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.