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.