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.
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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.
Medication safety is a topic I am focusing on these days. How to prevent errors and keep our patients safe.
If I ever had a call – a double shooting or a status seizure — where I could look back and say here is where it all came together, then I have forgotten it. 
A number of years ago a young woman was driving along the road when a bee flew through her open window and stung her on the knee. She panicked. She was allergic to bees and she had left her epi-pen at home. She immediately pulled to the side of the road and dialed 911. A police officer arrived first and found her very anxious, but with no visible signs of a reaction. He helped her into the ambulance that arrived shortly thereafter, and then retuned to his cruiser to make arrangements for her car to be taken off the road. When he returned to the ambulance to give her the information about where to locate her car, he was startled to find the ambulance crew doing CPR on the young woman who within an hour would be pronounced dead at the hospital.
These actions are now filtering down to EMS, and we are considering requiring medics to use epi-pens as their first line approach to anaphylaxis. We will likely keep epi 1:1000 available on the rigs in a separate location so that it may be utilized in special circumstances (nebulized for croup, for bariatric patients, for infants too small for epi-pen juniors, for epi-pen failure, for epi ET if unable to get IO or IV).
The last couple weeks have been pretty mundane – the typical pneumonia, hip fracture, lift assist, nausea, minor MVA stuff.
I have written much about pain management in the last several years. Most of the time when I deal with pain it is for broken bones from falls or motor vehicle accidents. Between snow blowers, lawnmowers and all the machine industry we have in our town, I do several digitit amputations a year – all of which I offer morphine. They may not all be in immediate pain and they are usually tough guys, but all who refuse are in pain by the time they reach the hospital. Since our guidelines changed, I give morphine quite frequently to abdominal pain. I am quite liberal with pain relief and have never yet had a bad outcome beside an occasional nauseous patient that I then treated successfully with an anti-emetic. I admit to having delivered my share of sleeping patients as well as patients singing “The Farmer in the Dell.” All good in my book.
When I was hired as the EMS coordinator at the hospital there wasn’t much mention about one small part of my job – that of being the hospital’s trauma data collector.
As many of you may have heard, hip fractures have a 15-20% mortality rate within a year of injury. I see this all the time. Occasionally a patient will come in with a hip fracture, and expire in the hospital from other medical causes. But more often, in reviewing EMS run forms throughout the year I will see familiar names. The medics bring in a patient with pneumonia. The patient had a hip fracture three months earlier. The medics bring in someone with sepsis. Hip fracture two months before. They presume someone on scene. A familiar name. Entered her as a hip fracture six months before. Hip fractures are tough on old people. They don’t heal well, fear limits their mobility, immobility makes them susceptible to illness. While some recover to lead full engaged lives, for others, a hip fracture is the beginning of the end. Farewell to independent living, hello skilled nursing facility, hello dark and lonely descent to death.
If there is one EMS conference I go to next year, I would like to go to the annual EMS state of the Science Conference — better known as the 
The November 2009 issue of the Annals of Emergency Medicine has a new study called 
