Rescue 471 Page 4
“I don’t think so,” he says. “You’re the paramedic. It’s what you get the big bucks for.”
SAVING LIVES
I always want to be perfect; it’s what people expect from medical professionals. However, like most everything in life, you never bat a thousand. You don’t like to think that you can come up short.
Perfect
My old paramedic preceptor, Tom Harper, once told me that if you are a paramedic, you need to be cocky to survive. While I never agreed with him completely, I understood that you need the force of conviction to make your decisions, and you have to be able to defend yourself. When I started as a paramedic, anytime a nurse or a doctor questioned me, I panicked and thought maybe they were right and I was wrong. In time I learned to trust myself.
The seventy-seven-year-old man in the nursing home has a sudden onset of shortness of breath. He is sitting up, struggling to breathe. His lungs sound like a dishwashing machine. His skin is cool and sweaty, blue around the lips. His pulse is 132, his blood pressure 200/120, his respiratory rate 46. He has a history of emphysema and hypertension but none of congestive heart failure (CHF), which he is now suffering. In CHF the heart’s inability to pump efficiently causes the lungs to back up with fluid, impeding the necessary exchange of fresh oxygen into the bloodstream.
The nursing home has him on an oxygen mask but at only two liters. I hook the mask up to my portable oxygen and crank it up to fifteen liters. We move the patient quickly out to the ambulance, where I get an IV in his hand. I give him nitroglycerin under the tongue, and push 40 milligrams of Lasix through the IV. The nitro will dilate his veins, causing fluid to pool in his legs. The Lasix will cause fluid to move to his kidneys and soon cause him to urinate. The effects of these drugs work to lessen the load on the severely overworked heart and help clear the lungs so they can efficiently exchange oxygen into the bloodstream. I call the hospital on our radio and ask for a doctor. I describe the patient and ask for orders for an additional 80 milligrams of Lasix and 3 milligrams of morphine. The morphine, like the nitro, will dilate his veins and reduce the load on his heart. It will also help relax the man and take some of his anxiety away. He is still sucking away as we pull into the hospital. The medicine combo usually gets the job done, but it hasn’t seemed to this time. I check the sheets; the man has yet to urinate, which ought to happen with that amount of Lasix.
They have a room ready for us. I give the report to a doctor and nurse. The nurse is dubious. “For my money, it’s pneumonia or emphysema,” she says, listening to the lungs. “I don’t hear any rales. Just some wheezes.” Rales are the bubbling sounds of fluid in the lungs.
“How much money do you have?” I say. “It’s CHF.”
“He has no history of CHF. I hear no rales, and he hasn’t urinated,” the nurse says. She lifts the sheets and pulls her hand back suddenly. The pee is streaming out of the man. For the first time, the patient looks relaxed. “I guess it could be the end of a CHF episode,” the nurse concedes.
“Thank you,” the patient says when I tell him they’ll take good care of him. “Thank you.”
What the hospital staff doesn’t always understand is the patient we present them with is not always the same patient we saw when we walked into the room. Our interventions have made the difference.
I always want to be perfect; it’s what people expect from medical professionals. However, like most everything in life, you never bat a thousand. You don’t like to think that you can come up short.
It’s three in the morning when I get sent to a wealthy neighborhood in West Hartford for a chest pain call. An attractive woman in her late forties lies on her bed and won’t answer my questions. “Just take me to the hospital,” she says. “I’ve never had pain like this before. My husband waited too long to call you.”
I touch her forehead. It feels warm to me. Her color is good. Her pulse feels a little faint. My partner says he can’t hear the blood pressure. I listen and get 96/60. Her husband says she had four martinis at dinner, which was unusual for her, and she has been vomiting. “You want her on a mask?” my partner says.
“A cannula will be okay,” I say.
I put her on the monitor, thinking all along this is bullshit. My three-in-the-morning stare sees a normal rhythm. I check all three leads—the same. I run an ECG strip and put it in my pocket.
“Where exactly is the pain?” I ask the woman.
“Just take me to the hospital,” she says.
“I need you to help me here,” I say.
“I’m not being a crybaby,” she says. “Just take me there.”
I feel the urge to snap at her, to call her a whiner.
My partner gets the stair chair and we carry her down. In the ambulance under the brighter light, she does look a little pale to me. I realize the light in the house and her makeup have fooled me. I feel her skin again. It feels a little cooler, but it is hard for me to tell because the night is cold and my hand is cold. We go on a priority two, and I put in an IV on the way. I don’t give her a nitro or morphine because her blood pressure isn’t quite high enough, plus I’m not buying this as cardiac. It’s just some rich lady who had too many martinis.
In triage I tell the nurse, chest pain with vomiting. The woman had four martinis and it started after dinner. They send us down the hall. I feel her forehead again, and I can say it definitely feels cool. In the room, I give my report to the nurse.
“I’m not a crybaby,” the woman says. “I’ve never felt pain like this before.”
I label the blood tubes I drew, then go write my report. When I come back, the woman is vomiting again. There are two nurses and two doctors in the room. I hear one of them mention morphine. I see the twelve lead on the table and glance at it. Elevated T-waves, it says, have physician review. I ask the doctor who has just left the room what he thinks is going on. “She’s having a heart attack,” he says.
I walk back out to the car. I reach in my pocket and pull out the ECG strip, which I couldn’t find when I was writing my report. I look at it now. There is a small but distinct elevation there. Elevated T-waves are an indication of a heart attack. I looked right at it but didn’t see it. The three-in-the-morning stare. I missed it. I missed everything on that one. I swallow hard. You go for months thinking that you’re doing a pretty good job, then boom, you blow one like this. I did some things right. I put her on the monitor. I gave O2, though I should have gone with a higher concentration through a mask. I stair-chaired her, rather than making her walk. I put in an IV. I went on a priority. I got her to the hospital. What I didn’t do was get enough sleep.
* * *
On Rescue 911, every critical patient is saved. That’s not real life. Sure we save some critical patients, but often if the body has betrayed its owner there is little we can do to reverse events. Being perfect, or close to it, doesn’t matter.
The seventy-year-old woman was sitting in a chair when she collapsed and vomited. When we get there she is lying on the kitchen floor. She is alert and oriented but has no radial pulse, and I can’t hear a blood pressure. Her stomach is large and misshapen. I touch below the belly button and can feel a pulsing mass. She denies that she is in any pain. She is just dizzy when she tries to get up. We get her on the stretcher right away and I say to Arthur, “Let’s up-tempo this one.”
In the ambulance, I say, “We’re just going to use the lights and sirens to get through traffic, so don’t you worry, okay?”
“Whatever you say,” she says. “I don’t suppose I am going to die, am I?”
“We’re going to try not to let that happen. I’m going to give you an IV and run some fluid into you to get your blood pressure up a little bit.”
I lay her arm on my knee, wrap a tourniquet around it, and look for the biggest vein I can find.
“I’m supposed to have surgery next week. I have an aneurysm in my stomach, I think,” she says. “They took X rays yesterday at the medical office in West Hartford. Is that what made me pass
out?”
“I think so. The aneurysm may be leaking.”
“Oh, dear.”
Triple A means an aortic abdominal aneurysm, where the wall of the descending aorta, the main blood vessel out of the heart to the lower extremities, bulges and thins. If it tears open, you exsanguinate. It can happen all at once, or it can slowly rip, the aortic wall stretching thinner and thinner like a balloon. In a dissecting aortic aneurysm, the blood gets into the wall of the vein and flows between the layers of the wall, producing a terrible tearing sensation. The elderly and those with high blood pressure are most susceptible to triple As. The only cure is surgical intervention to repair or replace the damaged aortic wall. In the field we treat a triple A like a trauma rather than a medical call. Load and go, oxygen, two large bore IVs, military antishock trouser (MAST) pants if you have time to put them on, and call the hospital and let them know what you are coming with so they can have a surgical team standing by.
“You are going to feel a little poke now,” I say as I put a sixteen-gauge IV catheter in her arm. I get the flash, and advance it. She needs the biggest needle possible, but I was worried a fourteen gauge was too big for her vein. The sixteen just fit. I attach the IV bag. The fluid runs great. I just want to put in enough to reach a blood pressure of 90. The main thing is if her aneurysm bursts, I can let the fluid pour in, but if she bursts, there is little I can do to save her.
“You have such a nice knee,” she says. “It’s very comforting.”
“Thank you. Do you have any pain in your back at all?”
“Just a little. It’s nothing really.”
I call ahead to the hospital, using the key words: “pulsing mass in the stomach,” “tests that confirmed an aneurysm,” “BP only 90, pulse weak.”
At the hospital we wheel her right into room 14, where an attending physician is waiting to get a glimpse. The mass in her abdomen is huge. You can see it pulsing. The staff looks at each other. This may be too late. “That young man had such a nice knee,” she says to the nurse. “Why are there so many people here?”
We’re sent to West Hartford and find a naked man lying on the carpeted basement floor. He has some alcohol on his breath and is thrashing about. I try to get a blood pressure, but I can’t keep him still. He vomits and I notice some black coffeelike grains, but then I look harder and see it is just spinach. We try to get him on the stretcher, but he can’t sit still. “My back is killing me,” he says. He violently scratches his back but gets no relief from it.
“Lie still,” Arthur says, but he can’t. We put him on the monitor and an O2 mask, and strap him down tight, but he is screaming with pain. In the back of the ambulance, I put in a sixteen in one arm. We head out lights and sirens. I put in another sixteen on the way. He is thrashing so much he is now lying on the monitor. I try to ask him questions but he just swears at me. I can’t hear a blood pressure. He keeps punching himself in the back, trying to get at the pain. I radio ahead. Unable to get pressure. Tearing sensation in back.
Neither patient makes it out of surgery alive.
* * *
Sometimes you get the job done and look like a hero, even when no one else knows how close you came to screwing up.
I get called for a man barely responsive, just got out of the hospital for a heart bypass. A police officer meets us at the curb. “He looks awful, cold clammy.”
The man is slumped backward in a chair at the kitchen table. He is ashen white. His eyes look helpless, as if he is saying to me, Just let me die. He has massive fresh scars running the length of his inner thighs and down his chest, the surgical stitches still visible. He looks like a dead man risen from the grave, a ghost. I quickly feel his pulse. Very irregular. His wife hands me a long list of his medications on a tattered index card. Mega heart meds. “He just had surgery. He has a terribly weak heart,” the wife says.
“Let’s just get him out of here,” I say to Arthur. They want him to go to Hartford hospital, and we are a good fifteen minutes away. I put an oxygen mask on his face and turn it on full. We lift him up onto the stretcher. He is heavy, dead weight. I put him on the heart monitor and see three premature ventricular contractions (PVCs) right in a row. A bad sign. I am thinking this man may go into cardiac arrest before I can get him to the hospital. We hustle him outside and into the back of the ambulance. I tell my partner to head to Hartford on a priority. I’ll do everything en route.
The man keeps looking at me, saying nothing. He seems dazed, as if life has knocked him down for the last time and what he is seeing now is the final part of the final reel. The credits are about ready to roll as the light grows dim.
I take his blood pressure. It is 180/90. High. That doesn’t seem right to me. He should be low. I get a large-bore IV in his left arm. I set the needle on the bench to do a routine blood sugar when I get a chance. I look back at the monitor. He is still having PVCs but not at the rate he was. The oxygen seems to be helping. In my mind, I am running through what I will say in my report on the radio. I will call Hartford, and they will get room fourteen—the cardiac room—ready so that when I wheel the patient in, their doctors and nurses will descend upon him, hoping to avert imminent death.
I look at the man again and feel the wheels turning in my head. What am I missing? I get this feeling something is staring me in the face and I am not getting it. I glance back at the list of medications his wife gave me. Lasix, Lanoxin, Vasotec, HCTZ, ASA, isosorbide, Zyprex, Moban, Accupril, Sinemet, Zantac, diltiazem, glyburide. Glyburide. Glyburide. The man’s a diabetic.
I pick up the needle I left on the bench and tap out a drop of blood onto a chemstrip. The reading comes back 0-20. Way low. I take a amp of D50 (dextrose) out of my drug box and inject it through the IV line. D50 is half sugar, half water. It can wake up an unresponsive diabetic in less than a minute. The sugar-thick fluid is carried in the bloodstream right up to the brain.
When we arrive at Hartford, the patient’s wife bursts into triage, undoubtedly having braced herself for the possibility that her husband has expired en route to the hospital.
Instead he’s sitting up on the stretcher with a big grin on his face. “Honey,” he says. “This guy’s the greatest paramedic in the world. He’s got me all fixed up. Great fella.”
She just starts crying and throws her arms around him, weeping huge grateful sobs.
“There, there,” he says.
The triage nurse looks on at this inexplicable scene. Once the man woke up with the D50, I never bothered to radio the hospital. They only like reports for dire calls. “What do you have?” she asks.
“Diabetic,” I say. “Gave him an amp of D50. He’s doing much better.” I fill her in on the rest of the details.
“Room fifteen,” she says.
I imagine if I hadn’t pieced it together until they discovered what I did—that his sugar was low—and the man woke up, healed, I would have felt like an idiot. Diabetic, huh? Oops.
Tunnel vision is a real problem. I got the heart bypass going in my head, the sight of the scars, the wife’s comment about his bad heart, the PVCs on the monitor, all the heart meds. If I had been sent to an unknown or sent to a diabetic, I probably would have figured it out right on scene and revived him in the kitchen. At least I caught it in time.
No Luck Left
We see a lot of bad accidents in this job and our share of truly injured people, but I am continually surprised at how lucky some people can be.
I’m working an overtime shift at night. My partner, Kristin Shea, and I are coming off the Sisson Avenue ramp when we notice an accident by the entrance divider. A car has spun into the guardrail. Several other cars are stopped. We tell dispatch we’re going to stop and check for injuries. I see two people in the car. The one in the driver’s seat seems okay. He is talking to the other passenger, who looks injured. The windshield is shattered. I go around to the passenger side. The hood is bent back and crashed through the windshield. The man’s head is on the dashboard, pinned at the neck by
the glass and the hood. He can’t move it. I learn that the guy in the driver’s seat is just another motorist—an off-duty firefighter who gets out of the car now and calls for the tactical unit on his radio. The guy with the wedged head is the driver. His feet are in the driver’s seat. I can’t believe what I am seeing. I go around and get in the driver’s seat so I can talk to the guy whose head is facing me now. “Are you all right?”
“Yeah, I’m fine, I just can’t move my head. Get me out of here, please.”
He has alcohol on his breath, but he is alert. He has no other injuries. I inspect his head. He is wedged. The hood and glass are biting into his neck.
“You’re lucky this didn’t cut your head off,” I say, then hold my tongue. He is not out of danger. One false move and that glass could slice his jugular vein. I don’t know how we’re going to get him out. Leave it to the fire department. I can hear their sirens approaching.
Jeff Huffmire and Janice Mihalik in 471 show up on scene, and though we only have one patient, they stick around to help with the extrication.
Fire shows up and they conference repeatedly, trying to form a game plan. I have no idea what they will come up with. I’m glad it’s not my decision. There is no margin for error.
“Just get me out of here, please,” the guy says.
Janice sits on the other side, holding the guy’s body up. We put a blanket over our heads to protect us from flying glass once the extrication starts. I try to slide a trauma dressing in between his neck and the glass, but the glass is right on the skin. Kristin gets the stretcher ready for quick extrication once we get him out and spikes a bag of fluid in the ambulance. Jeff stands close by the door to relay word to fire if anything starts to go wrong.
I hear a mechanical noise. I can’t see what they are doing, but the extrication has begun.
The guy screams. “It hurts. It hurts. Stop! Stop!”