The Night Game

He went up to block the shot–a great save by all accounts–but his feet met an unforgiving patch of mud when they returned to the ground.  Under the bright lights of the stadium, spectators looked on as he threw his arm behind him to cushion the fall.  The mud gripped his hand and his arm bent as he approached the ground.  In an instant, his elbow gave way with a pop, the bones slipping out of the joint, the result of anatomical vulnerability.  "Dislocated elbow" was the call.  Dislocated–the term doesn't begin to describe the agony of the injury, or the terrible anxiety produced by the fragile, horrible feeling of having two bones rubbing against each other with every move.  He screamed.

We cut through his long-sleeve jersey.  Sure enough, the elbow glares at us, angulated, unstable.  Good movement, sensation, and a strong radial pulse.  The referee peeks over our shoulders with interest from a safe distance, sees the injury, shakes his head and walks away.  I wonder if the scream was enough–if he heard the cry and stopped the game immediately, knowing that this was no show-boating for a yellow card, but a serious injury.   

I wasn't thinking about the spectators at the time, but now I wonder what they thought as we strolled slowly onto the field.  I wonder if they could see from their elevated point of view the purpose with which we worked.  Quickly, because each second the player spent lying on the field was one second that he didn't have the relief of morphine.  Carefully, because each movement of his body caused clenched teeth, stifled screams, or sobs.  

McWhacker grabs padded boards and the stretcher, and I practice a forgotten art; one of the few truly creative skills an EMT can apply to patient care.  I put a splint on either side of the arm, gently snake a cravat through the patient's armpit, and secure the two boards above the elbow.  At the wrist, the stabilizing planks are pressed together by loops of roller gauze.  It wasn't a great splint, but there are a few things they missed in EMT class when they taught us how to do elbows–how do you do a sling and swath when the patient is lying down?  With nothing holding the splint to the body, the elbow wasn't truly immobilized, and the patient didn't have the pain relief from splinting I would have liked.  

The splinting done, it's time to boogie.  I look at the patient and at the stretcher a few feet away.  This is going to suck, I think to myself.  McWhacker seems to be thinking the same thought–how are we going to get him onto the stretcher without lifting in a way that will cause undue discomfort.  I almost see the light-bulb come on over his head: "Hang on a second, scoop stretcher!"  McWhacker for the win.

We slide the cool aluminum frame underneath him, clicking the halves together.  We lift the scoop stretcher in concert, gingerly guiding it onto the waiting stretcher.  Sheet wrapped, belts clicked together, we start to pull the stretcher towards the waiting truck.  

The wheels haven't turned one revolution when the crowd explodes.  Cheers, whistles, applause.  Players from both teams, previously locked in battle, scream the patient's name.  The applause and rallying still haven't stopped when we reach the truck.  I can't help but let a charged feeling creep over me.

McWhacker picks up the phone after C$ gets a blood pressure to get orders for morphine.  I wrap a tourniquet around his good arm and slide in an 18 gauge IV catheter.  It is a good stick, but either the short extension set came out of the package with one of the connections loose, or I bumped the wings where the tubing connects to the needleless port, and blood oozes out onto my pants.  I identify the problem, screw it closed, and secure the line.  McWhacker pushes the first four milligrams of morphine, and I hop up front to drive.

Typically, lights and sirens are used to speed response (whether or not they do is a debate I won't get into).  On this call, I use them to slow our transport.  I glide over the streets, weaving around potholes and manhole covers.  I start slowing down for stop signs and turns a block in advance.  As we get to the Point Street bridge, I figure I'll take advantage of the smooth surface to make up for lost time, and accelerate the truck to about 30 miles per hour.  As we come over the top of the bridge, shrouded in the shadow of the median, a manhole cover escapes my attention, and thumps underneath the rear wheels.  It might as well have been a land mine–screams issue from the back of the truck.  Making the turn onto Eddy Street, I idle the truck over a patch of uneven road.  Finally, we arrive at Rhode Island.  After we move him onto the hospital bed, the patient thanks us earnestly.  I'm grateful; I feel like I caused him more pain than we had to.  After 8 milligrams of morphine, he still grimaces continually, and complains of 5/10 pain.  As McWhacker and C$ finish transferring care, I clean the back of the truck, sweeping out grass, mopping up mud.

Finishing up, I look at C$ and McWhacker.  "What the... How are your uniforms so clean?"  My pants are covered in mud at the knees.  The dark blue hides the droplets of blood, but I know they're there.  "Hey," C$ answers, "You jumped in there to splint and knelt down, we just crouched." She grins.

The Tough-guy

What's the saying?  "The only unfair fight is the one you lose?"  It certainly would explain why a call for a combative drunk elicits a response from four police officers, a security guard, and our three-person crew.  You can fight, but you're just going to go to the hospital or jail tired.  Going up the stairs to the scene, I even feel the rush of adrenaline I used to feel with every sound of the tone, and then only when the call was for chest pain, a cardiac arrest, or a person unresponsive, until I arrived here, where I often dread getting out of bed for a call, and am only fully awake when we're already on the way to the hospital.  

"Rescue 1, officers on scene now have that party restrained," the radio crackles.  

"Received," McWhacker answers, "you can put us on scene."  We walk past a loud party in a dorm room before finding our destination.

Our patient lies face down on a couch in the center of the room, handcuffed, and screaming obscenities.  His face is cut, and the handcuffs bite into his wrists as he strains against them, chewing up skin and issuing a slow trickle of blood.  "Fucking faggots!  I'm going to pound your asses!  Bitches!"  We've heard worse.

His friends tell us he's been like this for the better part of an hour.  His roommate came home to find him ranting in the room; a flat screen TV lies smashed on the bed.  He fled from them, heading for the stairs before they could stop him.  Out of sight, they heard him tumble down the stairs.  When they tried to help him up, he swung at them.  "I hit him back," one of the friends admits, abashed, to a police officer.  They managed to drag him back to his room before calling the police.  When the first police officer arrived, he was met with a fist flying towards his face.  The struggle only lasted a few seconds.  

We listen to the story.

"Yup," McWhacker says, looking at me.

"Yeah," I reply, an unfortunate expression on my face.  We have to backboard him–we know he's combative because he's drunk, but he could have a head injury from the fall.  

"Grab the soft restraints, too," he tells me.  I retrieve the equipment while he and C$ look for other injuries.  

When I come back in, the cops are chatting with the friends, and the patient has temporarily stopped screaming.  "Tell him he can't drink vodka anymore," one of the officers tells them.  "Different things affect people differently–it's like my wife, if she drinks vodka, she turns into an evil bitch."  They laugh.

"Yeah," I add, "I've never seen anyone get belligerent from red wine."

We ready the equipment, and make sure we're all on the same page.  One person to each limb, someone to tie off the restraints to the board.  They'll uncuff him, and we'll roll him back onto the board that sits at an angle on the couch.  We put a collar on him, and take position. We slip the padded cuffs of the restraints around his wrists and ankles.  "BITCHES!" He screams louder.  "Fucking FAGGOTS!  LET ME LOOSE, I'LL KILL YOU."  The cuffs are off.  I take a leg, but he draws his knees towards his stomach, and I lose leverage.  A police officer reacts quickly and sits on his legs.  I grab the leashes from both ankles and snake them through the handholds on the backboard.  The police officer releases the legs as I pull both leads tight, locking his ankles to the board.  I hand off one to the cop while I tie the other.  I fumble with the knots because of my gloves.  Once both ankles and wrists are secured, we rotate the board flat.  C$ quickly produces straps from the collar bag, which we use to flatten his body against the board.  Everybody is sweating.  Apparently, the patient feels exposed on the board: "Just leave me something to cover my dick!" he yells repeatedly.  McWhacker secures his head, but the collar has slipped up over his face in the struggle.  He removes the headblocks to adjust the collar, then replaces them.  We clean up the board job; fix straps that aren't well-placed, then stand back for a minute before moving to the truck.

"Hey bitch," our patient says, making eye contact with McWhacker.

"Hey BITCH!" he says, louder.

"HEY, BITCH!" he screams.

"WHAT?" McWhacker finally acknowledges.  A surprised look on his face, the patient shuts up for a minute.  

Ready to go, McWhacker moves for the feet of the board, leaving the (heavier) head to me.  (Thanks, buddy)

"They're all standing out there waiting for this kid to go by," the security guard comments.  The police officers leave to clear the hall.  

As we move him, the patient flips the bird with not one, but two hands to all who look on.  In case they didn't know, he was not having a good time.

At the end of the hallway, a student gets in the face of one of the cops trying to clear the hall.  In the real world, he would go to jail, and undoubtedly experience some discomfort on the way.  In the cushy bubble of the university, the cops' hands are tied.  Their only recourse is to break up the party and take the names of the problem children.  An unfortunate byproduct of a generous judicial system.

We make it to the truck.  A set of vitals, a blood sugar, and we're off.  A police officer accompanies us.  McWhacker calls triage at Rhode Island, but has trouble hearing over the enraged screams of the patient.  Hey, at least they'll know what to expect.

Sure enough, a fleet of security guards meets us at the curb of the ambulance bay.  One of my favorite triage nurses comes out as we're unloading him.  We give him a quick summary of the story and point out his wounds.  I feel vindicated for having exercised caution by boarding him when we're sent to a critical care room.  It takes four 5 mg doses of haldol to subdue the tough-guy so that they can scan his head.  Before the haldol takes its effect, they put in a foley catheter.  He screams even louder, but I'm sure he won't remember in the morning.  

We disinfect the bloody board and clean the straps.  I clean up the back of the truck.  The adrenaline leaves my system.  I feel calm.  Other places in the country, this might not have gone the same way, I think to myself.  We might not have shown as much restraint.  Nothing he said got to us.  Nobody took anything personally.  The same armor that protects us from the personal tragedies we're exposed to blocks insults, attacks, and physical assaults.  We don't have time to be insulted by someone struggling against us; all we can do is handle it as safely as possible and get back in service for the next call.  

Pieces of the Puzzle

We spot the police car pulled into a dark gas station.  In the back seat, a man sits halfway into the car, hunched over.  The police officer leans against the open door, looking at his would-be passenger with only mild interest.

"I don't know what's going on," the cop tells us.  "I got him out of his car and he asked for a rescue... now he looks like he's going to throw up."  He's friendly, especially considering we love-tapped his cruiser with the truck last week.

I look at our patient.  He had been living in his car at a gas station, and his clothes show it.  He wears a thick down jacket, a baseball hat with a wool cap pulled over it, and dark aviator sunglasses.  I try to ask him what the problem is, but he mumbles a quick reply I can't understand.  "Okay," I say, "Why don't we go to the truck so we can check you out?"  We make the short walk together, illuminated by the pulsating red glow of the ambulance's lights.

In the truck, I have him sit on the stretcher.  "Can you take off your sunglasses so we can see you?" I ask him.  He offers only a staccato shake of the head and more mumbles.  "What happened tonight?" I probe again.  

"I have drink, I have drink" he answers with a thick accent.  

"Okay, how much did you have to drink?"

"I don't know."

He looks uncomfortable on the stretcher; he fidgets with the railing and squirms in the seat.  I ask Gorilla-EMT to get a set of vitals;  I wouldn't be surprised if our patient was asking for a ride to the hospital to avoid a ride to a jail cell, but something about his restlessness gives me an inescapable feeling that there is something more to the call.  

As he looks down towards the pulse-ox probe clipped to his finger, I catch a glimpse of his left eye over the rim of his aviators–it is dark purple.  "John, I'm going to take your glasses off," I tell him as I slide the glasses off of his face.  A plum-colored hematoma stains the area around his eye, and swells his left eyelid shut.  "John, how did this happen?" I ask

"I have hit, I have hit."

"Tonight?"

"Yes."

"What did they hit you with?"  The police officer's ears perk up from the side door where he stands.

"Hand."

"Okay, we're going to get your jacket off so we can take a better look at you."  I try to help him out of his jacket by lifting his left arm, but he winces, and clutches at his left upper chest.  

"What's the matter?"  I ask

"I have hit," he repeats.

"They hit you in the chest?"

"Yes."

"With what?"

"I don't know, maybe chair, I don't remember."

"Did you fall to the ground?"

"Yes," he nods.

"And did you pass out?"

He nods silently.

"For how long?"

"I don't know," he shakes his head.

I press against his head and neck; his face tells me that it hurts all over.  

A quick, wordless glance at Ugly sends him out of the truck to get a backboard, straps, and a collar. 

In the meantime, Gorilla gets the patient's shirt off so we can look at his chest.  There's no real deformity, but when I try to press against his ribs to make sure they're stable, he shoves my hand away, guarding his injury.  His breath resonates equally in both lungs.  His mental status is hard to assess across the language barrier, but all of his neurological signs are intact.  We board him, and start towards the hospital.  I place an IV-lock, not in the interest of being able to give any medications, but because I anticipate John's destination being a trauma room.  There are just too many unknowns–the timeline, the exact mechanism of injury, the length of loss of consciousness, his baseline mental status, whether his intoxication is masking a more serious injury, or if the head injury had caused a bleed, to name a few.  Showing up with a patient with so many unanswered questions of that nature not on a board and without an IV in place would be poor form.  

During the ride, I try to get more information, but the continual grimace on John's face tells me that he'd rather lie on the board in silence than relive the bar fight.  Not making any headway, I give up and call ahead to the hospital.  Once there, he does wind up in a trauma room as a level 2.  I give the story, holes and all, to the trauma team, finish up my report and leave.

It is hard to capture the pathos of the situation, but it is a little sad to have to bring a man who lives alone in his car to the hospital after he got his ass handed to him in a bar he was probably drinking at alone.  Then again, maybe he's a jerk, and that's how he ended up homeless, alone, and with a shiner on his face. I'd like to think that's not the case, but who knows.

Freshmen

I'm more dangerous than a loaded gun, and more insecure than a freshman on the first day of high-school.  I'm a brand new EMT-Cardiac.  I've been cut loose for a few months, and it's been smooth sailing.  I've cracked the drug box more than a few times, but mostly for pain management, occasionally for nitro or Benadryl.  Unlike my paramedic counterparts in other states, my clinical experience is limited to the patients I've treated as an EMT-Basic in the field.  

I haven't been truly pushed since I got my license.  Yet.

I'm working with MedicTrunkMonkey (BrandNewBasicTrunkMonkey at the time) and Sharps-Out-Bobby.  C-Money, another relatively new EMT, has come out for the day to do a ride-along, so I'm happy when we are dispatched for difficulty breathing; maybe she'll get to experience something new.  

We find our way to the house, and are met by the patient's son, who leads us back into a dark room.  Our patient lies on her side in bed, sweat beading on her forehead, taking shallow breaths.  The room reeks of fresh feces; not the week-old stench that permeates nursing homes, but the smell of shit that introduces the patient to the EMT faster than words, saying "Hi, I'm your patient, and although I'm only 50 years old, I'm so sick I just lost control of my bowels."  MTM quickly goes to work setting up a non-rebreather mask to administer oxygen while C$ takes a blood pressure and I interview the patient.  

"Hi, I'm Dan, can you tell me what's going on today?"

"I'm just... tired," the patient tells me.  She says her name is Donna, and that she doesn't have any noteworthy medical problems.

"Are you having trouble breathing?" I ask.

"No, I'm just fatigued," she persists.  MTM tells me her oxygen saturation is low, in the high eighties.  C$ reports a normal blood pressure.  As I listen to her lungs, I see the fire chief in my periphery, collecting information for us and writing it on our clipboard.  Her breath sounds are junky, but not congestive heart failure-bad.  Even in the shadowy bedroom, it's easy to see that this woman is sick.  I reach into the blue bag, producing a plastic bottle.

"Donna, this is some chewable aspirin," I explain.  "It's possible that your heart is causing you some problems, so we want you to take it as a safety measure."  She nods in understanding and I lift the mask off of her face long enough to drop the four orange tablets into her mouth.  The three of us slide her from bed onto the stair chair.  In a flurry, we have her belted in and are on our way out the door.

MTM takes the top of the chair, and I carry the bottom.  Halfway down the front steps, Donna draws in three deep, sharp breaths.  MTM's head and mine snap up instantly.  Neither of us has heard agonal respirations before, but there can be little doubt about what we've just heard.  "DONNA, are you still with us?"

I can't describe my relief when Donna nods and manages an "mhm."

We load her into the ambulance.  We work in concert.  C$ switches the oxygen to the truck's large tank and places the lifepak 12's blood pressure cuff around Donna's arm.  MTM spikes a bag of IV fluids with a drip set.  Sharps-Out-Bobby unlocks the ALS cabinet and breaks the seal on the drug box.  I quickly place the monitor's leads, and print a rhythm strip that shows a normal sinus rhythm (if memory serves me).  I put six more sticker's across Donna's chest before leaning her back in the stretcher and pushing the "12-lead" button.  The printer whirs and I tear the strip off, spreading the printout between my hands.  

Gulp.

The EKG shows a serious STEMI–a blockage has caused a heart attack.  Her heart, starved for oxygen, is struggling to keep squeezing blood through her body with each beat.  "Bobby, let's go,  Rhode Island."  With that, Sharps-Out-Bobby makes his way to the driver's seat and sets the ambulance in motion towards the hospital.

I wrap a tourniquet around Donna's arm then splay out my IV materials on the bench seat.  A catheter, gauze, alcohol preps, Tegaderm, and tape litter the bench.  "I have terrible veins," Donna manages to say before I plunge a 20 gauge catheter into the inside of her elbow, searching for the small spongy spot I had felt moments before.  Nothing.  I weave the needle into flesh, digging for a vein, probing in different directions, changing my angle of attack.  I know the vein is there somewhere, but something is pulling my attention away.  Donna's chest heaves again, as she draws in three more sharp breaths.

"Dude, those are agonal resps..." MTM says. 

I look at Donna.  I look at the monitor.  The yellow lines that trace her heart rhythm look like the furious scribbles of a toddler's drawing.  Her heart has stopped.  

Totally weak.

"MTM, check a pulse, hook up a BVM and start bagging.  C$, start CPR."

"Like... Compressions?" She asks in disbelief.  

"Uh, yeah."  

"Bobby, she's fucking coding!" I call up to the cab.  I probably would have been more tactful if I had known that her son was in the front seat.  Oops.

Bobby has the dispatcher notify the hospital.

I tear open the defib pads, connect them to the cable, and stick them to Donna's chest.  Defibrillation within the first minute of her heart stopping is her best chance of survival.  I glance down at the 12-lead wires that stretch across her chest.  No one has ever told me if you can defibrillate somebody with the precordial leads on, but I don't want to take any chances.  I rip the leads off before charging the pads to 200 J.  

I have everybody clear the patient, look up and down her body, and hit the shock button on the monitor.  Before C$ can resume compressions, I see that Donna's heart is still quivering.  I noticed that the rhythm, which I assumed to be V-fib, seemed oddly organized.  If I had bothered to print a strip, or if the monitor were still set up to print a six second strip surrounding each shock, I would have recognized that she was actually in a rare rhythm–torsades de pointes.  In the end, the treatment is the same, and we don't carry the one drug that is useful for resolving torsades, but it still would have been satisfying to identify it correctly.

I take out the intubation kit, attach a mac 3 to the handle, grab a 6.5 ET tube, test the balloon, and slide into position to put the tube down Donna's airway.  I maneuver the blade past Donna's teeth, but am surprised when her tongue retracts, snaking away from the cold steel blade invading her mouth–could she really still have a gag reflex?  I suppose it's possible she's been oxygenated well enough to keep one of the more basic reflexes intact.  I grab a nasal airway, lubricate it, and slide it into her nose instead.  

Moving back to the bench, I charge the monitor to 300 joules, and once again call for the patient to be cleared.  MTM holds back the BVM, and C$ sits back in her seat.  Finger on the shock button, I look up and down the patient.  I clear my throat and point to Donna's arm where it rests against C$'s leg.  Grimacing, she flops the arm back on Donna's body.

I push the shock button.  I can tell the rhythm has been converted.  We do compressions a little longer before MTM announces he has a carotid pulse.  I look at the monitor, which shows a rapid atrial fibrillation, and a good blood pressure.  

Again I go to work trying to put in an IV.  We need to give her antiarrhythmic drugs to keep her heart from stopping again.  I feel a vein in her forearm, clean the site, and deftly plunge the catheter into the flesh.  I feel the crisp, satisfying pop of the catheter entering the vein, but when I look down, no blood has filled the flash chamber.  I was sure I was in the vein.  Before I can  think about whether to pull the catheter, or try and run it, MTM draws my attention to the monitor screen.  Her heart has stopped again.  I absentmindedly pull the catheter out, and reach across to charge the defibrillator.  Once again, 300 joules of energy course through Donna's body, restoring her pulse.  

Seconds after the shock is in, I look down at the site where I had tried to start the IV.  Venous blood oozes from the small hole.  I had been in.  Lack of venous pressure probably prevented the flash chamber from filling up.  It's a stupid mistake.

I grab the phone and give a quick report to the waiting team.  "Hi, we're enroute to your facility with a 58-year old female patient, initially alert and oriented and complaining of fatigue.  She had a low room-air sat, congested lung sounds bilaterally, and was pale and diaphoretic.  Her 12-lead showed a large anterior STEMI.  She went into v-fib arrest about 7 minutes ago, we've converted her twice, we're five minutes out."  Hopefully, they'll activate the cath lab team.

I go back to looking for a vein to start an IV in when her heart stops a third time.  Again, we send electricity through her body, arcing her back off of the stretcher.  

"Owwww," Donna says, pulse restored.  "You're hurting me!" She groans, and claws at the mask of the BVM.  When MTM pulls the mask away momentarily, she pulls the nasal airway partially out of her nose.  I take it the rest of the way out.

"Donna," I tell her, "Your heart stopped, we need to help you breathe with this mask."  It's no use.  She rolls her head from side to side to avoid the ambu-bag, and pushes it away from her face.

"Fine," I say to MTM, "Leave the BVM connected to the oxygen and put her on a non-re-breather."  It's more important for her to get high concentration oxygen than positive pressure ventilations if she's breathing adequately.

With that, we pull into the ER parking lot.  When I pull the stretcher out of the truck, I realize just how ridiculous this is going to look: a cardiac arrest patient is being brought into the ER with no tube, no lines, no airway adjunct, not being bagged, no compressions being done.  The only intervention immediately apparent is that we've put her on an oxygen mask.  In fact, as we wheel her into the trauma room to the waiting team of doctors, nurses, aides, respiratory therapists, and med students, I hear somebody let out a disappointed "oh...".

I give my report to the ER team, and make sure the 12-leads and rhythm strips make it into the hands of the cardiologist from the cath lab.  I write my narrative on the run report.  She goes back into cardiac arrest twice, and is converted twice.  We leave.

Was it a cluster-fuck?  Sort of.

Would I do a lot of things differently if I had to do it again today?  Definitely.

Did she survive to hospital discharge?  Yes.  

And that's all that really matters, right?

Let's put this one to rest...

Para-myth #472: Giving Albuterol to someone in congestive heart failure (CHF) will cause an increase in pulmonary edema

"The Rhode Island protocols are terrible," my partner tells our patient, a nurse.

"Why?" I ask, "I think the BLS protocols are great."

In Rhode Island, EMT-Bs have a wide scope of practice that allows them to deal with a number of situations without the need for ALS.

"Well, for example, Albuterol is in the CHF protocols.  Albuterol will kill someone in CHF.  When I showed that to my medic instructor in Massachusetts, he just laughed."

I roll my eyes.  "I've had this debate before," I tell him.  "Why do you think that Albuterol kills people in CHF?"

"The wheezing you hear in CHF is from compensatory bronchoconstriction.  It's the body's defense mechanism, and it prevents edema from filling up the lungs.  Albuterol opens up the airway and increases the negative pressure in the lungs that draws in each breath, and also helps draw fluid into the alveoli."

It's a new one.  In the past I've been told that albuterol opens up the upper airways, directly creating more space for fluid to fill the lungs, or that albuterol is bad because it allows fluid to return to circulation before the fluid overload problem has been resolved.  Either way, I've been laughed at for suggesting that albuterol might not really be that bad, and yet I've never been given a satisfactory mechanism through which it kills all the victims of the terrible Rhode Island congestive heart failure protocol.  

The first thing I did was look up the contraindications to albuterol through epocrates on my iphone.  This is what I found:

While neither pulmonary edema nor CHF is listed as a contraindication or caution to albuterol administration, many common CHF comorbidities–ischemic heart disease, hypertension, arrhythmia, diabetes, and old age- are.  Nonetheless, I point this out to my partner:

"If albuterol were really so terrible for CHFers, don't you think CHF or pulmonary edema would be listed as a contraindication in the drug insert?"  I ask him.

"I don't go by drug inserts," he tells me.  I wonder what he does go by.

Well, after some debate, and being told that I've forgotten my anatomy and physiology, I'm still not satisfied, so when I go home I surf over to pubmed to see what I can find.  I type in "albuterol" and "congestive heart failure" and am happy to see the first result: 

Maak A, Tabas J, and McClintock D.  Should Acute Treatment with Inhaled Beta Agonists be Withheld from Patients with Dyspnea Who May Have Heart Failure? Journal of Emergency Medicine.  2008 (published online before print)

This paper is a meta-analysis of 24 different studies on the effects of beta-agonists, including albuterol, in patients with heart failure.  Here are some interesting points:

• Many patients with chronic heart failure who do not have COPD as a comorbidity still have an airway obstruction problem–"cardiac asthma"– that results from CHF directly.  When bronchial vessels become congested, edema of the airway wall occurs, much as pulmonary edema occurs when pulmonary vessels become backed up.  The plasma that causes the edema also brings with it paracrine cell-signaling molecules that are bronchoconstrictors, and further cause upper airway swelling.  

• We know that albuterol decreases bronchial edema, but in animal and human trials, it has also been shown to increase fluid clearance from the alveoli themselves.  In one sheep study, nebulized salmeterol, another beta-2 agonist, decreased pulmonary edema by 60%.  

• 20 human studies demonstrated a 13-51% reduction in systemic vascular resistance after administration of beta-2 agonists in heart failure patients.

• While the beta-1 effects of albuterol might be concerning when treating a patient in heart failure or with a suspected MI, one study showed that 31 patients suffering from MI and cardiogenic shock improved hemodynamically when administered albuterol, and none developed worsening ischemia.  Two other studies found similar results in patients with left sided failure. In other words, the benefit derived from decreasing cardiac workload indirectly by decreasing respiratory effort outweighs any increase in workload caused by increased heart rate or contractile force.

• Chronically administered inhaled beta-2 agonists have been associated with increases in mortality, incidence of dysrhythmias, and hospitalization for CHF in heart failure patients.  Despite the trend, the causal link is unestablished.  

• The authors were unconcerned with the possibility of pulmonary edema when acutely administering beta-2 agonists to CHF patients.  They were more concerned with the possibility of dysrhythmia secondary to beta-2 agonists' induction of hypokalemia, or low potassium.  However, no link was found between inhaled beta-2 agonist use and an increase in incidence of dysrhythmia in heart failure patients.

I'm not saying that my next CHF patient is going to see me walk into the room with an albuterol bullet in hand; they won't.  But, if after a nitro or two and some Lasix, I hear wheezes in the upper fields, I certainly won't worry about albuterol causing a biblical-lung-flood.  And if I'm debating the cause of a patient's dyspnea, it's good to know that albuterol may help, even if left ventricular failure is to blame.  

I was going to print out a copy of this paper to show to my partner, but then I remembered what he told me– "I can get a study to say anything."  Good thing he's got all those anecdotes and that in-depth understanding of A&P to rely on.  

Confession

Forgive me, EMS Gods, for I have sinned.

I gave a nursing home nurse attitude, and I was wrong.

Ugly, Gorilla EMT and I answered the call for a diabetic seizure.  In an uncharacteristically professional manner, the nursing home has a nurse waiting to give us a report.

"She had a fifteen-minute seizure around 8:15," she tells us.  I do a double take as I look at my watch; it's almost 9:30.  "We checked her sugar, and it was 52."  A person's blood sugar can vary, but should be between 80 and 140.  "We checked it again 20 minutes later, and it was 36," she continues, "we rechecked it a little while after that, and it was 25.  We put some jelly under her tongue, then put two sugar packets in her mouth."

The patient lies in her bed.  She's pale, but her skin is dry.  She takes deep breaths, occasionally exhaling through pursed lips.  She perks up when I call her name loudly, and withdraws her hand when I pinch her fingernail.

Another nurse comes in with a syringe full of liquid.  "We got the order for glucagon," she announces, "can I give it?"  Glucagon is a hormone that prompts the liver to convert stores of a starch into glucose, the sugar that the body uses to create energy.

"Why don't we hold off," I tell her.  "At this point, if we're going to give her sugar, it'll be IV."  Injecting sugar intravenously produces results much faster than glucagon, and given the age of our patient it may be important to administer the sugar gradually, so we don't overshoot our mark.

Gorilla is already almost done testing her blood sugar, and I get a quick blood pressure, which is normal.

"What's the sugar?" I ask him.

"99."  99 is a normal blood sugar.  This throws off my thought process.  Sure, they gave her sugar, but two sugar packets?  When we give diabetics with blood sugars in the 20s oral glucose, it often takes two 15 gram tubes of concentrated sugar to bring their blood glucose up that significantly.  A sugar packet can't contain more than 5 grams of sugar.  Maybe she had a transient drop in blood sugar because of the physical activity of the seizure, I tell myself, or maybe the nursing home's glucometer is faulty–a plausible explanation given how finicky the machines can be.  

"This brings me back to my nursing school days," one of the nurses says, "this is insulin shock."

I look the nurse up and down and think that her nursing school days must have been in the 50s.  "You can't be in insulin shock with a sugar of 99," I tell her, somewhat rudely.  

"She's postictal, then," she says, referring to the hazy mental status from which seizure patients gradually emerge.  

"For an hour and a half?  I don't buy it."  While people can have postictal symptoms long after the seizure, the change in responsiveness is comparatively short-lived.  I look at the patient again.  She doesn't have the absent look of someone who is postictal.  I look at how she occasionally exhales through her lips.  I've seen this respiratory pattern before in two kinds of patients, and I'm fairly certain she's not drunk.  "I think she has a head bleed," I say.  It would explain the seizure and the continued altered mental status.  As for the blood sugar, I'm dumbfounded.  We put her on the stretcher and get moving.  In the truck, I have Gorilla recheck her blood glucose.  I'd hate to have our glucometer be the faulty one and arrive at the hospital with an untreated hypoglycemic patient.  The machine reads 106.

Gorilla is a brand new cardiac, but I hesitate when it comes time to start the IV.  I know I should let him start it, but I'm still so new to EMS in the big picture that I don't always feel secure enough to let other people perform procedures.  In the end, I do have him start the line.  He struggles a bit at first, but manages to finesse the catheter into the vein.  We draw blood samples, knowing that the hospital we are transporting to is one of the few in the state that will accept them.

Before we clear the hospital, the patient has perked up some, but is still very out of it.  The triage nurse seems to agree with my stroke/head bleed theory, but I remain unconvinced.

Later in the week I go back to the same nursing home to take someone with a minor problem to the emergency room.  I take the opportunity to find out what happened  with my patient.  Apparently, she really did have a diabetic seizure that left her altered for some time.  There was no stroke, and no head bleed.  Perhaps a blood sugar of 100 was still low compared to her baseline.  Maybe if I had slowly squeezed a few grams of dextrose into the IV, she would have perked right up, and we would have arrived at the hospital chatting about the weather.  Right or wrong, I shouldn't have rejected the nurse's ideas so openly in front of her coworkers and mine.  It was poor form, and a mistake I won't soon forget.  

Motherhood

In one split second, my compassion turns into anger, my empathy into disdain.  All the negative feelings I should never feel towards patients swirl in my head.

We picked her up from home.  In the back of the ambulance, I carefully took her history.  She was 4 months pregnant, but was experiencing abdominal pain and had been bleeding for two hours.  She was crying.  I understood; she thought she was losing the baby, but it was way too early to know.  Despite the fact that she had been pregnant many times, had only one child, and had never had a spontaneous miscarriage, I reserved judgement, and pulled out all the stops.  I comforted her, reasoning with her that there was no cause to be upset until she knew what was going on, that she wasn't bleeding that much.  I even got her to smile, to slow her breathing and relax some.

So, when I see her outside the triage area of Women & Infants hospital ten minutes later smoking a cigarette, I want to run her over with the ambulance.  I want to scream into the PA "I know you weren't just crying about possibly losing your baby two minutes ago, only to be smoking a cigarette now."  She had told me it was a high-risk pregnancy because of her hypertension, and now I'm sure that her hypertension is due to her continual smoking or her obesity, both of which are within her control to stop.  

I don't mind taking care of people who can't take care of  themselves–they constitute 80% of my patients.  I don't really care if people smoke, either.  But to sob in the back of my ambulance, to make me care about what happens to your baby, and then show me how little you care about him yourself?  I hate her in that moment.

Futility

We're at the nursing home to take a male patient to a doctor's appointment.  He's not terribly old, but is non-verbal at his baseline due to dementia.  He doesn't make eye contact with me when we enter his room.  He doesn't shift his gaze when I call his name, and tell him we're taking him to his appointment with a urologist.  

My partner, the Deer Hunter, and I slide the man onto our stretcher.  As we wheel him down the hall, back to the ambulance, we notice the raspy, gurgling sound issuing from his lungs every time he breathes, and the way his chest heaves with every breath, drawing the flesh between his ribs and collar bone inwards–a sign that he is working hard to breathe.  

At the door, a social worker from the nursing home stops us.  "I think I'm coming with you," he tells us.  "I'm a CNA, we like to have one go with residents to appointments." I tell him okay, and take the opportunity to ask about our patient's condition– "Is this his baseline?"  I ask.  

"I don't know him that well, but he's been steadily declining since he got here a few weeks ago."  The social worker goes off to get his things, and we put the patient in the truck.

"Dude–" DH says to me.

"I know..." I tell him, standing at the back doors.  He presses a stethoscope against the man's chest, listening to his lungs.  "Rales all over," he reports; our patient is having trouble breathing because fluid is filling his lungs.  DH clips the pulse oximeter probe to his finger before wrapping a blood pressure cuff around his arm and pumping it up.  The pulse oximeter reads 77%, a low number even for someone who is not well oxygenated at baseline.  

Shortly, the social worker comes out.  "Uh, he's in a condition we would normally treat..." DH tells him; "He may be in heart failure."

"The family wants him evaluated by this urologist," he tells us.  "He's known to them, and they want to hear about his condition from him.  This was the only time he could see him."  I go inside with the social worker to call the urologist while Deer Hunter puts the patient on oxygen.  I talk to the nursing home administrator.  She explains to me that the family–a son and a daughter– want their father evaluated by this doctor, who will tell them if a miraculous cure is possible, or if they should obtain a DNR for their father, paperwork that withholds the violent, undignified act of CPR if he should slip into cardiac arrest.  She tells me to do what I think is best.  I get the phone number for the doctor's office and dial it on the ambulance's cell phone.  After first talking to a receptionist, then a nurse, I'm connected to the doctor.

"Hi, this is Dan from XXXXX ambulance.  I'm here with a patient of yours, Mr. Roland.  I understand you were supposed to evaluate him in your office today, but we think he's in congestive heart failure."  After describing his condition, the doctor tells me to take him to the hospital:

"I'm a urologist, I can't treat heart failure..."

"I know," I tell him, "We're just–"

"Just trying to appease the family, I understand."  We say goodbye.

"Off to the ER," I tell DH, and get into the back with him.  He has a bag spiked, and has put a non-rebreather mask on our patient, delivering high flow oxygen.  For probably the eighth time in two weeks, I wish we had CPAP on our ambulances.  

"The nurse said she gave him Vicodin for pain, right?" DH asks.  "Check out his pupils, they're pinpoint."  Indeed, his pupils are constricted and unreactive.  "Maybe they accidentally dosed him twice," he suggests.  Accidents like that routinely occur in nursing homes, so it's well within the realm of possibility.  

I start an IV in a large forearm vein.  On the way to the hospital, I give Lasix, which should help the patient eliminate fluid by peeing it out, hopefully making space for the fluid that now fills his lungs to reenter the circulatory system.  Because he is unresponsive and having trouble breathing, I give Narcan–slowly–it will counteract the Vicodin.  If the Vicodin isn't causing any problems, I'll just be bringing back the pain it was meant to alleviate.  

During the twenty minute ride, his color does improve slightly.  His pupils become reactive, although they are still constricted.  He looks around the ambulance, and moves spontaneously now.  Whether his improvement is because we relieved hypoxia or reversed an opiate overdose, I don't know.  I'd probably stake money on some combination of the two.  Either way, he's still very sick.  

At the hospital, the doctor sees him relatively quickly.  Before we leave, he's been put on CPAP.  If Lasix pulls fluid in the lungs out by creating space in the vasculature, CPAP pushes it out of the lungs by filling them with air at higher pressures.  

The call leaves a bad taste in my mouth.  "We did the right thing," I tell DH, who nods in agreement.  "I don't like putting him in the hospital, but that's where they would have sent us if we showed up at a doctor's office with him like that."  We both know that the probability of the man ever coming out of the hospital is grim.  

Later, we drop off another patient at the same ER.  I peek into the corner room where we had left our previous patient.  I wish I could say I was surprised to see him intubated, sedated, and on a ventilator.  I shake my head.

People have different beliefs about death, what happens after death, and whether or not it is right to withhold potentially life saving measures.  TV and the media contribute to the notion that anybody can be saved.  All too often, I see patients who have no interaction with the outside world, with end stage diseases that will kill them, be it today, tomorrow, or a year from now, who are "full codes."  I think the children or spouses who demand that "everything be done" would feel differently if they had seen a working code–watched blood tinged emesis spill out over someone's face as strangers pounded on their chest, felt the pop of ribs breaking underneath the heel of their hands as they compressed the sternum, or, most importantly, experienced the frustration of working against nature, knowing fully that natural forces have already dictated that this person will not survive.

When I went back to the nursing home where we had picked up Mr. Roland two weeks later, I went around the corner to the room we had found him in.  I was surprised to see his name still on the door.  I saw the administrator walking down the hall, and asked after him.  "He's still alive.  His family put him on a ventilator," she told me.  "He was in the ER for 3 days before they had an ICU bed to give him.  It's a shame," she said, reading the disappointment on my face.  

"Let me guess," my partner said, "they visited him once, maybe twice while he was in here?"

"That's right," she said.  "People don't understand what they're holding onto."

Pepper Spray

Some of the best moments working in EMS are the truly absurd events we are often party to.  My usual Rescue partner, Ugly, and I have spent a lot of time laughing in the front of the truck after clearing the hospital or documenting a refusal, taking a moment to point out all the ridiculous things that have just happened.

One night at about 1:30 AM we are dispatched to a bar in town for an unknown medical– "meet police on scene."  I'm working with Ugly and Medic-Trunk-Monkey (MTM), an old friend of mine.  The bar is only two blocks away, so we beat the police there.

Dismounting our vehicle, we're confronted with a scene that is neither chaotic nor calm; about fifteen patrons are milling around in front of the exit, but unlike most scenes where someone is hurt in a crowd, there is no focal point.  I hear a few scattered coughs from the crowd, and notice someone spitting.

"What happened?" I ask no one in particular.

"Someone sprayed pepper spray in the bar," one of the bar-goers tells me.  

"Is anyone left inside?" I ask him.

"Nah, man, everybody got the hell out of there.  It's impossible to breathe in there."  

We look around, but don't see anybody who looks acutely ill.  Pepper spray is a great tool for the police to use in subduing combative suspects, and can often take the fight out of very angry people, but has to be used with caution; spraying OC indoors or upwind can result in unintended exposure.  

The police officer, a well-liked female cop, pulls up to the scene.  We learn that the pepper-sprayer has fled, but they know who he is.  

At this point, we figure that anybody who is ill enough to merit treatment will approach us.  The cop asks us if anybody is inside "I don't know, but we're not going in there to find out," I tell her.  "Pfff, me, neither," she says.  A short while later, a firefighter who works as a bouncer at the bar shows up and walks into the building, coming out almost immediately, rubbing his eyes.  "Yup, that's definitely pepper spray," he tells us.

The four of us stand in a line at the curb, watching the drama unfold; one group smokes cigarettes, two women excitedly drunk-dial acquaintances to gossip about the story, and others mill around not really knowing what to do.  At some point a man comes out of the crowd and starts talking to us–small talk, or telling us about what happened.  I can tell he's inebriated, mostly from the way he stands in front of our group without looking at anyone in particular.  He talks, we stand there, we nod, we smile, he keeps talking, we keep nodding and standing there.  

"Well, I'm out of here," the cop says abruptly, shrugging, and gets back into her car.  We turn and start to shuffle back to the Rescue.  

No sooner has the door to the cab closed when Ugly asks us: "Do either of you have any clue what that guy has been talking about for the last five minutes?"  We look at each other, and shrug.  We all just kind of assumed that someone had been paying attention.  We laugh–none of us had heard a single word he'd said.  "Get us out of here," I tell Ugly, "I'm dying."

It feels hard to capture the humor in writing, but I think the dispatchers probably hear the three of us laughing a few minutes later when I call us "Clear–No EMS needed."

Aim High

We're covering one of the 7 towns my company holds 9-1-1 contracts with when we're sent to "meet the police."  I can count on one hand the number of times I've been sent to a call to "meet the police" that didn't involve a drunk person who was causing problems.

The police officer meets us on the front porch.  "Hey guys," he speaks in a low voice, "Basically, we were called here because this guy's been walking around in front of the windows naked constantly."  So far, we're off to a good start.  "He's drunk out of his mind," he tells us, "he thinks it's 1988, and Reagan's president.  Don't touch anything in here you don't have to.  You'll see what I mean.  He's a veteran, so I guess he should go to the VA and see if they can detox him."  I nod, prepare myself for the worst, and head in.  

Inside we find our patient sitting naked on his bed.  What surrounds him is the most abject squalor I have ever seen a person live in.  His bed looks wet, and I can see the telltale chunks of vomit spread around it.  Half-eaten plates of food are cluttered everywhere.  Papers, garbage, and pill bottles are strewn about the room.  Half a handle of vodka rests on the coffee table, and at least six empty cartons of orange juice are strewn about.  Unfortunately, the papers and garbage don't cover the carpeted floor, which squishes damply under my feet–soaked with I don't even want to know what kind of liquid.  Fruit flies hover over a pizza box on the floor.  I think I see a flea hopping across the bed.  A kitchen pot on the floor is filled with a yellow liquid that looks like a mix of leftover broth and urine.  

With the help of the police officer, we find a pair of shorts and a shirt that we help the man put on.  He's incoherent and physically uncoordinated, but seems to agree to go to the hospital to get some help.  He tells me he was in the Air Force, and used to fly helicopters.  I'm not sure it's true, but we find his VA card in his wallet.  

As we assist him in shuffling out of the house, the police officer thanks us.  "I'm sorry you guys have to deal with this," he tells us.  I shrug; "He's a veteran."  Inside I tell myself that I'd take this mostly cooperative ex-serviceman over a drunk, belligerent, over-privileged college student any day.  He's sick, and needs help.  I don't know how he'll be treated at the VA; I don't know if he'll get the help he needs to stay away from booze, or if the damage has already been done, and before long another ambulance will find him dead and bloated on the floor–maybe because his rent was late and the landlord went to check on him, or maybe because the smell got too strong and started to bother the neighbors.  I doubt he'll remember the ride, but I try to treat him with as much respect as I can muster.  I think about how I would feel if I treated him coldly and were later sent back to the same address for a presumption of death.  

Recess

I was exhausted.  I hadn't been able to sleep before my shift yesterday–the product of alternating working nights and days too close together.  I was in a bad mood, so when I found out we were going to have to participate in a hot dog detail, I was wary.  

You see, I had forgotten how awesome hot dog details are.

I was working with one of my usual partners, "Gorilla EMT."  We brought Rescue 2 over to the elementary school, which was to be the beneficiary of hot dog detail, where we found Rescue 1, the Chief, and a gaggle of guys from Hazards, Ladder 1, and various engine companies.  

880 hot dogs.  We made 880 hot dogs.

The weather prevented the typical giant grill method of preparation, so hot dogs had to be boiled in a giant vat over a propane burner.  Our assembly line of dog-to-bun insertion provided fodder for a never-ending chain of inappropriate jokes.  

Between batches, I joined in a conversation with the chief and another FD member:

"We come and do this every year," the chief explained, "because of things like this, I can get residents to show up and vote, and approve the multi-million dollar bond we needed to get our new equipment."

"That's right, Chief," I said, "They don't remember when we put out fires in their houses..."

"well, they–"

"They don't remember when we come to their homes and pick up their sick loved ones."

"They defin–"

"But they remember the hot dogs!"  We laughed.

At some point, I lost track of Gorilla.  After looking around for a minute, I spotted him on the schoolyard, talking to a teacher who was supervising students at recess, and started walking towards him.  Before I reached him, I walked through a group of kids playing wall ball with a rubber hand ball.  

"What are you guys playing?" I ask no one in particular.

"Wall ball!" one tells me.  I ask if I can play and am granted permission, and instantly recognize the game from my childhood, "suicide."

I talk to the kids, who I find out are first and second graders.  We play.  The group grows.  We joke around.  I am a celebrity.  Gorilla comes over and joins in.  The students don't come up to his waist.  

At some point, the ball ricochets off the wall and hits a girl in the eye–pretty hard for her size.  She covers her eye with one hand.  I instantly recognize the look in her other eye.  She's hurt, but not badly, and whether or not she bursts into tears depends on what happens next.  A teacher hurries over to her.  "Alice, are you okay?!" the teacher asks her.  Before she can answer, I snatch up the ball from the ground, and jog over to her.  "Here, do you want to throw the ball?" I ask her, handing the ball over.  Her frown recedes, and she runs towards the wall to throw the ball.  Medicine: It sometimes comes in the form of a pink rubber ball, I think to myself.

The students are called to line up and go back inside.  After pretending that we are lining up with them for a minute and getting busted by a teacher, Gorilla EMT and I start back towards the apparatus and hot dog detail, only to see the next group of students coming out for recess.  Not ones to miss out on play time, we decide to head back to goof around with some more kids.  

I invite myself into a circle of boys and girls that seems to be doing some kind of choreographed dance.  By the time I realize what they're doing, Gorilla has wandered over.  "They seem to be doing a little dance to 'This is why I'm hot,'" I tell him.  They giggle.

He looks at me, bewildered look in his eyes, before saying "This is why I'm hot/I'm hot 'cause I'm fly/You ain't cause you not."  They laugh even more.  We talk to them, and establish that they're in third grade.

And this is when things went south.

My hyper-acute ninja-EMT senses detect movement behind me, so I spin around, catching a boy jumping up behind me, making the bunny ears symbol while I talk.  Ouch.  I got served.  The 10 other students clustered around me begin to laugh.  "Ooohhh, heck no," I say.  They laugh even more.  With my back to them now, one imitates the first offender and attempts to bunny ears me.  Well, that must have seemed like a good idea to the rest of them, because within 5 seconds, 10 third graders are jumping up and tapping the top of my head.  That's right; they'd abandoned the bunny ears all together and settled for slapping my head.  I'm  caught in the middle of a pack, and the pack is growing exponentially.  There is no refuge.

From tapping the top of my head, things spiral rapidly into a game of kill the carrier.  Without the ball.  It's kill the EMTs.  I am pulled in all directions.  Third-graders hang from my belt, my legs, and pull on my arms.  Feeling a tug at the left side of my waist, I quickly reach down and shut off my radio–just in time– "HELLO, 9-1-1, WE'RE ATTACKING HIM!" a boy screams into the speaker-mic.  I can see just how well that would have gone over at dispatch.  

In horror movies, small creatures often encircle secondary characters before swarming them and killing them.  Zombie children, evil-T-virus infected dogs, whatever they may be, I always have a problem suspending my disbelief–how could something so small take down a human?  I understand completely now.

With a third-grader latched onto each foot, another flies over the crowd that encircles me, connecting with an NFL-worthy tackle to my shoulders.  I lose balance and fall.  Having been at the bottom of it all, I have no idea how big the pig-pile that ensued was, but judging by how sore I am today, I imagine it was at least five feet high.  

Taking care not to crush anybody, I extricate myself and look for my partner, hoping to form an alliance.  Here I should mention that Gorilla EMT's pseudonym is not based on an unnatural affinity for banana's, but physical build.  Gorilla stands 6'5", a strong 235 lbs, easily, so I am surprised when I look around and see him at the bottom of a similarly large pile of third-graders.   

I run, and picture the hare-chase from the movie Snatch.  I am faster than the schoolchildren, but the zipper on my right boot burst open during the struggle.  Pursued by fifty screaming kids now, backed into a corner, I have no choice but to adopt a wide stance and hope for the best.  I feel like the guy in the zombie movie, armed with a revolver with three shots in it, facing a hoard of the un-dead, telling his friends "Go! I'll cover you!"  I know what is going to happen, and quickly find myself at the bottom of another pig-pile.  This time, I'm pushed over and almost land on top of one of the kids.  I have to maintain myself in a front leaning rest to avoid crushing him.  Luckily, I am saved by the bell, as one of the teachers yells: "Third-graders, time to line up!"  Slowly, the weight is lifted, and I am freed.  

Exhausted, t-shirts damp with sweat, Gorilla and I walk back to the truck.  The firemen have already stricken the hot dog setup and put everything into the utility truck.  We get into the rescue.  "You know, another group is probably about to come out for recess..." he says.  I stare into the crowd of lined up third-graders.  "I can't go back in there, man..." I tell him.  He nods in agreement.

As we leave, I hit the siren and air horn.  The students scream in delight and wave.

I didn't have any interesting calls during our 12-hour shift; I wasn't presented with medical challenges, nor did I perform any noteworthy procedures, but it was the best shift I have worked in a while.

"It was Always You"

"Ambulance fifty-six, 5-6, make it the NEMC ER for a female 12 going to Bournewood."

Psychiatric transfers represent a significant fraction of the runs undertaken by private ambulance companies.  Patients with suicidal ideation or those who have attempted suicide cannot be taken directly to a mental health facility, but must first be evaluated and cleared medically at an emergency department.  Once a patient has been cleared medically, they can be transferred to a psychiatric hospital.  Since they could potentially be a danger to themselves, and are often medicated or sedated in the emergency department, the preferred transport vehicle is an ambulance, where the patient can be supervised, or, if absolutely necessary, restrained.  In Massachusetts, the commitment papers and process is called a "Section 12," commonly referred to as a "section," or a "12."  My company makes it a rule to send a truck with a female EMT to transfer female sectioned patients, mitigating the risk of accusations of inappropriate behavior by male EMTs in the back of the truck.  

I normally relish the challenge of comforting emotionally distressed patients.  Each panic attack, each suicidal ideation call, and each suicide attempt is an opportunity to improve the tact and empathy it takes to handle this distinct breed of call.  Some patients are despondent, they don't want help, they don't want to talk, and they sure as hell don't want to go to the hospital.  These patients are the most challenging, and by far the most frustrating.  

In the non-emergency setting it's a little different.  You're not coming into the situation at the crisis point.  The biggest hurdle, getting the patient committed to seeking help, has already been overcome.  It can be a little awkward.  That doesn't mean comforting the patient isn't important.  They're about to be committed to a psychiatric facility, many for the first time.  Anybody who has seen or read One Flew Over the Cuckoo's Nest is bound to be at least a little apprehensive.  

As we pulled into the NEMC parking lot, I had no idea that this "female 12" would scare me far more than any raging-drunk, 250-pound football player ever could.  What's that?  Calling me a wuss?  You just wait and see.

My partner, another college student, and I pull the stretcher into the ER.  "She's not going to be ready for another minute," our patient's nurse tells us, "but here's the paperwork."  I glance through it before handing it to my partner so that she can copy the information down.  Some parts catch my eye: "Borderline personality disorder," "the patient became violent," and in the physician's notes: "PATIENT HAS THOUGHTS OF HARMING HERSELF AND OTHERS."  The nurse comes back and gives us a short report:

"Apparently she had some kind of fight with her boyfriend.  She presumably just found out she was pregnant while she was here, but might have taken a home test and found out.  That could have caused the break or the fight that caused the break.  We don't really know because she won't talk to us."

"She won't talk to you?" I ask.

"She hasn't said a word since she got here.  I think she talked to the psychiatrist who came down for a consult, but that's it.  Look, she's been fine since she's been here, and she's been told she's going out, but I don't know how she's going to react when it's time to leave.  I think you'd better get your restraints."  I nod, and tell my partner I'll go out to the truck to get them.  Eventually, we get the ball rolling, and follow the nurse into the room.

As soon as we hit the door, I feel it; the unwavering stare of the patient.  She's tall, but petite, and very pretty.  Her eyes remain locked on me.  "Janet, these are the people who are going to take you to the other hospital," the nurse tells her.  

The stare is not hollow, but penetrating.  Uncomfortable, I avert my eyes.

"It was always you," the girl says in a quiet voice, barely above a whisper.

"What?" the nurse asks.

"It was always you," she repeats, still staring at me.

The nurse turns her head to look at me, eyebrows raised.  The expression on my face speaks for itself; I have no idea what she's talking about, either.

"Okay," my partner says after an awkward pause, pulling the stretcher next to the bed and moving the seat-belts off of the mattress.  "Janet, can you move over to the stretcher for us?"  She doesn't mind, and pushes herself up to slide over onto our stretcher from the hospital bed.  To my dismay, she manages to do this without breaking her stare.  I find it hard not to react to the absurdity of the situation by laughing.  If I had had a choice, I would have pushed the back of the stretcher, out of the patient's view, but the tight quarters in the room meant that I would be pulling the foot end.  As we leave the room, the nurse mimes to me "I think you'd better drive."  No kidding, I mouth back.  

Pulling the stretcher out of the ED, I can feel the patient's eyes on the back of my head.  When I turn backwards to negotiate corners, I find her unrelenting gaze again and again.  I am relieved to finally load the stretcher into the truck and close the door.  I can't help but feel a little weirded out, and want to get the 30-minute drive over with.  

I hear my partner ask unanswered questions in the back of the truck ("Are you comfortable Janet?... Do you want a pillow?")  A few minutes into the trip, I can feel the hairs on the back of my neck stand up.  I glance at the rearview mirror.  I have to keep myself from shuddering when I see the patient turned 180 degrees on the stretcher, hand on the corner of the frame, eyes peeking over the mattress, staring at me.  I do my best to shake it off and keep my eyes on the road.  I don't think she maintained that necessarily uncomfortable position for the whole ride, but I definitely look back a few more times only to find her still staring at me.  

I'm relieved when we arrive at the receiving facility.  After removing the stretcher, I make a somewhat obvious play for the back end, so that I'll be behind the patient.  We are met by a security guard, who accompanies us into an elevator.  I maintain my strategic position behind the stretcher.  The security guard carries a radio that has "SECURITY/B-TEAM" written on it.  "Not quite good enough to make the cut for the A-Team, huh?" I ask him.  He chuckles and looks down at the radio.  "No, I guess not."

We arrive on the floor and exit the elevator into a small anteroom.  "You can let her off here," the guard says.  We drop the stretcher to within a foot of the floor.  "Janet, why don't you lean forward and I can tie your gown behind you," my partner says.  When she leans forward, she exposes a black tattoo of a dragon that spans her upper back.  I gulp.  Scenes of the tattooed serial killer from Red Dragon flash before my eyes.  

Finally, gown secured, Janet stands.  The security guard starts to walk forward and unlock the door to the unit.  "Come on," he says.  She turns, facing me, eyes locked on mine, and shuffles slowly backwards through the door.  She stops as the door slowly closes, staring, unmoving, detached but focused.  I think I catch a hint of a wry smile at the corner of her mouth.  A chill runs down my spine.  

The door closes, and my partner and I get back on the elevator.  We laugh because, in the moment, it's the only immediate way we have to deal with the situation.  

Later, I call my girlfriend and tell her about the call.  "Creepy," she says.  "You'd better check your closet when you get home," she teases me, "she might be waiting for you there."

"Stop," I tell her, "you're creeping me out."

"Seriously, you better watch out!  Creepy staring girl is going to get you!"

I check my closet before I go to sleep.

"The humans are dead..."

I haven't been in EMS that long, so the fact that I have observed changes in the way things are done at all is a testament to the rapid nature of progression in the medical field.  

Recently, at a major area hospital, the triage system was made paperless.  Nurses enter patient information, history, medications, and allergies into one computer, while CNAs take vitals and enter them into another.  Registration clerks put billing and address information into yet another computer.

One of my first experiences with the new system came on a Sunday morning.  We had responded for a nosebleed.  My previous experiences with nosebleeds had mostly been pediatric calls, nervous mothers who were concerned about a relatively small amount of blood loss.  This would be different.  Walking into the apartment, we found a deaf man who lived alone.  Blood had soaked through a towel he pressed to his face, the pajamas he still wore, and left a trail throughout the dwelling.  My lieutenant, leading the patient care, asks me to find out what medications the patient takes while she applies a trauma dressing to his face.  I write the message down on a piece of paper and hold it in front of one of the patient's friends–also deaf– so that he can relay the question to the patient.  He signs something to her.  I intercept his reply with the limited sign language my girlfriend had taught me.  D-E-P-A-K-O-T-E.  C-O-U--oh, great.  Coumadin.  "He takes Coumadin, LT."  

"Okay, we need to get out of here."  Releasing pressure on the trauma dressing for an instant unleashes a stream of blood from the patient's nose.  We put him on the stairchair, but "getting out of there" would prove harder than we thought.  Overwhelmed, frightened of being out of control, the patient didn't want to leave without all of his articles, keys, motorola sidekick, cards, wallet, overnight bag.  Things we just didn't have time to collect.  My lieutenant scribbles on the notepad: "He may be bleeding to death, we need to go now," and showed it to the friend.  He frantically signed to his friend, presumably urging to let go of the door frame, and let us take him to the hospital.  ("I hate using scare tactics," she told me later, "but I knew we wouldn't be able to stop the bleeding.")

In the truck, I overcame my timidness about using sign language, which I'm not very comfortable with, in order to calm the patient down.  I told him that we had to start an IV to replace lost fluid,  and that it would hurt.  We raise his legs on the stretcher.  I asked if he had pain, and he pointed to the nose.  I tried for an IV with an 18 in the left AC, but missed.  The lieutenant got the line in a vein close-by.  We spiked another bag, and I placed another 18 in the other arm.  Blood soaks through dressing after dressing.  The patient signed "mom," and gave me his mother's phone number.  I told him we would call as soon as we could.  The small exchanges we have take forever–they're sent back and forth one letter at a time–still, I can see the patient is less frantic for having been able to communicate with someone.  We call the hospital, advise them that we're bringing in a patient with uncontrolled hemorrhaging, and that we'll need an ASL interpreter.

We get to the hospital, wheeling the patient into the ambulance triage area.  We expected to be waved into a trauma room immediately.  "What do you have?" a hidden voice asks us.  I look around.  The voice came from behind the desk where the triage nurses usually stand, but I can't see anybody behind the 22 inch computer monitors that are mounted on rolling carts at eye level.  I walk up and give a report.  Each time I use words that should be red flags for the nurse–"hemhorrage, coumadin, large blood loss before our arrival, bleeding uncontrolled by pressure, two large bore IVs"–I expect her eyes to snap up, for her to just look at the patient and recognize the gravity of the situation and assemble a team in a critical care room.  Instead, she clicks through the fields on the computer program, entering information as she goes.  

Under the old system, a triage nurse standing at the waist-high desk would have given the patient a once-over glance that would generally tell them more about the patient than the rescue report itself.  If the patient were critical, he or she would have time stamped the triage form at the desk and accompanied the rescue into the trauma room to gather information.  

My partners and I exchange wide-eyed "WTF" looks as we stand there in triage, our patient still bleeding.  Eventually, the nurse walks out from behind the computer stand and lifts the trauma pad off of the patient's face, revealing a very-actively bleeding nose.  We are finally sent to a trauma room, where I stay to help interpret as long as I can before we have to leave.  The ASL interpreter is still half an hour away.  

I believe that kinks in the new system will be worked out.  As nurses become proficient in working the machines, data entry will become automatic, much like the scribbling of notes on the intake form, and hopefully won't prevent eye contact between the nurse and provider or patient.  Computerized triage conceptually sounds like something that would break down delays in patient care, but until the system is optimized it may cause undue delays.  

Not Taking "no" for an Answer...

"I don't want to go to the hospital."

It's a phrase EMTs and medics hear frequently.  To some, it is the cue to hold the clipboard in front of the patient, pointing to the signature line for refusing service, regardless of the patient's physical condition.  "I can't kidnap them," this breed of EMT will tell you, "they were alert and oriented."

Alert and oriented or not, we're medical professionals.  If someone is sick, it's our responsibility to urge them to seek treatment.  I'm not saying that everyone we see is having an emergency, or that every patient we meet is even sick, but when they are, making the case for being transported to the hospital is as much a part of our job as bandaging a wound or splinting a fracture.  Often, in an attempt to be stoic, patients will initially refuse treatment or transport, despite being in genuine discomfort.  In these cases, merely giving them an opportunity to change their mind may be enough.  Some patients require a little more persuasion.  Learning how to talk to people has been a huge part of my development as an EMT and a person.  Recently, my friend and I joked that we could convince a 23-year old triathlete in perfect shape that he needed to go to the hospital. (Of course we wouldn't... we'd probably want to get back to whatever meal, movie, or nap the call had just interrupted)

I had stopped by rescue headquarters to pick up a DVD that I needed to return one day when rescue was dispatched for a person fallen who couldn't get up.  The first-due rescue, which is typically staffed 24/7, was still at the hospital, so two EMT-Bs and I hopped into my car and drove to pick up one of the standby ambulances, calling dispatch to let them know we were responding along the way.

We arrive to find that the person who had fallen and was unable to get up had indeed gotten up, and was sitting in a chair.  This call has refusal written all over it.  The female patient, in her 70s, had tripped and fallen.  She says she is fine, just banged her knee a little.  I ask if she wants to go to the hospital.  "No way," she tells me.  I put an ice pack on her knee and explain that we're going to check her vital signs–just our standard procedure.  I clip the pulse ox probe, a device that measures the percentage of oxygen-carrying molecules that are actually carrying oxygen, to her finger.

It reads 85%, and holds steady.

The low reading makes me take a step back.  Look at the big picture, I tell myself.  The woman sits in the chair, but leans on one arm on the table.  Tripod position.  She is pale.  Most importantly, her chest heaves significantly with each breath.  

"Are you having trouble breathing?" I ask her.

"No," she replies, "I'm fine."

I take my stethoscope out and press it against her back in the upper fields.  Nothing.  I slide it low, over the bases of the right and left lungs, and hear rales, the sound of fluid in the lungs.  COPDers may have wheezes at their baseline, but nobody should have fluid in their lungs as a matter of business as usual.  We take a blood pressure, which has a systolic in the 190s.

"I can tell that you're working a little bit extra to breath," I tell her.  "Why don't we take you to the hospital so that the doctor can look you over and make sure it's nothing serious?"

"No, no... I'm fine, I just got worked up because of the fall... I just need to catch my breath," she insists.

"Well, what if we put you on our heart monitor just to be sure, and in the mean time we can give you some oxygen; it might help you catch your breath."  She nods her consent, and I put her on a nasal cannula.  Her SPO2 climbs to 90%, but she is still working hard to pull in each breath.  My partner gets back with the monitor, which I attach to her limbs.  She is in sinus tach at a rate of about 110.  

Rescue 2 calls back in town–the town is covered, so I am in no rush.  I continue to urge her to go to the hospital.  She continues to resist.  As the female EMT with me attaches EKG electrodes across the patient's chest to perform a 12-lead, I call dispatch, letting them know we'll be on scene a little while longer.  Because the patient is using the muscles that weave through the rib cage to breathe, the EKG is all but unreadable, but it may have bought me necessary time– the extra three minutes where the patient may realize they're feeling pretty lousy.  Sure enough, a few seconds after looking at the EKG, I tell the patient she should really get checked out.  I tell her I hear fluid in her lungs.  I tell her I don't want her to wake up at night feeling worse when we might be able to get it taken care of right now.  "I don't think this problem will get any better unless you get treated," I tell her.  And then I catch it.  A sideways, concerned glance.  The rook has knocked over the pawn that was blocking checkmate.  "If I went with you, what hospital would I go to?"  She asks.

"What hospital would you like to go to?"

"Well, I don't know... Could I just go to Miriam, and they would see me?"  I call dispatch to make sure Miriam is open and accepting.  They are.  "Well, I guess I'll just go," she consents.  We take her out on the stair chair, gently.  I don't want to have convinced her that going to the hospital was what she needed only to have her remember a frightful, terrible experience.  

In the ambulance, I switch her to a nonrebreather to see if the extra oxygen will alleviate her shortness of breath.  Her oxygen saturation climbs to 98%, but I can still see her using accessory muscles to breathe.  We give her nitroglycerine to create extra space in the blood vessels for the fluid that has been pushed into the lungs to return to the arteries and veins it came from, but I hold off on Lasix.  She's stable.

We arrive at the ED, and wheel the patient into a room.  We transfer her to the hospital stretcher.  The nurse accepting the report wants to establish the woman's baseline without oxygen therapy, so she removes the oxygen mask.

The pulse ox readout plummets. 

95%

85%

80%

75%

The woman gasps for each breath.  She grips the side rails of the hospital bed forcefully, a frightened look in her eyes.  The nurse has seen enough and puts the non-rebreather back on, but the woman's saturation holds below 80%.  She continues to struggle to breath.  The attending is called over.  Respiratory therapy is STAT paged to the room.  The doctor orders lasix, a foley catheter, a chest x-ray, labs, and CPAP.  "Draw up sux and etomidate for intubation, but we'll see how CPAP does first," he says to a nurse.  One minute after her oxygen therapy was cut off, our patient was in a downward spiral.  "She probably flashed," a nurse I'm friendly with tells me.  

I spent nearly 45 minutes on scene, but each of those 45 minutes counted towards making sure the patient was in the hospital, and not at home, at least 25 minutes from definitive care, when her health worsened.  I'm sorry the patient got sicker, but I can't help but feel like I did my job.  The call feels good for the three of us.

A drowning

The dispatch is to a nursing home for congestive heart failure.  The fact that the staff called 9-1-1 instead of a private ambulance company could suggest that the patient is critically ill... or simply that the private ambulance company they called gave them a wait time for the next available ambulance that was too long.

We roll into the parking lot behind the nursing home.  I pull the stretcher out of the ambulance–one of my partners had already loaded it with the jump bag and monitor– and start into the facility.

As soon as we round the corner onto the patient's hallway I can hear it; the bubbling, gurgling sound of air being forced through water.  Walking into the patient's room, I find an elderly female supported by a police officer and a nursing aid, struggling to breathe despite the oxygen she's receiving through a non-rebreather mask.  I don't need a stethoscope to identify the sounds.  Heart failure has caused a backup of blood in the vessels that travel through the lungs.  The pressure builds until it forces fluid across the gap between the pulmonary vessels and the alveoli, coating the surfaces that allow oxygen to pass into the blood with fluid.  

The patient is pale.  Her chest heaves with each breath.  She can't get any words out in-between breaths.  "She's a DNR," the nurse tells me.  In her mid-nineties, the patient has declined resuscitative efforts in the event of cardiac arrest.  I glance at the patient.  I can see the exhaustion in her eyes, and hear the fluid that fills her lungs.  I can't help but feel a sense of relief upon hearing that the patient has a DNR.  All the drugs in the truck won't bring her back from this.  

We orchestrate a quick initial assessment.  She's a little normotensive for someone in CHF, but there can be no doubt about the diagnosis.  Surprisingly, her oxygen saturation remains in the mid-nineties.  She's winning the fight... for now.  The rhythm strip we print shows a wide complex tachycardia.  "Let's get going," I say to my crew.  We slide the patient onto our stretcher.  As my driver and I buckle the safety belts, the other EMT goes out to the truck to prepare an IV setup to facilitate the rapid administration of the drugs she needs in order to improve her breathing and alleviate the strain on her heart.

"You guys are fast," remarks one of the police officers.  I'm consciously moving quickly.  I know we can't save this woman, but hopefully we can make her more comfortable.  

As we load the patient, I overhear traffic on the police radio: "ANY CAR TO CLEAR FOR A CODE?"  One of the two officers says the two units will clear and respond to the cardiac arrest.  "Good luck," I tell him as he jumps into his cruiser and peels out of the parking lot.

In the truck, we get the patient set up on monitoring equipment.  I wrap a tourniquet around the woman's arm; by protocols we won't be able to administer the medications we need to before having an IV in place.  Feeling around the inside of her elbow, I find a few acceptable candidates for line placement, but I make a classic rookie mistake.  I slide my fingers along a large vein that cuts diagonally across her AC, and while it was the biggest, it was not the best.  When I try to glide the catheter below her skin, I am met with scar tissue that makes advancing the catheter difficult.  Pushing too hard, I shred the vein.  With her other arm, she lifts the oxygen mask off of her face, and gasps two words.  Even without hearing the words, I know what she's said: "I'm dying."  "Keep breathing," I tell her, "you're doing a good job."  I find a better vein and get the IV.  "We're going to give you some medications to make it easier to breathe."  We put a nitro underneath her tongue, and push 120 mgs of Lasix through the IV.  Already on the way to the hospital, I put more electrodes on her chest and print a 12-lead EKG, which reveals a left bundle branch block–a blockage in the electrical pathways that coordinate the heart's beating.  I drop another nitroglycerine tablet underneath her tongue and call the hospital to let them know we're coming before we complete the short 7 mile trip to the emergency department.  While congestive heart failure patients often praise our treatments as making them feel "born again," quickly clearing fluid from their lungs and surfacing them from the depths of hypoxia, this was not to be the case with my elderly patient.  As I suspected, her body had been subjected to too much abuse.  When I ask if she feels any better, she is barely able to shake her head "no."

When we wheel the patient in, we're directed to the back of the ER.  Nobody looks at the woman on our stretcher, although her gurgling breaths reverberate throughout the unit.  We have the patient moved onto the new stretcher before a nurse wanders over.  I give her the story as I help her get the patient hooked up to the room's blood pressure cuff, pulse oximeter, and cardiac monitor.  As soon as I finish listing the treatments we've given, the nurse walks away, leaving me confused.  The patient is in critical condition.  She needs treatment.  Not to save her; she's beyond saving, but to make her comfortable.

I realize that the 24-year old cardiac arrest victim that the police left my scene to respond to is being transported to this hospital.  When a different nurse comes over to get some additional information, I decide to get some information, too.  "How many doctors do you have working right now?"  I ask.  "Just one," she tells me.

"No residents?"

"No, we don't get residents."

"What about a PA or NP?"

"The PA goes home at 3 PM," she tells me with an painful, "what-can-you-do" expression.

"This sucks," I tell her.  "At Rhode Island [hospital], she'd be on CPAP, she'd have gotten more lasix, maybe more nitro, and definitely morphine.  She'd have been seen within 5 minutes of hitting the door.  Now, the doctor will be tied up with the code for at least half an hour before he'll even lay eyes on her."  

"I know," she says, "it sucks."  

They shoot a chest x-ray that the doctor ordered before the code arrived.  I go back into the room to finish writing my report.  The nurses and radiology tech are gone.  The patient pulls the oxygen mask away from her face.  She's tiring, taking increasingly large breaths, and she doesn't want the oxygen.  I think she is going to go apneic while I am right there; she will stop breathing and I'll have to watch as the monitor records her death.  With her other hand, she reaches out to me.  I take her hand.  "Keep breathing," I tell her, "they're going to give you more medicine soon."  I glance at my watch.

I move to her other side so I can sit and write.  I continue to hold her hand.  When I slip away to attach my 12-lead EKG to the run report, she extends her hand towards me again, and again I take her hand.  I finishing signing everything a little before the doctor finally comes in.  He doesn't introduce himself to the patient or even speak to her.  I suspect that he also knew she was dying–and why should he bother attaching himself, even if it means negating the most basic human courtesy?  Half an hour after we arrive, she receives treatment I could have initiated myself in many other states: CPAP and morphine.  The doctor orders 4 mgs.  About 6 too few, I think to myself.  I can tell she doesn't want to fight anymore, but can't suppress the urge to keep on breathing.  As soon as the respiratory therapist straps the CPAP mask on, the patient tears it away.  She vomits, her lungs overflowing with fluid.  I say goodbye to the elderly woman and leave.

I would have preferred to stay.