Archive for the ‘Medical’ Category

Aug
0

System Status

System Status

sys·tem

1 – a condition of harmonious, orderly interaction

2 – a group of interacting, interrelated, or interdependent elements forming a complex whole

3 – a set of principles or procedures according to which something is done; an organized scheme or method

 

stat·us

1 – a social or professional position, condition, or standing to which varying degrees of responsibility, privilege, and esteem are attached

2 – a state of affairs or a change in social standing

Beep, beep, beep. “Medic-20 copy Code-3. Respond Code-3 to 123 Main Street for the three year old unconscious.” The dispatcher’s voice comes across the radio interrupting me as I am filling out my status report. I glance at the computer to see where the address is in comparison to where Medic-20 is posting. Medic-20 is about a mile from the call location and I’m another mile further than they are from the call. I put the SUV in drive and start heading that direction. There is a certain advantage to having the entire system status on my computer in the supervisor’s rig.

There’s a sixth sense to interpreting the description that the dispatcher gives to a call and actually knowing what is going on before arriving on scene. The wording in this call and the location put the little hairs on the back of my neck on end and I feel it’s something that I should get involved in today. For one thing, a three year old doesn’t know how to fake going unresponsive. We see it every day with adults who just plain decide to shut down and let EMS pick up the pieces. But a three year old isn’t quite that devious. Besides that, the address is an indoor swimming pool and water park and there is nothing good about a kid who’s unconscious near water.

I’m catching too many red lights as I head in the direction of the call so I remedy the situation. “Dispatch, S-4, can you attach me to Medic-20’s call and show me en-route?” The dispatcher comes back at me in a monotone response, “S-4 copy, showing you en-route.” The computer on my console starts making tones and a green line is routing me to the location where I’ve already started driving. Now that I have clearance to run hot to the call I can turn on the lights and siren and make better time. I take my little SUV through the red lights without a partner to help clear intersections. It’s still a bit unnerving to drive Code-3 without someone to help navigate, but it’s necessary. The traffic backs up in front of me and I switch tones in the siren to activate the rumbler; a low harmonic pulse that literally rattles the inside of the vehicles in front of me until they pull to the right. Unbelievably traffic clears, allowing me to make good time to the call. As I’m pulling into the parking lot I see my crew walking through the doors at the main entrance with a gurney and the fire engine is already sitting in front of their rig. I park my little SUV behind all of the big boy toys and casually stroll into the building without any equipment and not wearing my gloves.

It’s a strange experience to enter the scene of an emergency without equipment or protection, but the fact is that I’m not here to work on a patient or bring tools to the scene. There are two Paramedics ahead of me and the entire complement of advanced life support equipment has been carried in by others. My job is to support the team and ensure that patient care is seamless in regards to agencies and environment.

I walk solo through the water park and just keep the others in sight as I follow in silence. Screaming kids and teens are playing in the water and on the slides, lifeguards are watching from elevated chairs, chlorinated water splashes my boots. Finally I catch up to the crew in the lifeguard office where the child is sitting in a chair.

I know the paramedic from my service who is Medic-20 today. She was a new Level-1 Paramedic that was assigned to mentor under one of my old partners last year. My old partner was assigned to mentor under me a number of years ago so it seems the cycle continues. My teachings have passed to my partner who passed them to this wide eyed young Paramedic standing in front of me who is now on her own and making her own calls. She takes the report from the fire medic as I listen over her shoulder.

“So, apparently the little girl was pulled out of the water without a pulse and not breathing. They did CPR on her and then someone brought her here when she started breathing and they called us. She’s doesn’t speak English, her parent’s aren’t here, and all we have is a neighbor who is basically no help at all. Right now she’s just lethargic but she’s alert, at least, as much as I can tell she’s alert, but she’s really not talking much at all.”

I’ve been looking at the little girl while listening to the report. It seems to fit her presentation. With all of the strangers poking her and taking vitals right now I would expect her to be a little more agitated. Yet she’s looking like she just woke up from a nap. I slip an ungloved finger up to her eye and touch her dark skin while pulling her lower eyelid down a bit; bright white. Okay, good enough for me, she had a hypoxic event and she’s recovering. The mucus membranes of the eye shouldn’t be that white yet if they are the person is either very dehydrated or recently had a hypoxic event; that seems to fit the story. As the EMT from Medic-20 and the firefighters are transferring the patient to the gurney I catch the eye of the Paramedic. She looks over with big round eyes and a bit of a question.

I quietly lean into her ear. “You have to treat it like a near drowning with return of spontaneous circulation. Your only question is do you want to drive close or far away and how fast to drive.” With kids you don’t take chances. Presumably the life guards have their CPR cards and should know what to look for in terms of breathing and pulse. If the kid truly had neither and now she does she needs a full work up and some chest x-rays looking for water in the lungs and ensuring that the CPR didn’t displace any ribs. The driving close or far away only refers to which hospital to go to. The kids’ specialty hospital is 45 minutes away in rush hour traffic. The local hospital is just seven minutes away.

She looks undecided for just a few seconds and then comes to a decision. “I want to drive close and I’ll start off Code-2 and upgrade if I need to.” It’s half a statement and half a question as she looks to me for approval in her decision.

“Sounds good to me. I’ll run interference with the neighbor so you can get out of here.” I would have said any decision sounds good right now. The patient is doing fine and she, as a new medic, just needs the exercise in making a decision and sticking to it. But in this case she made the same decision that I would have made – I guess my old partner taught her well.

As the Medic-20 crew starts to push the gurney with the patient towards the front of the building I step in front of the neighbor and start asking her questions. She’s a heavy set woman in her late forties who walks with a walker and moves slowly like she’s in constant pain. As I question her she’s distracted as she looks over my shoulder at the patient disappearing in the crowd as they head towards the rig. I know the Medic-20 crew just wants to transport as soon as possible. All medics are the same when it comes to kids in this situation. If the kid is fine they just want to get them to the hospital and out of their charge before something changes for the worse. Had I let the neighbor follow she would have delayed them another ten minutes on scene with her slow moving and a long production of climbing into the truck. Not to mention the liability of helping her climb out of the truck on the other end and the overall delay in getting the kid to a doctor is unacceptable in this situation.

Having intercepted the neighbor long enough to give Medic-20 a clean getaway I walk over to the head lifeguard and ask to talk to the lifeguard who pulled the girl out of the water. I want to get a better understanding of how things happened. She’s a very emotional fifteen year old girl. She can barely catch her breath from the sobs and stuttered gasps for air as she attempts a retelling to me. After three or four minutes and a few stops for tears I finally have a story that makes sense and I feel I can leave.

Pulling out of the parking lot I glance down at my computer on the console. Medic-20 is about half way to the hospital and they are still driving Code-2. So the kid is probably doing fine. I punch the Medic-20 identifier into my cell phone and get the driver.

“Hey, so I finally got a good story and some contact info for the family. The little girl was on a water slide between two bigger kids. They went down the slide and the two big kids came up but the girl didn’t. She was under water for approximately twenty seconds when a nurse pulled her out, found her to be pulseless and apneic, and started doing CPR on her at poolside. After 30 seconds of CPR she started breathing again and was taken to the lifeguard room. All I have is a first name for the kid and the parent’s first name and phone number – the neighbor really didn’t know much. I called the father who speaks enough English to understand what’s going on and he said he’s on the way to the hospital.” She thanks me and hangs up. No doubt she is now relaying the information over her shoulder to the medic in the back of the rig so she can tell a better story to the doctor when she does a hand off.

I take a slow drive to the hospital and once I arrive I see Medic-20’s rear doors open and the patient compartment trashed with all sorts of bins and wrappers strewn around with a disheveled monitor propped in the corner with all of its wires hanging out. I spend ten minutes wiping down the interior and putting everything back into place. I then walk over to my little SUV and pop the cooler open to pull out two ice cold gatorades and prop them in the front cab so the crew will find them once they get out of the hospital.

I drive off before they can get out of the ED so they don’t think I’m interfering in their day too much. It’s a fine line to be involved in the call and supportive of my crews yet still allow them to function as the independent Paramedics and EMTs that we value in this service. I try to tread lightly and reward often. If I do my job right they may even forget that I was on the call yet they will remember that everything ran smoothly. I find a quiet corner of the parking lot in some shade and go back to updating my status report.

 

 

Apr
1

Stagnation

Stagnation

stag·na·tion

1 - the condition of being stagnant; cessation of flowing or circulation, as of a fluid; the state of being motionless; as, the stagnation of the blood; the stagnation of water or air; the stagnation of vapors

2 – in acupuncture: a pattern of excess that occurs when the smooth flow of Qi is stuck in an organ or meridian – the primary symptoms are pain, soreness, or distention, which characteristically change in severity and location

3 – in western medicine: the retardation or cessation of the flow of blood in the blood vessels, as in passive congestion or occlusion

“My mind rebels at stagnation. Give me problems, give me work, give me the most abstruse cryptogram, or the most intricate analysis, and I am in my own proper atmosphere. I can dispense then with artificial stimulants. But I abhor the dull routine of existence. I crave for mental exaltation.”

Sir Arthur Conan Doyle – Sherlock Holmes

Officer Leung arrives at the Chinatown police sub station early every morning. He has a personal sense of ownership in that he opened up the station sixteen years ago and he’s been walking the streets of Chinatown ever since. After checking last night’s crime reports he sets out on his morning rounds of getting out to interact with the community. He’s a familiar face to the locals and he can’t walk more than ten yards at a time without saying hello to someone. Being a native Cantonese speaker he easily communicates with the locals and they feel the ability to approach him with everything from neighborhood concerns to telling him about the birth of a son.

It’s an experiment in community policing that started decades ago and is only now beginning to take hold and show results. Many people living in ethnic enclaves of our mostly urban city seldom venture outside of their comfort zone. They may have a mistrust of police and authorities and an inability to easily communicate in English. Because of this they are many times the victims of crimes that go unreported. The community policing model is an attempt to put a familiar face on the authorities and give the people in these areas the ability to thrive in a safe environment. Officer Leung is that face in this community and he loves his job – he feels he gives back to his community every day.

Chinatown is in the midst of its morning wake-up routine: produce trucks double parked and offloading fresh goods, vendors stacking baskets of fruits and vegetables partially in the sidewalk, succulent looking roasted duck and pork hanging in windows. Quickly following the produce trucks are the professional recyclers – men in small pick-up trucks, stacked high with cardboard, providing a service to the vendors and a small income for their family.

Jin has been doing this for years and he knows all of the vendors on his street. As he methodically breaks down the cardboard boxes and stacks them in the back of his truck his shoulder continues to hurt from the strain and the cold morning. He’s thankful he wore extra layers of clothing as it’s a cold day but he seems to be working up a sweat faster than usual today. as each layer of cardboard gets added to the pile in the truck the strain on his shoulder increases. Finally he drops to one knee, holding on to the side of the truck, and grimacing in pain as he sees Officer Leung stop next to him.

I really don’t like running Code-3 through Chinatown. The public cliché about Paramedics and EMTs is that they are adrenaline junkies who love to drive fast and live for the blood and guts of a gory scene. In truth, just about every co-worker I know is really happy when a call gets downgraded to Code-2 and we get to shut down the lights and drive slower. We get far more satisfaction from a complex medical call than a bloody trauma.

But running Code-3 in Chinatown is its own special kind of hectic. Putting aside the normal stereotype about Asian drivers, the real problem is the one way streets with delivery trucks double parked on either side and the intersections where pedestrians can cross in all directions at the same time. It’s a very confusing place to drive – much less Code-3. Fortunately, my partner is handling it pretty well and I just have to help keep an eye out for the random jaywalker.

When we pull up to the scene I open the door and I’m hit with the smell of Chinatown. It’s not unpleasant yet it is unique in the city. The fresh pastries from the Chinese bakery have a sweet smell that blends well with the roasted meat from the next storefront. Layered on top of the food smells is pungent odor of Chinese medicinal herbs that waft from the herbalist’s store. All of this mixes in with the closest and least appealing smell: burning brakes from our rig.

I walk over to the officer and the man sitting on the curb. “Hi Officer Leung, what’s going on today?” Over the years I’ve seen Officer Leung walking the Chinatown beat. He’s a refreshing fixture of the Chinatown landscape.

“Not really sure. Jin collapsed while stacking his truck. He said his shoulder hurts and he saw a doctor for it yesterday but it’s worse today. He only speaks Cantonese but I can translate for you.”

“Okay, how about we move into the rig so I can check him out. Ask him to have a seat on the gurney. Thanks.” The rig has plenty of room and Officer Leung is able to sit at the foot of the gurney without getting in the way. He’s easily able to translate all of my questions pertaining to the onset of symptoms as I try to figure out what’s going on and my partner sets up the monitor to take vitals for me.

Jin has the skin signs that scream MI: pale/cool/diaphoretic, wincing in pain, holding his left shoulder, respirations coming in small gasps. My priority is to set up the 12-lead and have a really good look at the heart. Yet as I open his shirt I’m surprised to see evidence of trauma – he has bruises all over his chest. I’m a little confused as this was presenting like the perfect MI; I remove his shirt so I can fully appreciate the bruises.

As I step back to get the overview of his condition it all comes into focus. He looks as though he was just attacked by a giant squid. He has maybe a dozen circular bruises on the front and back of his left shoulder – they look like giant hickies. Turning to Officer Leung, “Can you ask him to clarify, did he see a doctor yesterday or an acupuncturist?”

After a quick exchange of Cantonese I can rule out the giant squid theory and replace it with the likelihood that he is the recent recipient of fire cupping. It’s an acupuncture technique where a piece of flash paper is lit inside of a bulbous cup which is quickly placed on the skin. The fire sucks the oxygen out of the interior of the cup which then pulls the skin into the cup as it creates suction. The result is a number of circular bruises on the skin that look like a giant squid attack. The theory is based on the principlel that stimulating areas along a meridian will release the stagnation of energy and restore normal circulation. It’s a treatment that’s been around for millennia yet as I look at the results of the 12-lead ECG printing out of the monitor I can see it’s not the treatment he needs right now: ***ACUTE MI SUSPECTED***

 

 

Mar
0

Backdraft Postscript

Backdraft Postscript

post·script

1 - a paragraph added to a letter after it is concluded and signed by the writer; or any addition made to a book or composition after it had been supposed to be finished, containing something omitted, or something new occurring to the writer

As it turned out, Missy was a WUS. That’s not a disparaging comment about her intestinal fortitude – it’s a classification of stroke known as a “Wake Up Stroke.” According to a recent article in the American Heart Association / American Stroke Association entitled Thrombolytic Therapy for Patients Who Wake-Up With Stroke, approximately 25% of all strokes are WUS. Given that people may sleep 25%-30% of their life it can only be expected that a stroke will happen during that time in a proportionate number. EMS currently deals with a short (4-hour) window of time to rush a patient to a stroke center for thrombolytic therapy – if a stroke has a known onset of four hours or less, the patient is eligible for thrombolytic therapy. Outside of that window it is considered a “cold stroke” and thus ineligible. If the onset time of the stroke cannot be verified, such as in the case of a WUS, the patient is automatically ineligible for thrombolytic therapy. This latest article, however, states that the therapy may be safe in longer periods of time from onset of symptoms. Further studies are being conducted to explore the possibility of an extended time period for this treatment.

I recently attended a lecture series by a panel of neurologists on strokes and the latest trends in therapy. During the session the extension to the thrombolytic window was explained in greater detail. To paraphrase four hours of lecture, in the event of an ischemic stroke there is a proportion between necrotic (dead) brain tissue and the surrounding ischemic (under-perfused) brain tissue which can be visualized with a Functional MRI. With a proportion of 80/20 thrombolytic treatment would have very little effect. With a proportion of 25/75 thrombolytic treatment may have a greater effect and the potential benefits of extending the window would then outweigh the possible risks. The ramifications of this line of research is that every patient has their own personal window of opportunity for thrombolytic therapy which can only be viewed once that patient reaches a stroke center. This same research is showing that an extension of the window to as long as sixteen hours may be safe in some situations.

In the case of Missy I took her into the hospital running Code-3 because of the smoke inhalation and potential for an airway that may be in the process of closing. Yet I transported her to a stroke center, bypassing a regular ED with no specialties, to ensure that neurologists would be on hand to quickly evaluate her recent stroke symptoms. Unfortunately the extension to the thrombolytic window is still in the research phase and has not progressed to cover the WUS scenario at the local hospitals. The deficits from Missy’s stroke did not immediately resolve and she was not a candidate for thrombolytic therapy. She will undergo extensive physical therapy in an attempt to regain some of her left-side functionality.

Meanwhile, Stacy, the fire medic/RN who got caught up in the excitement of the fire to the point that she missed an obvious stroke in her patient, has since been promoted to Lieutenant…

 

 

Mar
0

Backdraft

Backdraft

back·draft

1 – a reverse movement of air, gas, or liquid

2 – an explosion that occurs when air reaches a fire that has used up all the available oxygen, often occurring when a door is opened to the room containing the fire

Missy woke up a little early and from the start she knew something was wrong. She just didn’t feel right and the world seemed just a little more confusing than usual. She tries to get up out of the bed but the weakness is just a little more pronounced than usual and she never makes it all the way out of bed. Thinking maybe it would help to bring the world into perspective Missy reaches for a morning cigarette with her left hand, but finding she can’t quite make that work she finally reaches across her body with her right arm, grabs the cigarette, puts it between her lips, and lights it while laying in bed. With the smoke inhaled deep into her lungs she starts to relax again and nod off.

There’s shouting from outside the house – someone is yelling at her. She opens her eyes and sees the flames overhead – gently rolling across the ceiling with the smoke starting to burn her lungs on every breath. She tries to get up but again the weakness is stopping her from getting out of bed. Suddenly there is light in her bedroom, as the door opens, this is quickly followed by intense heat as the flames erupt as if seeking the oxygen from the open door. Strong arms grab Missy and start to drag her out of the house. Once on the front lawn she can see the flames well above the roof as firefighters are breaking windows and drenching her house with water.

As we roll into the neighborhood my partner and I stop following street signs and just follow the smoke to the location of the medical call. We have to park a block away as the small residential street is full of fire apparatus and supply lines. We roll the gurney closer to the house, avoiding the standing water and six inch fire hoses that snake across the road. Sitting in front of a burned-out house is my patient, leaning forward in a tripod position, sucking hard on an oxygen mask, with both arms being held out to either side.

Stacy, the fire medic, is supervising two Explorers who are simultaneously taking blood pressures, one on each arm. Our county has a Fire Explorers program for youth who someday want to be firefighters – it gives them the opportunity to volunteer with a local fire unit and learn the basics of the job. Both of the Explorers seem distracted by the commotion of the fire; they glance repeatedly from the blood pressure dial to the flames. It’s obvious they would rather be squirting water than taking care of this woman.

Finally, Tracy has had enough and asks each of them for their findings – she knows I’m not going to hang out here all day waiting for kids to check a vital sign that I’m going to recheck regardless of their findings. The kid on the left gives us a report of 90 over 60, the kid on the right tells us it’s 180 over 110. I have a dead pan stare on my face as I wait for Stacy to give me a report.

Stacy is writing the two sets of blood pressures on the patient care form and handing it to me. “Yeah, I know, you’ll have to check the BP again. Basically she was smoking a cigarette in bed and fell asleep. The blinds caught fire and the whole house went up. She got caught in a backdraft when they went in to get her. She had moderate smoke inhalation without any visible burns. That’s about it. Are you good?” Am I good? Hell no I’m not good. But I’m absolutely ready to leave.

Having moved Missy onto the gurney we start the long trek back to the ambulance. We have to double back a few times because of standing water creating small lakes in the street and fire hoses blocking our way. Throughout the ordeal I’m grumbling to myself about the poor treatment of Missy. Yeah, great, they got her out of the fire, but her treatment stopped there. Stacy knows better, she’s also an RN at a local Emergency Department, yet she released her helpers to let them fight the beast while the Explorers tried in vain to take vital signs. She didn’t have a history and knows almost nothing about this patient except she was in a fire.

Once we’re back in the rig I can start over and give Missy a proper check-out prior to going to the ED. Looking her over I can’t see any obvious burns but I’m more concerned with her breathing and airway at the moment. I slip the oxygen mask off and shine a flashlight in her mouth and nose and find singed nose hairs with soot extending the visible length of the nares – not good. Soot in the mouth and on the lips – not good. Oxygen saturation of 86% on room air – not good. Wheezing in the apex of each lung with a stridorous noise starting to come from the throat – really, really not good!

As my partner prepares the Albuterol and Atrovent nebulizer to affix to the mask I put an end tidal carbon dioxide nasal cannula on her nose so I can keep a good record of her respiration trends and quality of breathing, but looking at her face something just isn’t right.

“Missy, we’re going to give you a breathing treatment to help you breathe a little better but I have to ask about your medical problems. First off, have you ever had a stroke?” I’m seeing the telltale facial droop on the left side with an eyelid that looks like it’s being pulled down in the corner.

“Yeah, I had me a mini-stroke a while ago. They said it’s because of the A-fibs. But I all better now.” Now that I hear her speak I can tell there’s a bit of a slur to her speech.

“So you’re saying you didn’t have any lasting deficits from the stroke; like facial droop or weakness on one side?” My partner just finished setting up the nebulizer but I need to finish this line of questioning before putting it on and obscuring her face with a mask. He moves up to the front and starts getting us out of the neighborhood; I haven’t given him a destination yet – we both know that destination will be critical with this woman – yet we need to get moving.

“You know, now that you say it, it feel kinda like that mini stroke right now. I could’t get out of bed and my arm jus’ seem like it don’t want to move like it should.” That’s enough for me. I run Missy through a series of stroke tests; facial droop, slurred speech, left side weakness, change in sensory appreciation from left to right side and minor cognitive disassociations (how many wheels on a tricycle, what color is an orange, that kind of thing).

I glance out the front window as I place the mask over Missy’s head and see that we’re just exiting the neighborhood. Rechecking her blood pressure I discover that the Explorer on the left was closest – she’s 84 over 48. I start to set up the Sodium Thiosulfate drip for the IV.  “Okay, you ready for this?” I yell up to my partner.

“Yeah, go ahead, where we headed?” He yells over his shoulder as he lights up, turns on the siren, and heads for the freeway.

“Well, you already guessed we’re going Code-3. We’re going to Hilltop ED; 44 year old female, moderate smoke inhalation, hypotensive, tachycardia, tachypnea, Albuterol/Atrovent/Sodium Thiosulfate running. She’s also got a cold stroke, unknown onset time, left side weakness, with a history of.”

“Seriously?”

“Yeah, seriously, that’s what started the fire.”

 

 

Mar
4

Dead Space Postscript

Dead Space Postscript

post·script

1 - an extra piece of information about an event that is added after it has happened

The patient in question did in fact have a massive pulmonary embolus known as a Saddle PE. Because the embolus lodged in the pulmonary artery at the bifurcation between the left and right branch, much of his lung capacity was not actively engaging in gas exchange. He was not able to offload the EtCO2 or fully oxygenate the blood. His altered state was actually a hypoxic event even though his lungs were clear and had perfect tidal volume. The EtCO2 reading was the only finding, other than skin signs and oxygen hunger, that pointed me in the right direction.

Upon turning him over to the MD at the ED I concluded my report with my findings and a differential diagnosis of PE. This bought me a raised eyebrow from the MD as a PE is a very difficult thing to diagnose without the help of a CT. That same MD seemed a little more on board with my findings when the patient flat lined ten minutes later and subsequently three more times before they pushed thrombolytics to dissolve the clot.

Later that night he was moved to the ICU and extubated the next day. He recovered with no lasting deficits yet he remained in the hospital for two more weeks as they continued to administer blood thinners and observe for any reoccurring emboli.

The bifurcation of the cherry tree is a beautiful analog for the inner vasculature of the lungs. Nutrients are carried along the trunk to the blossoms where gas exchange occurs and photosynthesis creates energy that is then carried back along the trunk. When a branch is injured the blossoms die and create a dead space. The cherry tree has the advantage of many bifurcated branches to continue the cycle – we only have one.

Dead Space

A decrease in perfusion relative to ventilation (as occurs in pulmonary embolism, for example) is an example of increased dead space.[3] Dead space is a space at which gas exchange does not take place, such as the trachea. It is ventilation without perfusion.

Saddle Pulmonary Embolus

A large thrombus lodged at an arterial bifurcation, where blood flows from a large-bore vessel to a smaller one. The ‘classic’ saddle embolus—which occurs at the bifurcation of the pulmonary arteries in fatal pulmonary embolism secondary to a centrally migrating venous embolus—is distinctly uncommon.

Segen’s Medical Dictionary. © 2011

Massive pulmonary embolism

As a cause of sudden death, massive pulmonary embolism is second only to sudden cardiac death. Massive pulmonary embolism is defined as presenting with a systolic arterial pressure less than 90 mm Hg. The mortality for patients with massive pulmonary embolism is between 30% and 60%, depending on the study cited. Autopsy studies of patients who died unexpectedly in a hospital setting have shown approximately 80% of these patients died from massive pulmonary embolism.

The majority of deaths from massive pulmonary embolism occur in the first 1-2 hours of care, so it is important for the initial treating physician to have a systemized, aggressive evaluation and treatment plan for patients presenting with pulmonary embolism.

 

 

Mar
0

Dead Space

Dead Space

dead

1 – having lost life, no longer alive

2 – having the physical appearance of death; a dead pallor

3 – not circulating or running; stagnant: dead water; dead air

 

space

1 – the infinite extension of the three-dimensional region in which all matter exists

2 – an empty area which is available to be used

dead space – a calculated expression of the anatomical dead space plus whatever degree of overventilation or underperfusion is present; it is alleged to reflect the relationship of ventilation to pulmonary capillary perfusion

Walking back into the ED room to get a signature from the nurse I’m momentarily surprised at the level of commotion surrounding the man that was my patient just a few minutes ago. I look up to the overhead monitor that displays his vitals and see the obvious cause for excitement – asystole, the most stable heart rhythm in the world, is marching across the screen and slowly erasing the beautiful complexes of normal heart beats as it fills the screen with the flat line of death. The Paramedic Intern pulls a short step stool out from the corner just as the attending MD makes the call for him to begin CPR. Well, I guess my differential diagnosis was correct, small comfort considering he’s dead now.

There’s a question in paramedicine that is useful to the Paramedic in deciding a course of action on any given call – is this person big sick or little sick? The speed at which we can determine the acuity level of any given patient helps us in determining how fast we move through the call. On occasion the first look at a patient can tell you everything you need to know in terms of acuity. As I walked into the bedroom I could see that this is one of those times. My new patient looked up at me from the bed and it’s obvious that this is big sick and I’ll be moving fast today.

The firefighters arrived just a few seconds before us so they’re still attaching the monitor  leads and trying to get a blood pressure. I know what they’ll find based on the patient’s skin signs alone. The term – pale/cool/diaphoretic – gets overused in our business but it still surprises me when I see these skin signs manifest on a patient. A man of his ethnic background would be hard pressed to look pale so the fact that he looks ashen tells me all I need to know. My first thoughts on a call like this are about extrication. I want to get this guy out of here, into my ambulance, and start driving. Everything else can be figured out on the way to the hospital but the main priority is getting him from the bedroom to the ambulance. The problem is that he’s over two hundred pounds and there are three flights of stairs between me and my ambulance.

I send my partner back to the rig for a stair chair as I start to take in the vital signs and patient history to see if I can paint a picture of the last few hours that led to this big sick presentation. It seems that he and his wife were out running some errands and he started feeling sick about an hour ago. He vomited once and now he’s presenting with an altered mental status, very low blood pressure (72/48), fast heart rate (118 bpm), clear lung sounds, and skin signs that are screaming “heart attack” at me. Of course that was until I ran the 12-lead for the second and third time. The results keep showing nothing even remotely concerning in the cardiac department. In his altered state the only intelligible uttering I can make out from him is, “I…can’t…breathe…”

I put a non-rebreather oxygen mask on him and start the trek of three flights of stairs to the ground floor and the relative comfort of my ambulance where I can start to figure this thing out. The new stair chairs with the revolving treads make quick work of the stairs while preserving our backs in the process. It seems we’re on the ground floor in just a minute or two and headed towards the ambulance.

Finally inside the ambulance, I have decent light and all of my tools at hand so I can try to analyze his condition while driving to the closest hospital. I’ve already ruled out the possibility of a STEMI (S-T elevation myocardial infarction – a.k.a. heart attack), which would require a cath-lab, so I am free to head to the nearest hospital. As I check his 12-lead a fourth time – on the right side this time, still looking for the elusive STEMI – the firefighters decide it’s a good opportunity to leave. Figures. Looks like I’m on my own on this one.

With lights flashing and the siren singing a duet with the air horn I bounce down the road while starting two IVs in my quickly fading patient. Once that’s done I set up two bags of warm saline flowing wide open to drop as much fluid on him as possible and try to keep that blood pressure out of the double digits.

I slip the non-rebreather off of his face and put on a nasal cannula that has a receptacle for reading the exhaled breath and measuring the end tidal carbon dioxide (EtCO2). I actually do a double take as the reading comes back as 8 when the normal reading should be between 35 and 45. Hell, I’ve stopped CPR and pronounced people dead with higher EtCO2 readings!

A number this low just doesn’t make sense. I listen to lung sounds again and they are still coming up clear. I check his blood sugar to rule out a DKA (diabetic ketoacidosis)  presentation and it comes up perfect. Sepsis could possibly take the reading this low and explain the presentation but not with an onset of just one hour. There’s only one other differential diagnosis that is making sense to me right now and when that flashes into my head I’m more relieved than I can admit to see the bright lights of the ED out of the back window as my partner backs us into a spot by the double doors and I prepare to give my findings to  the doctors on the other side.

In these days when science is clearly in the saddle and when our knowledge of disease is advancing at a breathless pace, we are apt to forget that not all can ride and that he also serves who waits and who applies what the horseman discovers. 

Dr. Harvey Cushing

 

Oct
0

Impalpable 1/2

Impalpable 1/2

im·pal·pa·ble

1  :  incapable of being felt by touch

2  :  not readily discerned by the mind

3  :  the quality of not being physical; not consisting of matter

I have wrestled with death. It is the most unexciting contest you can imagine. It takes place in an impalpable grayness, with nothing underfoot, with nothing around, without spectators, without clamor, without glory, without the great desire of victory, without the great fear of defeat.

Joseph Conrad

The morning sun illuminates the interior of the church in a kaleidoscope of color from the stained glass windows. I slowly walk up the center aisle towards the coffin that is on display at the front of the sanctuary, with a backdrop of systematically aligned vertical pipes from the organ. A nine foot crucifixion is mounted to the wall and the eyes from the depiction of Jesus seem to follow me as I make my way up the aisle. The candles along the wall are giving off the slight smell of burning wax that mixes with the occasional whiff of recently burned incense. After what feels like a very long and somber processional, I finally reach the front of the church and kneel – as if accepting communion – and place my stethoscope in my ears.

“Hold CPR.” A firefighter rocks back on his heels with sweat dripping from his brow as I feel the neck for a pulse and listen to the chest for respirations and heart tones on the pale, lifeless, body laying in front of me. No heart tones and I can’t feel a pulse, yet I catch the occasional autonomic gasp for air as the body attempts to breathe even when all of the control centers of the brain have been turned off by death. I look at the monitor and see the organized complexes of pulseless electrical activity (PEA) march across the screen, each having failed to stimulate the heart to form a contraction. “Continue CPR.”

The flash chamber of the IV fills with blood as the needle finds a vein and saline is pushed into the body by a pressure bag which is pumped up on the IV bag to force the saline into the vein faster. The standard medications are pushed into the IV tubing at regular intervals in accordance with our county’s protocols, as a CPR machine replaces the tired firefighter and applies perfect compressions at the push of a button. The floor of the church is littered with the remnants of our resuscitation effort: the purple and gray medication boxes, various wrappers, etc.

A man in a white shirt and gray hair is leaning into our little clearing here in the middle of the church and trying to get close to the patien’s head. With tears streaming down his face and a cracked voice of anguish he’s pleading with my new patient not to die. “Mom, you’ve got to come back to us. You can do this. It’s not time yet. Please mom, come back…” I take the IV bag from the firefighter and hand it to the man in the white shirt.

“Sir, can you hold this for me? Hold it up high and make sure it keeps flowing. Thanks.” He continues to plead with his mother not to die but at least he’s standing up and out of my way as I prep my intubation equipment. I tend to think that CPR and drugs have a better chance of bringing her back – more so than pleading – but it seems to make him feel better to be doing something so I’m okay with getting him involved by giving him a job. This is obviously one of the worst days of his life and he’s going to remember it vividly for as long as he lives. He came here to say goodbye to a loved one and watched his mother clutch her chest and fall to the ground not ten feet from the casket of another family member.

Kneeling in the aisle of the church, under the watchful gaze of Jesus, I bow my head – as if in prayer – and insert the laryngoscope into a lifeless mouth. The autonomic reflexes of the body are still attempting agonal respirations as I expose the vocal cords and pick my landmarks to sink the tube into the trachea. Like a surfer sitting in the line-up waiting for the perfect wave, I watch the vocal cords come into view every eight seconds or so. On the next rhythmic exposure I sink the tube home and inflate the cuff while securing it to my new patient. The firefighters begin strapping my patient to a back board to facilitate transport to the ED.

At the next break in CPR I’m feeling for a pulse and watching the monitor as the rhythm changes to the erratic zigzag of ventricular fibrillation. The drugs and perfect mechanical CPR have created an electrical change in the heart – or possibly she’s deteriorating as the heart can no longer create an organized complex. Either way this code just turned into a mega-code and we’re going to chase the rhythm with electricity and different drugs in the hopes of restoring a perfusing heart beat.

I push the charge button on the monitor and the high-pitched whining sound increases in volume until the modulating alarm tells me that it’s ready to deliver a shock.

“Clear.” The simple word is repeated by the others as they move slightly away from my patient. The son is a little confused as he stands holding the IV bag next to me. I reach up and take the bag from his hands and set it on the ground. In the background the monitor’s alarm impatiently reminds me that it’s time to deliver a shock. I let the son know, “You’re fine right there,” and I push the button.

Electricity courses through my patient’s body and her muscles contract and release tension as her arms splay to her sides. Nine feet above me the lifeless eyes of the crucifixion stare at our futility and the religious parody taking place on the floor of the church. Have I not tortured this poor woman by stripping her to her undergarments, stabbing her in the hands with needles, strapping her to a board, affixing a mechanical compression device to her chest, and finally sending electricity through her body only to create the mirror image of the crucifixion on the floor of the church?

The CPR machine is still doing its tireless job of compressions on my patient’s chest as we put her on the gurney and prepare to leave the house of God to go find the house of Science. Jesus’ eyes seem to watch our little procession of first responders push a gurney past the empty pews towards the back of the church. At His feet lies a casket with another dead body in it.

A priest in full robes stops us at the door. He says some words in Latin that I don’t understand and moves his hands in well rehearsed motions – passing on a blessing for my patient as the rhythmic noise of the CPR machine circulates blood in a lifeless body.

We exit the church and head toward the ambulance, walking past easily one hundred people standing around in black suits and dresses. All I can think as we slowly roll towards the ambulance is that it’s likely that all of these people will be back here in a week to pay their final respect to my patient.

We enter the ambulance and I have two firefighters with me – one squeezing air into the tube and one taking care of the monitor and CPR machine. I’m prepping drugs and reassessing my patient as the doors close and the four of us are finally alone  – away from our somber audience.

As the rig accelerates away from the church I look through the back window to see mourners start heading back inside. Parked alongside the church in the spot that we just vacated, a black hearse waits for its occupant so it can begin the slow transport to the final resting place.

 

 


Jul
0

Dia de los Muertos 3/3

The urban city life is far behind me as I take the off-ramp from the freeway to my quiet neighborhood. I’ve outdistanced the commuter train and the only traffic at this time of night are the workers who got held late in the city and are only just now returning to their bedroom community. I see the late night basket ball game at the well lit community park; black, white, asian, and middle eastern players all having a competitive game in racial harmony. I smell the water in the air as I pass the manmade waterfall that signifies the entrance to my master planned community. A mini-van has pulled over to the side of the road and a woman is taking a night time picture of her children standing in the lights with the waterfall at their backs. I chuckle at the van parked at the side of road as I feel the weight of the night lift and flappy paddles drop the gears down for the turn into my cul-de-sac.

Making the final turn into my house I push the button on the rear-view mirror that activates the garage door. The cleansing light of the garage washes over me while the horizontal shade of the door slides up to the ceiling. The turmoil, dirt, vomit, blood and death of the day are washed away replaced by the anxious squeals of the dogs who await my opening of the door and the multitude of interesting smells on my uniform after a day in the hood.

Having just left Jimmy in the ED – cashing in the last of his frequent flyer miles – I am more than ready to go home. I have some paperwork still left to do but I don’t care at this point; we’ve already been held over by an hour and I just want to clock out so I don’t get another call.

Lester, our favorite dispatcher, clears us to go home and I jump in the driver’s seat and tear out of the ED, through the hood, towards the freeway. If only my ambulance had flappy paddles! Kevin is beside himself with happiness to be done with the day. “Yes! We are finally done!” And everything stops working…

The lights are dead, the engine is off, the power steering is off, the brakes are gone, and we’re doing 45mph down a residential neighborhood deep in the hood.

It always comes in threes…

I put all of my weight into the brakes while torquing the steering wheel for all I’m worth just to coast into an empty spot on the side of the road. There we sit, dead rig, stuck in the hood – parked on the side of the road with tennis shoes adorning the phone lines and random hooded bangers walking the streets. I look at the dash and see that the problem is obvious; the odometer reads 213,356.7 miles. This rig has served it’s time and is ready to cash in it’s own frequent flyer miles for a retirement spot in the corner of the back lot of deployment.

A phone call to the supervisor and to Lester to let them know where we are makes me feel a little better. The supervisor tells us the tow-truck will be about an hour and we should just hang tight until they show up. Another unit, who was posting close by, comes over for moral support and parks next to us – safety in numbers. Twenty minutes later our supervisor shows up. Two ambulances and an SUV are parked in the hood and colleagues get a chance to decompress from a long day. I finish the day getting a chauffeur driven ride back to deployment with a nearly toothless tow-truck driver – at least I’m able to finish my paperwork by the time we arrive.

I open the door from the garage to the house. I’m bathed in the bright light of a happy home and three dogs eagerly vying for my attention. My wife gives me a huge hug with a kiss. “Welcome home love.”

Jul
0

Dia de los Muertos 2/3

Leaving the urban areas behind I accelerate into an increasingly empty freeway as the lights trail off, replaced by trees and scrub brush hills. There is solitude in the darkness, yet the open roof allows judgment from above as I navigate the quiet freeway home. With a crescent moon overhead I see the airliners strung out in their landing pattern like white Christmas lights hanging in the sky. I feel the rush of wind as I pass the big rigs hauling goods to far off destinations. Cold wind is still on my face, and I have a tightness in my chest when I breathe deep, so I allow my breaths to become increasingly shallow – it’s just easier that way. I wonder what he thought just before he took the last breath of his life.

“It’s Jimmy, looks like his asthma is acting up again.” Kevin pulls us up to the bus stop where Jimmy is sitting down and sucking hard on the Albuterol treatment provided by the fire medic.

We’ve seen Jimmy every few weeks over the years. Sometimes it’s drunk in public, sometimes it’s his asthma, or weakness, or hunger, or just a little cold. On occasion we even get the calls from the cell phone heros who think he’s dead yet keep driving so we have to show up and wake him up in the morning. Although he’s usually not in any serious distress he does have every chronic problem in the book: hypertension, CHF, diabetes, asthma, COPD, previous heart attack, etc. He’s an urban outdoorsman (a.k.a homeless), and a frequent flyer. It seems like he’s been in the county forever. The fire medic doesn’t even bother with a hand off because we all know him.

As I load Jimmy into the rig I hear the fire engine accelerate away from us. Jimmy’s having a hard time holding the Albuterol treatment so I convert it to a mask for him as I tell Kevin to start transporting – I’ll do everything en route to the ED because he’s looking pretty serious.

As I lean Jimmy forward to listen to his lungs I can actually hear the fluid level increase – filling up his lungs as I work my stethoscope higher on his back. FUCK ME!!! The asthma exacerbation triggered a flash pulmonary edema episode. Uncontrolled high blood pressure and congestive heart failure are pushing blood into the most porous organ in the body – his lungs. He’s drowning in his own fluids!

Just as I pull out the CPAP (continuous positive airway pressure) and affix a nebulizer to it, I see Jimmy’s head slump to the right. Fuck! Can’t use CPAP on an unconscious patient.

Looking out the window I see that we’re basically on the same block where my last patient checked out on me. I tell Kevin to upgrade to Code-3 and let them know we’re coming in with respiratory arrest. I switch the nebulizer over and attach it to the BVM (bag valve mask) and squeeze the football to try to oxygenate the lungs that have decided they are going to stop working tonight.

One minute later we’re at the ED and I’m watching his heart rate slowly drop; 60, 50, 40. “Start compressions.” The doc states the obvious – Jimmy just coded. Fifteen minutes later they are throwing the “Hail Mary” drugs at him in an attempt to counteract years of abuse to a body plagued by addiction and street life. Twenty minutes later I’m finished with my paperwork and the ED tech, Nick, walks up. “Man, I hope you’re going home now because I’m tired of working codes tonight.”

“Yeah, that was my last call, I’m done. It’s the end of my week – no more patients fixin’ to die on me.” I wave at him as I head out the doors. “Have a good one.”

Jul
0

Dia de los Muertos 1/3

Dí·a de los Muer·tos

1 : the day of the dead

2 : a holiday, particularly celebrated in Mexico, which focuses on gatherings of family and friends to pray for and remember friends and family members who have died

The fabric roof recedes behind my head in silent automation and reveals the stars in the heavens in all their glory. A moment of solitude and infamy which is quickly interrupted by the speeding commuter train on its elevated track, with its onslaught of light and noise, rushing off to unknown destinations. At the end of my shift I sit behind the wheel of my personal vehicle and take a deep breath – finally it’s over – and listen to the engine cycle into a familiar purr to tell me that it’s ready for the drive home.

I recline the driver’s seat to stare straight up at the infinite expanse of the universe and wonder where the three dead souls have gone this night. It wasn’t my fault, I mean seriously, how am I supposed to reverse multiple years of abuse in the fifteen minutes I’m with a patient? Well, the last one was probably my fault, I pushed him a little too hard, but even still – it was his time to die. 

Any why does it always come in threes?

Precision German engineering growls back at me as I depress my foot and accelerate away from the deployment center. Cold wind rushes past my face and street lights streak overhead as the flappy paddles on the steering wheel cycle the gears up in a desperate attempt to distance myself from the memories of a day from hell. Three hundred and thirty-three horses are unbridled at the on ramp to the freeway, with a rapid acceleration, as the increased g-force pushes me into the seat. The cold wind bites at my short sleeves and exposed skin – it’s a little too cold for a convertible ride so late at night – but I did it on purpose knowing full well what to expect. I wonder if that’s what a cutter says as she drags the razor blade in ever increasing depth across her forearm? Does pain and discomfort somehow remind you that your alive and in that revelation then become a celebration of life? Or is it time to check myself into Emergency Psych Services on a 5150 – should I start to worry when the madness actually starts to make sense?

“Medic-40 copy code three for the OD on the transit bus. PD is on scene, Code-4, you’re clear to enter.”

We’re only a few blocks away and Kevin puts us behind the bus and fire engine in just a few minutes. As we walk up to the bus I see a man in his early thirties surrounded by county sheriff officers and firefighters. He’s looking at me in this kind of thousand yard stare as the fire medic shows me the empty bottle of vodka they pulled out of his pocket. It’s the classic “drunk on the bus” and I’ll have to take him to the ED because he can’t even walk by himself. It takes four of us to pick him up and plop him on the gurney and the firefighters take off without even taking vitals or offering to help out.

As I strap the seat belts on my new patient I notice a little bit of plastic between his lips. I reach up and pull out a baggie that’s been chewed down so all that’s left is just a few white grains of powder – obviously an attempt to hide a drug possession from the officers. I hand the baggie to the officer and feel for a pulse; strong in the sixties – good for now. “Kevin, I’m good to go as soon as we load up, this could go downhill fast…”

My new patient isn’t answering questions or even acknowledging that I’m here so my only assessment is what I see on him and the monitor. The most obvious options for the white powder are crack cocaine, crystal meth, or heroin. Crack and meth speed you up; heroin slows you down – I really hope it’s the heroin because that’s the only one I can turn off.

We’re a half mile from the hospital when the vomit and head spinning scene from the Exorcist starts up right there in the back of my ambulance. First thing I notice is the heart rate climbing from 66 beats a minute to an incredible 236 in the course of twenty seconds. As I tell Kevin to upgrade to Code-3 the vomiting starts. Now I’ve got bio-hazard all over the back of the rig (not to mention the stench), and all of my focus is on keeping his airway open to prevent him from aspirating vomit into his lungs. I’d love to throw a line in and hit him with a sedative but I can’t do it at the expense of his airway. Well, I guess it wasn’t heroin.

Two minutes later we have him in the ED. Two minutes after that they are throwing the drug box at him to slow down his heart and attempting a gastric lavage to clean out his stomach. Fifteen minutes after that they are doing CPR – his heart had stopped beating when it gave out from fatigue. Twenty minutes after that the maintenance crew is mopping up the vomit from the floor and trying not to disturb the dead body on the table with the sheet pulled over its head.