the patient presentation in more detail as well as history and a more specific description of the 12-lead. “I have withheld the aspirin unless you want to go ahead and give it.”

In the ED, they have a team waiting for us.

“What do you have?” a nurse asks.

“A STEMI and a CVA?” I say. “Looks like it anyway.”

They repeat their own 12-lead (as well as a neuro exam). The MI takes the priority and they send the patient right up to the cath lab where they find a blockage in the Right Coronary Artery and place a stent. Next stop CAT scan confirms an embolic CVA as well.

While the patient faces recovery from the CVA, at least she didn’t arrest waiting in the triage line. The speedy trip to the cath lab no doubt saved some heart muscle.*

Once again routine earns its pay.

*I am confident the hospital would have eventually done a 12-lead as well because they have their routines, too.

Posted by medicscribe on August 10, 2010 • Filed under: ems-topics • Tagged: , , ,

Quiet

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8:30 in the morning.

The hallway is lined with beds — on each a clean white sheet, a pillow at the head and a bath blanket and folded gown at the foot. The floor is freshly shined. The rooms are all empty of patients. Two nurses stand watching the TV that hangs from the cieling. They are silent.

The main ED is also quiet. The triage nurse assigns us a room for our patient—an elderly woman from a SNF. I see two doctors and a nurse standing behind a secretary looking at the computer screen at her work station. The headline on the web page reads: “Breaking News! Work Place Shooting: At least 3 dead.”

In the EMS room, another EMT asks “what do you hear?”

“I hear the shooter’s dead. At least seven shot.”

“Seven shot or seven killed?”

“I don’t know. Depending on the number, you’d think we’d be hearing sirens coming in.”

But when we clear the ED, the parking lot is still empty.

Posted by medicscribe on August 4, 2010 • Filed under: ems-topics

Drug Seeker

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So this man is, based on my experience, a drug seeker. This is not a first impression or an instinct. I say this based on seven or eight years of transporting this patient (our service transports the patient anywhere from one to four or five times a month) to multiple hospitals. The calls are not all for pain or migraines. Some of them are for altered mental status because the patient has taken so much medication (somehow he manages to order Fiorinal over the internet) he is stuporous, drooling and unable to walk. The man does not have a general doctor because no one will take him his reputation is so well spread. When he is in pain and not stuporous, he becomes very whinny. He has a migraine. He hurts all over. His pain is always 8 or 9 on the scale. His gait is slow and tortured.

I try to be compassionate, and compassion for me with this patient is to merely ask what hospital he wants to go to today, and then to put him on the stretcher and take him there without getting into why don’t you want to go to the closest hospital or why are you such a drug-seeking loser.

This patient has called me an asshole before. This comes after I interview him trying to find out why his prescription bottle is empty when it was just filled five days ago or what the doctor said the last time he was at the hospital. The whining comes off and the patient soberizes with anger, and he calls me an asshole. So now I don’t even get into it anymore.

He will display this anger at the hospital as well. The patient will lay there all helpless and whinny while being examined by the nurse and doctor, and then when the doctor gives him a prescription for only two Percocets, he will tear his IV out, call the doctor a motherfucker and then storm out of the ED without a hint of feebleness.

Part of my reason for writing this today comes from the dilemma of how I describe this patient at triage. Sometimes it is easy. The nurse will look at the patient and say, okay, him again. And I don’t have to say anything. But what has been happening lately with the tremendous staff turnovers in the EDs, I often get nurses, and later physicians, who neither know the patient or me despite the fact I have been bringing patients to area hospitals for twenty years.

I try to be nonjudgmental at all times when giving my reports. I try to stick to the facts. I never say he is a drug seeker. I say patient complains of a migraine and pain all over. Patient has been transported to multiple hospitals multiple times for the same issues. Maybe this last bit about the multiple hospitals is a code for “he is a drug seeker.” I find sometimes when I say that, while some nurses will nodd knowingly, other nurses will look at me like I lack compassion, like I have no idea that a migraine or chronic pain is a true medical problem. I just shake my head.

On times when I have brought this man in when he has been stuporus and drooling, I have had the staff call stroke alerts or doctors want to intubate. I used to say give him a good sternal rub and then tell him he can’t have any more percocets and you’ll have one less patient in the ER. Read his chart, I will say.

I just shrug most of the time now. If they want me to go into all my experiences with the patient I will do so, but some people just aren’t interested. So pain all over, I say, been here before for same complaint. same condition.

***

There is another patient in town who we transport almost as frequently. Elderly woman with severe arthritis and chronic pain. She wears a Fentanyl patch and takes Percocet. Sometimes she just can’t take the pain anymore. I find her in her small apartment crying. I usually give her morphine. When I leave her in the ED she is at peace. History of chronic pain, I’ll say, was crying ten out of ten this evening. I gave her five of morphine. She’s down to a three and comfortable.”

“You know she’s a drug-seeker”’ a newer nurse told me once.

“Yes, she seeks drugs because she’s in pain,” I told her, but the nurse didn’t seem to understand that concept.

Maybe some of you are thinking to yourselves, “So what is the difference between these two patients?”

I ask myself that as well. Aren’t there needs really the same?

Do I treat one better because she is sweet and helpless? Do I treat the other worse because he is a miserable jerk?

If I met the man for the first time, I think I likely would medicate him as well, but time has taught me he is deceitful and abusive, so I do not. The old woman, I believe, is merely suffering, and so I try to ease her pain. At least that’s how I see it.

At triage, I don’t preface by saying “sweet old lady” or “miserable drug-seeking loser.” I try to stick to the facts. Let the hospital decide for themselves.

Still, something here is gnawing at me.

I want to provide relief to all my patients, and there is a possibility that this man is truly suffering as well. But it is hard for me to view him with unbiased eyes.

Sometimes I wonder what he was like years ago before pain and need and abuse found purchase in his soul.

Posted by medicscribe on August 2, 2010 • Filed under: ems-topics • Tagged: ,

A Cigarette

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As my entry for this month’s The Handover (This month’s theme – Crisis patient’s) hosted at EMS in the New Decade I am submitting a post I wrote back in 2006.

***

The mental health team meets us outside. “We should wait for the police,” the clinician says. “She’s a big woman. When we went back up there she had a knife near her that wasn’t there the first time we were up with her. She’s very anxious today. When she’s off her meds, she can be volatile. I’ve seen her tear a door off its hinges.”

“Okay,” I say. “We’ll wait for the PD.”

When the first officer arrives, she repeats the story to him. He calls for backup.

Once backup arrives, we walk up the three flights of outdoors stairs and then force the door open because she will not come to it. Inside we find a completely bare apartment. I am always surprised when I walk into what is actually a fairly common occurrence — a psychiatric patient living in an empty apartment. In the kitchen there is a bare table with no chair and in the living room, there is no furniture, except the single folding chair in which the woman sits facing the window sill, smoking a cigarette. She wears a dirty flowered robe and slippers. She is about two hundred and ninety pounds and built solid like a rhinoceros. When the officer starts talking to her, she turns her head around slowly and says, “Don’t you be talking to me in my house. I don’t give a good god damned about any of you, so for all I care, you can all go ahead and kiss my ass. I ain’t getting up, and I ain’t going anywhere.” She goes back to looking out the window and slowly smoking her cigarette

One at a time we try to talk to her, but she just gets more agitated. When it is my turn, I say in a soft monotone, “We’re just to give you a nice easy ride down to the hospital where you can get something to eat and talk with a doctor and nice nurse about all that’s going on.” She turns full on me, and even though I am several feet away, I can feel hot breath coming out of her flaring nostrils. I just let her rant, and whenever she stops to catch her breath, I start talking again in a real quiet, slow voice. It doesn’t get me far, but at least it wears her down some.

Our efforts to talk her into going having failed, the lead cop and I discuss various game plans. He wants us to get restraints. I offer chemical as an alternative, but suggest we just try to get her to walk first. They stand her up and she starts yelling, but once they cuff her she calms down. We walk down the stairs with her, and she yells again at the top of her voice about what motherfuckers we are and how the world is corrupt. “You think you can just go in and take a woman out of her house, you all a bunch of god damned honkey ass motherfuckers! I have my mind set to take you all out, and I will leave nothing, nothing in my wake. Do you hear me? I said do you hear me! Make no mistake. You all can kiss my black ass cause I’m going to take you all down, treating a poor black woman like this. You should be ashamed of your punk asses, motherfuckers!”

When we get her down on the stretcher, she says, “My wrists hurt.” I start talking soft to her again, “I’m sorry they hurt. I’ll ask the officers to take them off if you agree to not fight us.” I nod to my preceptee who is probably about six-four and close to three hundred pounds himself. “The two of us will ride in the back with you. We’ll just take a nice easy ride to the hospital, where you can talk to a doctor. You don’t even have to say anything to us.” She seems to be listening. “And we’ll let you have a cigarette outside the hospital before we go in if don’t fight us.”

“Okay,” she says.

The cops seem a little dubious. “You’re going to have to ride with her.” I nod at my partner. “We can handle her.” They look at the two of us, and they have to admit, she’s big, but the two of us are not likely to be easily handled even by an enraged rhino, and I do have the Haldol and Ativan at the ready. “It’s your choice.”

“She’ll be good,” I say. “We’ll let her have a smoke.”

“You best not be tricking me,” the woman says.

“We’ll get you a smoke.”

They uncuff her and she is quiet on the way in. She even lets us take her pulse and blood pressure. While we are still in the ambulance, I have a vision of us pulling her out on the stretcher and letting her smoke while still on the stretcher, and a newspaper reporter taking a picture of us “ambulance attendants” standing around letting our patient have a cigarette, and what a storm of controversy it might cause. When we get to the hospital, I ask her is she wants to walk in or go in on the stretcher. “I’ll walk,” she says. We’re supposed to keep everyone on the stretcher and while there is no policy about not letting them smoke, I think that is only because no probably imagined crews would let their patients smoke.

We have her step out of the back of the ambulance, and so she is standing when he give her the cigarette. If a photographer were there, it wouldn’t be apparent that she is our patient. She looks like your typical weary two hundred and ninety pound late fifty year old lady in a dirty flowered robe and slippers, smoking a cigarette on a cold grey day. And that’s good, because if she were on the stretcher people seeing a photo in a newspaper might not understand the power of a cigarette. It often works better than brute force, better than pepper spray, handcuffs, Haldol and Ativan. It’s a simple acknowledgement that a person is having a difficult day and needs a break, a chance to have a smoke and collect yourself before heading on into another tough day.

In the ER, she says she has to use the bathroom. The nurse tells her she has to pee into a cup.

“I’m going to need a bigger cup,” she says. “And why can’t I just go in the bathroom?”

The nurse says all females have to pee into a cup to see if they are pregnant.

“I ain’t pregnant,” she says.

“We require this of all females,” the nurse said.

“You’re wasting a cup on me.”

Still she takes the cup and shaking her head, waddles over toward the bathroom.

Posted by medicscribe on July 20, 2010 • Filed under: ems-topics • Tagged: ,

The Battle

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A couple of months ago I posted at the end of ET Interruptions about the battle I would engage in the next time I had a patient with a witnessed cardiac arrest. The battle between getting a quick airway via an LMA or fulfilling my paramedic I am an intubator ego. Finally, after a long dry spell, the challenge presented. Here’s how it went down.

The call was for a man on the ground. The caller wasn’t certain why. I am pretty good at sniffing out a code from the dispatch, but this one sounded like a lift assist. I figured we would likely encounter an elderly man who had fallen and his neighbor couldn’t get him up. As we approached the scene, I saw the man was not inside his apartment but was actually in the parking lot by a car. There were two bystanders kneeling over him. Since it was a hot day, I said to my crew, “Take the gear off the stretcher. He’s outside. We’ll just get him on the stretcher, get him in the back and see what’s going on with him.”

I stepped out, while they went around to pull the stretcher. I could see one of the bystanders was holding a tube of glucose and squeezing it into the patient’s mouth. “He’s a diabetic,” the other bystander said. I could only see part of the patient, but the patient looked a little too still to be getting oral glucose. I shouted at the woman to stop. “He’s got to be able to protect his airway for you to do that. We can’t have him vomiting and aspirating.”

Just then a woman called down from a porch apartment. “He was just at the doctor. He’s hasn’t been feeling well lately. They gave him some new medicine. Do you hear me! Are you listening to me! He was just at the doctor! He got new medicine! New medicine! Are you listening to me!”

“Okay thanks” I said, thinking I’m a little busy here.

I was noticing then the patient was awfully still. His skin was warm and diaphoretic, but he did not seem to be moving one lick. he wasn’t just unresponsive. I wasn’t even certain if he was breathing. The stretcher was beside the patient now and in low position. I tried to sit him up and he was dead weight. Oh shit! This is a code.

I had my gear in the truck. It was drop him and work him in the 100 degree heat or lift him on to the stretcher, and get him in back, which is what we did, with some compressions thrown in on the way.

He was in a PEA in the 40′s. With one partner doing compressions (we shoved a short board under him) and the other reaching for the ambu-bag, I went — hooray for me –right for the LMA — a #5. I love to tube, but I promised myself, no interruptions in CPR, no dicking around, just toss in a quick LMA. Which I did. It went in easy. I got a continuous wave form with an ETCO2 of 15 that remained fairly constant for the next 10-15 minutes despite our interventions.

The man was short but obese. I tried for an IV in the hand with no luck so I went for the IO. He had elephant legs all the way down to the ankles which had tiny toes sticking out from underneath them. His shoulder was also huge. I ran my hand down the length of his tibia and finally felt some bone about midshaft. I shifted some of his fat and drilled right in. We don’t carry the bariatric needle so I was pleased to get the regular needle in. Some epi, some atropine, continuous compressions, but no change in result. I started to prepare the patient for packaging. When I went to secure the LMA, I noticed the LMA looked like it was sticking out a little far, so I gave it a push in and went to secure it and suddenly I started having some compliance problems. What I realized later, was giving it that shove had doubled the mask over, which I understand is a common problem. As soon as my partner said it was getting harder to bag, I, to my shame, felt the approach of a little bit of joy. Maybe I’ll just pop the LMA out and tube him for the ride in. I was thinking, the LMA worked great for the time I needed it to. We did our best – fifteen good minutes of CPR and drugs — the patient is unlikely not coming back. I did the right thing by putting the LMA in and now I still get my tube. Hot Dog! I did try to see if I could fix the LMA. I stuck the laryngoscope in and tried to move the tongue out of the way to see if that would fix the problem, but as I did the whole LMA popped back at me. I just took it out then, had my partner give a few bags while I prepared to intubate.

The patient of course had an enormous tongue. I tried to move it out of the way, and it slipped off the blade. I swept it over again with success this time, but then when I went to look for the chords, all I could see was blood in the airway, which puzzled me. I wondered if maybe I had been too rough with my first sweep or if maybe something else was going on with the patient’s arrest. I finally saw the bottom half of the chords and tried to pass the tube, but quickly pulled it out on seeing I had no wave form. The tube was covered with a very sticky blood. Screw this, I thought. I reached for a second LMA (a #4 this time) and popped it in. It worked great. ETCO2 back to 15.

We worked the patient all the way in, but couldn’t get the ETC02 above 15. The PEA continued throughout. With epi i could get it up to the 90′s but it would slow back to the 40′s then 30′s. The complexes had deep Q-waves, and made me think the patient likely had been having a massive MI all day until he finally just keeled over. They called him dead at the hospital. It wasn’t until the next day — Duh! — it finally dawned on me that the sticky red blood in the airway was just sticky red oral glucose.

What lessons did I learn? The good (get an airway that works quick and avoid any CPR interruptions) medic hasn’t completely defeated the bad (I gotta get my tube) medic but there is hope for me. After sitting idly in my box for a few years, I am learning more about the LMA with each use. After this call I reviewed the manual and picked up a few more tips on its use. I think I clearly would have been better off going for the #4 to start. The other point that I had missed entirely was lubricating the posterior side of the cuff prior to insertion. I now have a package of lubricating gel at the ready.

As for the battle between the LMA and the ET, stay tuned.

LMA Manual

Posted by medicscribe on July 17, 2010 • Filed under: ems-topics • Tagged: , ,