Freshmen

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

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

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

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

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

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

"Are you having trouble breathing?" I ask.

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

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

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

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

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

Gulp.

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

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

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

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

Totally weak.

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

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

"Uh, yeah."  

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

Bobby has the dispatcher notify the hospital.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Was it a cluster-fuck?  Sort of.

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

Did she survive to hospital discharge?  Yes.  

And that's all that really matters, right?

Let's put this one to rest...

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Confession

Forgive me, EMS Gods, for I have sinned.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Motherhood

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

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

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

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

Futility

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

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

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

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

"Dude–" DH says to me.

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

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

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

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

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

"I know," I tell him, "We're just–"

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

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

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

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

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

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

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

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

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

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

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

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

Pepper Spray

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

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

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

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

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

"Is anyone left inside?" I ask him.

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

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

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

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

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

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

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

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

Aim High

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

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

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

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

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