Frank Blood

Sorry it's been so long since my last post... it's been a very, very busy winter.


Ugly and I respond to one of the local nursing homes for a hemorrhage. Hemorrhage calls are most often for people who think, incorrectly, that they are vomiting blood. This was not to be one of those calls.

We enter the room to find a man, in his 60s, with his wife. His wife smiles when we enter the private nursing home room. It's the pained smile of a spouse who has been at the side of their partner through years of illness; a sign that this is nothing new for her. She quickly rattles off the story, and closes with a summary of his medical history and medications--an oral report fit for med control.

The man suffers from hepatitis, and although he's in his sixties, his 6'4" body is withered, his jaundiced skin stretched tight over frail bones. His wife says his ammonia levels must be elevated; he tried to get out of bed while alone in the room. The staff found him on the floor, on the side of the bed opposite where his foley bag was hanging. I wince a little, and can't help but cross my legs a little bit. After putting him back in bed, the nurses noticed that the bag seemed to have a significant amount of blood in it. They removed the foley catheter, only to find that he was still bleeding from his urethra. Falling away from the foley bag must have tugged on the catheter, lacerating something internally. They put a towel under his diaper, the wife tells me.

I try to talk to the patient, but he's out of it. He can't answer orienting questions well. His eyes appear fixed on a distant object somewhere above the ceiling.

"Is this his baseline mental status?" I ask the wife.
"No, he's usually normal and talkative, like you or me."
I throw Ugly the "package" look, and he goes out to get the stretcher, backboard, collar bag, headblocks and straps. In the meantime, I ask the dispatcher to send an additional EMT to the scene. The patient's unwitnessed fall with altered mental status, complex medical history, and question of internal bleeding will certainly merit evaluation in a critical care room when we get to the hospital, and without another EMT, I can't perform advanced life support. Also, although he's emaciated, the patient is tall, making boarding him with two people difficult. I put the man on oxygen, take a set of vital signs, and apply a collar before my "backup" arrives. L1, a lieutenant, and the person who taught me most of what I know about taking care of people, helps us get the patient on the board and out to the truck. I give her the story as we work.

The more astute medically trained readers will have noticed that I haven't yet inspected the bleeding site.

"We should probably look at the bleeding, huh?" I ask her.
"Oh, I assumed you already had," she replies.  Duh.

As I lift the diaper and towel, I'm momentarily confused by the image in front of me. Glancing down, I see what appears to be a bright red stick extending from the patient's penis. It takes me several seconds to realize that the "stick" is actually a stream of blood, continually flowing, at a rate similar to urine's typical exit from the body. I look up at L1; "This changes things."

I tell Ugly not to waste any time, and he pulls out of the nursing home. L1 spikes a bag of saline while I wrap a tourniquet around the man's right bicep. After a moment, I run my gloved fingers up and down the inside of the man's elbow, pausing to gently press against the areas where I know there should be veins. Areas where there should be accessible veins, but there aren't. Visible scars on the surface belie the mess of scar tissue I can feel below the skin. I flip over the man's arm, looking for veins in the hand. A network of tiny, wiry veins are the only thing I find.  "I'll try, but it doesn't look promising, why don't you look on that arm?"

We go to work.  I think I feel something in the AC, and gently glide an 18 gauge catheter underneath the skin.  Nothing.  No satisfying "pop" of the needle invading a vein wall, no flash of crimson blood in the chamber.  I weave the needle in and out, angling its razor edge, hoping that it will find its target.  I pause for a moment and use the two fingers of my left hand to relocate the vein I had been aiming for, but the soft spongy spot I had felt before is nowhere to be found.  L1 meets similar frustration in the other arm.  I angle the needle slightly deeper and advance it one last time before giving up.  I shake my head, and secure the needle inside the plastic safety.  Click.  I cover the site.  "Nothing over here."  Click.  "Here, either."

I take a minute to recheck vital signs and mental status.  The blood pressure is holding, and he remains responsive despite being disoriented.

Back to the arm.

I try a new trick MTM told me about, and wrap a second tourniquet above the first.  L1 toils over the other arm.  Now I can't find anything.  I feel the soft spot just below and outside of the end of the biceps where I know there should be a vein.  I clean it with an alcohol wipe, and push another 18 gauge catheter through thick off-white scar tissue.  Nothing.  I pull the catheter back and change the angle, aiming deeper and towards the outside of the elbow, and push forward.  I suddenly feel slightly less resistance, and see a small amount of blood in the catheter's flash chamber.  I advance the needle a few more millimeters.  My index finger pushes gently on the catheter hub, trying to coax the plastic straw over the needle and into the vein.  It won't budge.  I push slightly harder, and something gives–in a bad way.  I know it won't be a good line.  Click.  I pull the needle, and leave the catheter and hub in place just to be sure.  There is no trickle of blood out of the IV.  I pull the catheter and cover the site.  Click.  L1 drops another spent catheter into the sharps box, shaking her head.

We're only a few minutes away from the hospital now.  I call in and give a quick history while L1 gets another set of vitals.  We make one last attempt at an IV, finding frustration, but no veins.  

At ambulance triage, I recount the story to the triage nurse.  I tell her that there is or was a stream of blood coming from his penis.

"Frank blood?" she asks me.

Hundreds of jokes about her choice of words run through my head.  Defeated by impossible veins, however, all I can say is "yes."

The patient is moved to a trauma room.  I don't know what his hospital course involved, but I know he survived to be transported by MTM from the same nursing home the next month.

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.