Silent Siren, page 18
It takes skill and intelligence to realize when it is necessary to deviate from protocol. It requires the ability to anticipate problems three, four steps ahead of when one endeavors to undertake a procedure or administer a drug. As paramedic students, we learn that the drugs Lidocaine, atropine, epinephrine, and Narcan can be administered via endotracheal tube as well as IV. However, the drug Narcan reverses the effects of opiates by knocking the drug off its binding sites on the cells. The primary concern in opiate overdoses, is that the patient’s breathing slows considerably or stops entirely, leading to hypoxia. Administering Narcan to a person who has overdosed on narcotics causes that person to start breathing, awaken, and, in many cases, become combative. Why would any paramedic want to administer a drug that awakens a person and generates spontaneous respiration in someone whose respirations are already controlled by intubation and ventilation? Be ready for a patient who abruptly sits up, pulls out his tube and his IVs, vomits, and then begins swinging at responders.
Many regional protocols state that Narcan can be used in all cases of altered level of consciousness. This works very well in someone with pin-point pupils and decreased respirations. It does not work well in a patient who is unresponsive but has adequate skin color and adequate respirations and is thrashing around on the stretcher. To give Narcan to a patient like that would transform an enigmatically unresponsive patient into a wildcat in a telephone booth that requires a police response, 4-point restraints, and additional medication for sedation.
Clinical judgment is required in all realms of paramedicine, from the treatment of a child with Respiratory Syncytial Virus, to the differentiation between asthma and congestive heart failure. A competent medic needs to take into account the patient’s history, physical symptoms, objective examination, events leading up to the point of severe distress, and other factors in order to make a good decision. A flowchart can never be the ultimate guide to patient treatment. A good hunch is a good place to start.
In short, though a monkey may make a fine technician, he would make a very poor clinician.
Blocked
I’ve gotten pretty comfortable in this job. The names and faces change, but the themes play themselves out, day after day, like orchestral themes with variations. Every once in a while, though, I am reminded of my complacency by the unexpected turns a call can take. On one 911 response I recall, a total disconnect occurred between the nature of the dispatch and the true nature of the problem.
I am working Med 2, downtown Mount Vernon, with Robert Saraceno. He’s a private ambulance refugee like me, from the dirty streets of Tacoma and Rural-Metro Ambulance. It’s late morning and we are called with Engine 111 to a 55 + mobile home park in South Mount Vernon. The call is for “possible food poisoning.” I groan. There’s been a lot of Salmonella hoopla in the media lately, and I figure this old guy has convinced himself he is its latest victim.
The dispatcher comes back with the short report: “Patient believes he ate some bad peanut butter and has been vomiting.”
Rob and I mumble about 911 system abuse, lack of self-reliance, and the general state of humanity. This should be an easy call, I think. Check this guy’s vitals, convince him he’s fine, sign the refusal form, badda-bing, badda-boom, we’re done.
I don’t carry any kits in with me. The fire engine crew, I am sure, has already brought in their basic life support kits. I can’t imagine that I would need IV supplies or a heart monitor on this one.
Seated in the front room is an old man, appearing rather washed-out and pale, leaning on his walker. Today, Mount Vernon Fire Department paramedic Dick Bond is on the engine crew, and he is attempting to get vitals on the fellow. Dick gives me the story—says the patient’s on dialysis, the dialysis staff gave him peanut butter and crackers the evening before, and he’s been vomiting ever since, every hour on the hour.
“What did your vomit look like?” Dick asks the man. It’s not polite conversation, but we need to know if there is any possibility of internal bleeding. Brightly colored blood usually indicates an ongoing upper gastrointestinal bleed; vomit that resembles coffee grounds represents partially digested blood and can be from a high or low source in the gut.
“Like…coffee grounds,” the patient says. “Do you think I have Salmonella?”
Dick says, “I’m more concerned with the coffee ground in your vomit than I am with Salmonella.”
Dick places a pulse oximeter on the man’s finger and then pumps up the blood pressure cuff. Rob knows the drill and goes out to retrieve the stretcher. As Dick pumps the cuff up, the man hesitates a few seconds, looks mildly concerned, and then says, “My shunt’s on that side.”
“Oh no,” says Dick, and quickly removes the blood pressure cuff. “I’m glad you told me that. I was getting like 260/130.” He tries the other arm.
The blood pressure is 160/62 on the right arm. Not bad, but Dick still can’t locate a pulse. “It’s really slow,” he says. “You might want to put him on the monitor.”
We elect to load the man up on the stretcher and place him in our ambulance before “setting up shop.”
The man stands. “How do you feel standing?” I ask.
“Spacey,” he replies.
I still don’t have a handle on the man’s underlying problem, but I am a little more concerned about his condition than I was when I nonchalantly walked the ramp to his front door. The fact that Dick can’t locate a peripheral pulse is concerning.
In the ambulance, Rob searches for an IV site. Dick and his partner close our doors and head back to their engine. I place electrodes on the man’s bony chest and he winces at the cold gel. He doesn’t seem overly nervous, just somewhat concerned.
I press the green power button on the Lifepak 12 and the screen glows blue. A very long wavy line is the first thing I see, followed by a wide, unusual blip, indicating a ventricular contraction. I re-adjust the leads to give me a clearer picture.
“Think I found the problem,” I say. “Your heart rate is only thirty. No wonder you don’t feel well.”
A normal heart rate is at least sixty. It’s a wonder this guy is able still to talk and maintain an adequate blood pressure. Two small bumps precede each large ventricular complex, but it is obvious that, unlike in normal conduction, the small bumps and the ventricular complexes have nothing to do with each other. The upper chambers of his heart and the lower chambers are beating independently, not communicating with each other, so they fire off at their own intrinsic rates. The man is in a potentially deadly heart rhythm known as third-degree block.
I move faster and hope the guy doesn’t notice the look of concern on my face. His heart could cease to beat at any minute. I place two pancake-sized pacer/defibrillator patches on either side of his chest in case we need to use electricity to jolt his heart back to a normal rhythm.
Rob says, “You want a fast ride?”
I nod and Rob gets up front.
I explain to the man that the two parts of his heart “aren’t talking to each other” anymore and that we need to get him to the hospital quickly to get a pacemaker implanted. He seems to understand. He’s a retired firefighter from east of the mountains.
The man maintains consciousness and blood pressure on the seven-minute ride to the hospital. I am thankful I don’t have to shock or pace him. It’s exquisitely painful for the patient and pretty stressful for me as well.
We are met at Skagit Valley hospital by the ER physician, as well as techs, nurses, and X-ray technologists. The ER doctor has already called a cardiologist to come downstairs and consult. We haven’t really saved the guy’s life by anything we did, but at least we recognized how seriously ill he was and got him the care he needed quickly.
My impression of that call changed in a matter of minutes from benign hypochondria with delusions of Salmonella, to gastrointestinal bleed, to profoundly sick with a heart block.
Rob and I clear the hospital and head back to the barn. “Can you imagine what would have happened if we’d left that guy on scene?” I say.
“Yeah,” Rob replies. “We didn’t even bring in the monitor.”
Problem Patients
I can hear Art swearing from the next room.
“Fuck!” he yells. This is followed by the clumping of boots and the mechanical whirr of the ambulance station’s garage door opening.
It’s 2 a.m. and Marjorie Calhoun has once again enlisted the services of the local EMS community to address the two-week old ache in her right knee that has inexplicably become an emergency at this ungodly hour of the night.
Plethoric and profane, Art deposits himself into Med 2’s driver’s seat, slams the door, and mutters something uncomplimentary about Marjorie’s resemblance to a certain part of the female anatomy. He is not a fan of getting up at night, nor is he a fan of Marjorie, who has called twice a shift, without fail, for several weeks.
His tones-induced Tourette’s syndrome is kicking in full bore as he sputters and stutters and finally gets on the radio with an irate, “Med 2 responding!”
Marjorie, known by Central Skagit’s paramedics as “The Cougar” for a rather garish and seemingly recent glamour photo of her she has up on her wall in which she is wearing little more than a feather boa and a smile, is seventy-four years old, overweight, hypochondriac, and has successfully alienated everyone in her life with the exception of her cat, on whom she dotes.
She has the usual geriatric laundry list of ailments, including high blood pressure, bad knees, and diabetes, but she is perhaps best known for her complaints of anxiety and shortness of breath, always in the middle of the night.
I’ve seen Marjorie twice already in the past week, and each time her M.O. is to talk a mile a minute as she explains how terribly difficult it is to breathe and then refuses transport when it is offered.
Sometimes Marjorie pretends to act bewildered when we arrive, claiming that she had misdialed and actually didn’t mean to dial 911. Nobody believes a word of it, and in fact after a few encounters, none of the paramedics are particularly pleasant to her. Still, she continues to call.
Tonight the story is the same. Marjorie sits sorrowfully, but not uncomfortably in her straight-back chair, fully dressed, her cat busy spreading fur throughout the apartment.
I offer to transport her to the hospital, though I advise Marjorie that I am unsure if the ER would be able to do anything for her terminal case of knee pain.
Marjorie says, “Well, I guess I’ll just sit here and die, then. You people don’t care about me.”
In fact, it is getting very difficult to care, especially at this hour of the night and after so many encounters with Marjorie in recent memory. Nobody requires us to care deeply for every patient, only that we treat every patient with respect.
Seeing Marjorie, and those of her ilk, is disillusioning, and temporarily causes me to question what greater role I might be playing in society through my work. I trained as a medical clinician and intend to function as one. Am I instead a safety net for the lonely and disenfranchised? As everyone knows, if you call 911, somebody will show up. Never mind whom. Mercifully, encounters with Marjorie-esque characters are interspersed with requests for emergent medical help. Thank God, or I’d go insane.
Melvin Kassell is another “frequent flyer” who, unlike Marjorie, has the decency to call 911 at 2 p.m. rather than 2 a.m. He calls because he feels anxious, despite the considerable pharmacy of anti-anxiety medications he possesses.
Though he lives independently at a motel in downtown Mount Vernon, he can’t seem to navigate the bus schedule to get him to the hospital and says he can’t afford a taxi. So, by default, Skagit Valley Horizontal Taxi service, i.e. Medic One, continues to provide his tax-supported transport to the ER.
At least the patient work-up is simple. “Hi, Melvin! Having some anxiety? Hop in!”
Though he takes up valuable resources that could better be used elsewhere, it’s difficult to be too angry with him, because, unlike Marjorie, he is completely incapable of guile. He really isn’t smart enough to come up with a logical care plan for himself. Every time I see him, he looks at me as though he expects I’m going to punch him.
When we don’t hear from our frequent flyers for a time, we do wonder what has become of them. Seeing them again is like a reunion, familiarity mixed with annoyance. Interviewing a patient is not difficult when you already know his medical history by heart.
There is a sense in which a “frequent flyer” as patients such as Melvin and Marjorie are known, becomes like part of the family, albeit an annoying part. Sort of like a jobless, alcoholic aunt who ruins every Thanksgiving dinner with her boorish conversation and drunken antics or a luckless, black sheep brother-in-law. It’s the characters that make this job interesting.
A Car, a Dead Man, and Some Cows
A cold drizzle blankets the Skagit Valley on a winter’s day at Med 3 on McLean Road. I stand inside the cramped apparatus bay, warmed by the dissipating heat from the hood of the ambulance and stare out at the rain. The tones hit for a motor vehicle collision with entrapment in La Conner, a small tourist town fifteen minutes south of our location. The initial report states one person is unconscious in the vehicle.
A few key words still get my blood pumping; one of them is “entrapment”—the injuries are almost always very serious and will require heavy equipment to access the patient. Another is “unconscious” in the context of a motor vehicle collision. In a medical context, it quite often is brief, maybe a fainting spell or even someone sleeping. In a trauma context, it is almost certainly dire.
Art and I roll out of the McLean Road fire station and onto the rain-slick streets. I am in charge on this one and running through my head what I may encounter on my arrival. Will there be a hazard such as power lines or fire? Should I transport directly to Skagit Valley Hospital or can I get Airlift Northwest, the helicopter ambulance, to fly in these conditions? Will the La Conner volunteers be composed enough to assist me adequately under the circumstances?
I route Art to the scene with our less-than-satisfactory map book, but he knows the area well anyway, so he is simply using my directions for confirmation. It takes us about ten minutes to get there.
Several hundred feet of mangled guard-rail leads to an open cow pasture with deep ruts and mud flung off onto the pavement. A four-door sedan sits upright in the middle of the field. The cows are unimpressed. Though the vehicle is right-side-up, heavy damage exists to the roof and hood. Tufts of muddy turf have adhered themselves to the twisted metal.
A bearded volunteer firefighter jumps from La Conner’s rescue truck to ready the Jaws of Life. His eyes wide, he looks in our direction and mouths one word: “Bad!”
I jump out and run towards the wrecked car, Art following closely behind. With trauma, we don’t bring our kits and set up shop next to the car. A victim of trauma needs rapid extrication and transport to a surgeon. Unlike the victim of a heart attack or a breathing emergency, there is little we can do but supportive therapy—intubation if needed, bleeding control, and a fast ride to a trauma center.
Three La Conner volunteer firefighters, clad in dripping yellow bunker gear, have managed to wedge open a door and are pulling a limp body out of the vehicle and onto a backboard. He appears middle-aged and is deeply purple from the chest up. Vomit and blood dribble from his mouth. He does not appear to be breathing. I tell the volunteers to place the patient on the ground so I can check a pulse. Victims of sudden impacts who don’t have pulses when aid arrives rarely survive; it is common to declare them dead on scene without an attempt at resuscitation.
No pulse. “I think this guy’s already dead,” I say to the volunteers. Just as Art approaches, the man takes one final gurgling breath and falls silent again. I can see Art wants to work him, so we lift the backboard and trundle his limp body, arms flopping unconsciously, to the back of the medic unit.
A La Conner volunteer grabs the bag-valve mask and claps it to the cyanotic, vomit-smeared face. As she squeezes, the odor of alcohol wafts up from the man’s mouth and fills the rig. He hasn’t got much of a chance of survival, but we will make the effort. I claim a small, cramped space for myself at the head of the stretcher to ready my tools for intubation.
EMTs Isle Lindall and Brett Lopes work on either side of the man to establish IV access while Art slaps the heart monitor patches on the man’s broken chest. A weak, agonal heart rhythm undulates across the blue screen. It is only the residual electrical activity of a dying heart. It produces no muscular contraction. The man’s heart has stopped.
I slide the laryngoscope into the man’s mouth and search for my landmarks through a lake of ethanol-smelling vomit. Art gives me some cricoid pressure and I slide the tube into place. I check lung sounds but can hear nothing. I palpate the chest and feel crepitus, the sensation of broken bone ends scraping against each other. The sternum is completely disconnected from the ribs. The entire chest has an unpleasant squishiness to it. The belly is rigid, full of blood. We make the call to cease the resuscitation. This guy’s injuries are incompatible with life.
We are stuck with the body in the back of our ambulance until the coroner makes it out there. Eventually he arrives, photographs the scene and the body, and then moves the body from our ambulance to the gray coroner’s van.
I can’t help but think this accident was intentional, given the high rate of speed with which the man careened off the road. Fueled by alcohol, he effectively put an end to all his earthly troubles. At least he didn’t take anyone else with him.
