STAT EP

Seizures suck.
Now that we’ve got that important announcement out of the way, lemme clarify some things bout EMS and seziures: If you call 911 right after someone seizes, the call type is just “Seizure” and they send EMTs. If you call while someone is having a seizure, they presume it’s been going on for long enough to qualify as status epilepticus, which is a prolonged series of seizures without a lucid interval inbetween, and the job becomes a “Stat Ep,” and they send paramedics. Also, if you call 911 and say “Yo, I’m abouta catch a seizure son!” they make the job a “Stat Ep” and send medics, unfortunately. This happens more often than anyone would care to know about. (More on the difference btwn EMTs and Paramedics here.)

Anyway, there’s a couple reasons one might catch a seizure. Most common is epilepsy, which really just means you’re prone to seize, but there’s also hypoxic seizures which you get from lack of oxygen and usually precede death by a couple seconds, withdrawal seizures, including delerium tremens, and seizures resulting from traumatic brain injury. But by far the most common seizure call I’ve ever done is this one guy, we’ll call him Fred, that we always find blasted out his mind and writhing in a puddle of his own pee on the last stop of the cross town bus in Harlem. This dude, every—-night gets obliterated, on what Fred?
“ABTHOLUTELY!!”
The Vodka?
“YETH!”
Are you sure?
“ABTHOLUTELY!!”
Ok.
And winds up cursing out everyone around and screaming that he’s having a seizure (so it’s a Stat Ep). Or sometimes chest pain (“The Cardiac”). Then we lug his pee-covered ass to the hospital and by some unknown bum magic Fred always emerges the next day at dawn, not only sober and with a British accent but wearing pressed pants and alligator shoes, all dapper and ready for another day of getting blitzed and writhing round in his pee.

True seizure patients are usually really out of it for a while after they come around, sometimes get violent and wanna pound you for taking them to the hospital, sometimes they do not under any circumstances want to be bothered by anyone and often act like a teenager not getting up for school in the morning. Also they’re confused, cuz last they remembered they were sitting at the table or whatever and suddenly they’re across the room with a fat lip looking up at me and I’m holding a big needle. Or, in what might a worst case scenario we had a while back, they wake up butt naked in the basement of an HIV shelter covered in their own feces. I’m still not sure how the dude got down there. I mean, he was a resident of the place, but still- damn. The security guard was ornery and couldn’t give us much of a story. I tossed the dude a sheet and he kinda cleaned off best he could, mumbled something about ‘yeah this happens sometimes’ (o.O) and walked out to the ambulance. Well…hobbled kinda.
When we got to the hospital he insisted on walking in, even though we realllllly dont recommend it cuz if you seized once you might damn well seize again. But dude wanted to walk and wouldn’t be dissuaded.
Halfway between the bus and the door he turns the wrong direction and takes two steps. I open my mouth to say “No it’s over…” and then realize what’s happening. I break into a mad dash towards him as his body goes rigid and he starts to keel over backwards, get there just in time to stop his head from exploding on the concrete and lower him down gently as his whole body rocks into a grand mal seizure. My partner that night,  a confirmed jackass, pokes his head around the corner.
“What’s wrong?”
I’m holding this 300 lb seizing man’s face away from the gravel in an ER bay. What the *#&(@*%)#@*#*Q@ do you think is wrong?! “Get me the stretcher!”
“What happened?”
“STRETCHER!! NOW!!”
Partner disappears and shows up not with the stretcher but with…an oxygen tank.
Lemme tell you something: yes, by the guidelines and protocols, a seizure patient gets oxygen. Yes. This is true. But what this one in particular needed was to not be seizing on pavement. And what this paramedic needed was not be holding him up. I think I cursed out my partner. I’m not totally sure, cuz it all happened very fast, but eventually he made the stretcher happen, after some grumbling. It’s probably a good thing my hands were busy. By the time we got dude on the stretcher he’d wrapped up the shaking and fallen into that deep sleep. At least he woke up in better circumstances the second time.

WEIRD LITTLE RUNNING GUY RUNS OFF

I know this job is gonna be ignorant the second it comes over because the text is telling me to go to a psyche facility to pick up a patient acting mentally unstable. I’m already deeply unimpressed and we haven’t even got on scene. However, I’m also happy: psych patients usually walk all by themselves and provide for good conversation to boot. This one, as if to prove my point. disappears up a flight and is gone the second we arrive. The guy running the place comes over looking exhausted.
“This guy’s acting fucking crazy!”
“Sir…this is a psychiatric facility, correct?”
(I shouldn’t even need to have this conversation)
“Yes, but he’s really acting bonkers man! He might set the place on fire or something.”
It’s amazing how two people can create total chaos all by themselves.
“We don’t chase people,” I say, putting down my bags and sitting my Cuban ass in a chair.

Usually PD is all over a job like this. They love gettn all hunkered down in their gear and tasering people or putting them in the slug outfit or whatever. But perhaps they gleamed from the job text how utterly ridiculous this was gonna be and didn’t bother. I get on the radio and ask for a squad car. Jumping on people is their job, not mine.
“I think he took too much of his meds,” the stressed out guy in charge tells me.
“You don’t mean too few?”
“No! Too many!” (maybe he’s not the only one?) “He was sitting right there and then he just started rolling around the floor! It was…crazy!”
Again…ah forget it.
Then the guy comes running past. He’s little, filthy, mustached. Wearing an Aerosmith shirt from circa 1976. And he’s fast! I barely realize he’s there before he’s out the door and off into the night.
“There goes your guy,” I tell the supervisor. He turns around and runs out the door too. I put some gum in my mouth.
Supervisor comes back in a minute later. Tells me PD showed up and took off after the guy down the block. My partner and i saunter outside, see PD reversing in a fury toward Fulton Street as homeboy cuts a hard left and disappears. We saunter into ambulance and at a saunterly pace roll around the block.

PD is having an extended negotiation with the dude when we show up, which is amusing mostly because they don’t speak Spanish and he barely speaks English. He’s carrying on about someone ganking his dinero, they’re all: ‘Sir, you’re gonna havta calm down. Sir.”
I tell him in Spanish he gotta go to the hospital, get on the ambulance right now.
He curses out all of us, all our mothers, all our sisters, all that we hold sacred but sheepishly complies.
In the ambulance, I notice he’s utterly wasted and won’t stop chewing. Not in the gum kinda way. In the way old people do all the time. Might be the Parkinson’s like effects of certain anti-pyschotic meds, or perhaps it’s just him being high. It doesn’t matter toooo much, and we roll of the hospital. When we get in the ER first thing he does is spit a walnut on the ground. Everyone groans.
I hate it when my patients are rude to the ER staff and I tell him. He looks at me like, meh? and he’s still chewing. Ugh. “Ju my frien’,” he informs me. “Ju too,” he tells my partner. Terrrrrific. While they’re taking his vital signs he produces an EKG electrode from somewhere in that mouth of his, regards it for a second and then puts it back in his mouth. I think me, my partner, the nurse and the registration lady all facepalmed at exactly the same moment.

NOTSOMUCH: The Truth About Black On White Crime

I took this little hipster dude to the hospital seven years ago; he’d left his apartment door unlocked and then got pistol whipped when he came home to find someone going through his stuff. Now why would I so clearly remember a minor injury from ages ago? Because in my eight years working EMS in Bed-Stuy, East New York, Harlem and the Bronx, that was the singular, solitary white patient I’ve had who was a victim of violence at the hands of a person of color.  I remember sitting in the Woodhull ER with him. He was holding an ice pack to his little forehead gash and going “God! I can’t believe I got pistol whipped! It’s like…it’s like a movie!” At that point I had already given up checking the newspapers in the morning to see if any of my crazy jobs from the night before would show up. They never do; the patients are all black and brown and their tragedies, no matter how gruesome, are automatically deemed run-of-the-mill and unworthy for news attention.

In general, the white patients we get are either little old ladies, drunk Polacks who tried to play frogger across McGuinnes Boulevard, college kid anxiety attacks and overdoses. We also get the occasional “All these Black people are trying to rape and kill me so I can’t leave my apartment!!” and sometimes “I stopped taking my meds and I’m about to do something really really bad.”

All this is to say that the amount of time and energy that white culture puts into being afraid of the crimes that will be committed against them in the ghetto could be better spent thinking about something that actually happens.

For instance, white on black crime, which we see faaaar more frequently. A lawyer was interviewing me the other day for a case they wanted me to testify in. A patient I’d had who’d also been pistol whipped, also seven years ago, this time by cops, was suing the NYPD and this lawyer was trying to take apart the guy’s story.  He showed me a picture of a middle aged black man with a swollen lip and busted eye and asked me if I remembered him. I had to laugh. “Do you have any idea how many times a week I go to the precinct to take care of black men who’ve been beaten by cops? Plenty. Times fifty-two times eight. No I don’t remember that dude.” Or the kid I met last night, who’d been cardoored by a police cruiser and then arrested before he could get up, all for riding his bike on the sidewalk. Or Iman Morales, who was naked on a fire escape in Bed-Stuy having a psychotic fit when PD tasered him, causing him to fall to his death. Or Sean Bell. Or Oscar Grant.
And then there’s the entire 81st Precinct, who’s institutionalized racism was recently unveiled by a defecting whistleblower and thoroughly detailed here.

Most white on black crime happens without the majority of whites having to perpetrate a single violent act. Another unspoken benefit of white privilege is the ability to win without  even having to fight. Gentrification, and the uprooting of communities that it entails, will happen regardless of how the incoming hipsters feel about their neighbors; the pieces are already in place, the gears turning. 911 doesn’t get called- it’s a slow motion race riot, which history has proven can be the most devastating kind.

ON EFFING UP

One time, when I was a brand new medic my partner and I gave the wrong medicine to a patient. It saved her life anyway but both meds in question were narcotics, the most regulated drugs ever, so we ended up getting dragged downtown to explain ourselves.
The lady was succumbing to a bout of Acute Pulmonary Edema- a situation I’ve talked about a few times on this blog that involves the failing heart backing up fluid into the lungs, essentially drowning a person inside themselves. You can have it just a little bit- your lungs sound like  a straw sucking out the last bits of soda around wet ice cubes- but it can also flash flood and pinkish fluid will gush up your airway and asphyxiate you. Plus, if you’re old, even having a mild amount of fluid can cause so much respiratory distress that the body will quickly exhaust itself with the effort of each breath and give up. This lady was a few minutes away from crashing. The fluid was at the top of her chest and would come pouring out her mouth any moment. Her eyes weren’t focused, her body was doing that spiraling down the toilet bowl swirl that I tell my students to watch out for. 
My partner and I had spent the day having a friendly debate about Morphine, cuz that’s what bored medics do. We use Morphine in that situation to help open the veins up and lower the blood pressure, which is usually through the roof in APEs. It also has the added benefit of sedation, which allows you to intubate, which is what this lady needed because she was about to stop breathing completely and a tube down her throat’d be the only thing that’d keep her alive.  When my partner called up the Online Medical Control people to get permission to use narcotics, he asked for Valium and they gave it to him. Valium is a sedative used specifically for the purpose of knocking someone out so you can tube ’em. But Morphine musta still been on his mind, cuz that’s what he handed me and that’s what I gave the patient, although neither of us realized the mistake until after everything calmed down.
The thing about knocking someone out to tube them is that then you HAVTA tube them, cuz you kill their respiratory drive too and that’s already low. And the thing about tubing a living person is you can see the weird little inner mouth that the vocal cords form and watch them open with every troubled breath the patient takes. And you wanna open up that airway, see the cords and then sit there poised with the tube ready to stick down there at just the right moment. It’s like some creepy Indiana Jones/William Burroughs insanity, but we love that mess as I’m sure you’ve realized by now.
Anyway, I opened her mouth, took out her dentures, got all up in her airway with the tube ready, holding her tongue out of the way with a metal blade, and watched the cords open, close…open…close…open and I pushed the tube through and secured it in place. It was in, confirmed, solid, %100 and we triumphantly zoomed off to the hospital all happy happy that we’d saved another life.

Until we realized we’d given the wrong sedative.
Anyway, like i said, we ended up downtown at EMS headquarters to explain what we’d done. My partner was the senior medic and he did most of the talking. He said- Look, we did mess up and give the wrong med, it was a very hectic scene, the lady was crashing and we were under pressure and we messed up. That’s it.
There’s always one EMS lieutenant they bring to be a total dick and then a doctor who’s mad coool (that was the only time I’ve been but everyone tells the same story)- the Lieutenant basically was like “Well, you’re job is to deal with stressful situations and not mess up. So that’s no excuse at all.”

And, much as I hate hate hate to agree with a lieutenant, the dude had a point. First of all, we deal with all kindsa situations and an old lady dying in front of us was really not the peak of insanity. She was on the bus, so it was a controlled atmosphere. Plenty of times it’ll be the same thing but there’ll be children crying for us to make mommy breath again, fire men crapping themsevles, angry husbands cursing us out, threatening our lives, crazy frothing dogs, cocaroaches, mice scurrying around, gettin in our equipment, endlessly cluttered apartments with no room to move in, let alone spread out and work up a cardiac arrest. PLUS, dirty needles, electrical volts, freakazoid partners, white supremacy and patriarchy…anyway, you get the point. We deal with stressful situations. It’s what we signed up for. It’s what we joke and carry on about at the bar after work. It’s part of what we love and hate about the job. And we all will and have made mistakes, it’s also a part of the job, we’re not super humans, but to ask for an out because the situation was hectic is to ask to be told: That’s your job. Do it.

I say all that because EVERY time, every DAMN time, a cop effs up and shoots an unarmed man of color, you get the mayor, the police chief and a hundred different union reps and apologists screaming and crying about the line of duty and you don’t understand what it’s like to possibly have a gun pointed at you. (or a wallet). And it’s true, I don’t. Nor do I want to. That’s why I chose the job I chose. But for someone who chose to be a cop, they’ve taken on the responsibility of living in the cross hairs and having the power of death at the whim of their trigger finger.  That you were in a stressful situation doesn’t get you a pass; it’s not the go ahead to go buck wild. Especially because it’s probably those same stressful situations that you go bragging about at the bar, that you roll your eyes and shrug off about at parties when someone asks you about the craziest mess you’ve had to deal with…. For both PD and EMS it’s those challenging moments of the job that makes us love it, which means we don’t get to run back and hide underneath them when things don’t go our way.

End rant. 

THE MOST SKEEVED OUT I’VE EVER BEEN

I was gonna write about death again- but I do that  (…reading back over old posts..) A LOT o_O
 so instead I’ll talk about um…oh crap this ones about death too but whatever…THE MOST SKEEVED OUT I’VE EVER BEEN.

it wasn’t on the evisceration, or the lady who’s leg was hanging off or any of the crazy shootings stabbings rectal bleeds or other bloody disasters I’ve been on. This might even come as kind of a let down, cuz people at parties are always asking me: What’s like the CRAZIEST ISHT You’ve EVER seeeen? And this definitely was not it. But it skeeved me to the bone none the less.
We were riding with this Hasidic kid that night, a student, and some of his boys were on the Hatzolah truck that works nearby- Haztolah is the all Hasidic ambulance group- and somehow they’d gotten a call for a jumper down- it was one of their guys and I guess he’d gone from the roof of one of the all Jewish projects on the Williamsburg/BedStuy border (yes there are Jewish projects). We were nearby and the kid wanted to meet them at the hospital and lend a hand, whatever, see what they’d done, learn something i suppose, so I rode over to let him take a peek.
Hatzolah is famous for rolling deep. They call it the clown car cuz the bus rolls up and nojoke like eight little bearded EMTs will pop out, all muttering at each other in Yiddish and usually dressed in tshirts and sneakers. But for some reason, that night, there was no one there, they all musta hopped out and scattered, or maybe they all decided to go in and notify the hospital together, the way girls flock to the bathroom. Either way, it was just this one little sad yarmulka’d fellow left to bring in the patient. Even my student was nowhere to be found.

I really don’t like to get involved in other people’s jobs. It’s wrong for so many reasons but you can’t roll into the hospital with a traumatic cardiac arrest and no one’s doing CPR, no one’s giving ventilations… It’s not because the guy might make it- that was definitely not going to happen- it’s just a really bad look. it’s like showing up to play baseball wearing a tutu. You dont do it. So like a idiot I gloved up and positioned myself on the stretcher to start pumping the guy’s chest.
Considering that he’d come down from a PJ, i was surprised that the dude wasn’t splattered. He was  white- literally white not just racial construct white- pale as a piece of paper, probably his internal organs had exploded and the blood was scattered inside somewhere, and his feet were pointing in all the wrong directions, surely from having been landed on. They said he’d just gotten out of woodhull’s psych ward and that Jews who suicided weren’t allowed to be buried in Jewish cemeteries but since no one had seen him jump, he might’ve been pushed or it might’ve been a freak accident and he’d get the benefit of the doubt.

Anyway, on my third or so compression, one of the man’s chest hairs caught me right where the glove stops and my wrist begins- that tendon right there? YO. It was like the long finger of Father Death tickling my soul and NOT in a good way. I can’t tell you what it was that eeeked me so much about that all i know is within 2.7 seconds I was off that stretcher and halfway across the street yelling “OH HELL NO!!” and making all kindsa faces. By that time, some other Hasids had materialized and took over but I couldt’ve cared less to be honest with you, I was DONE.

WE ALMOST LOSE A KID

One of the biggest decisions a medic has to make is Grab-n-Go or Stay-n-Play.
Most of the time it’s relatively simple- trauma’s are always grabngo as I’ve talked about before, because trauma patients really need a surgeon to help them, so whatever we do to ’em we do it enroute to the hospital, ideally. Most medical situations are the opposite: we ‘re equipped to do for an asthma or heart attack what any ER would do in the first line of treatment anyway, so it’s worth taking the time onscene to get the IV, the EKG, do the full workup.
Kids can seem like they fall into the inbetween category. When a kid is critically ill it feels like a trauma job because people are freaking out, tensions are high, there’s a certain element of chaos that makes you wanna go go go and be gone no matter what. Adding to that tension is the high compensation/sudden plummet thing that kids do. Unlike adults, who will spend hours sometimes circling the drain, kids tend to compensate and compensate and compensate- sure they’re struggling but they look okay, right? and then suddenly they’ll just turn blue and crash completely and  die in a matter of seconds. A good medic knows that, and it makes us anxious to pass the potato, but we also know that what happens in those fleeting moments between life and death determines whether a patient makes it or not.

So this kid was big for 13. A hundred and seventy-five pounds actually and foulmouthed to boot, and he was standing outside his house at 3AM flagging frantically at us. He stumbles over to the ambulance as we roll up, his pants falling down. “I’m gonna fuckin’ die!” he screams and jumps in the bus, crapping himself as he goes. Now, people saying they’re gonna die- you know that’s neither here nor there. You get the people that say it over a fight with their ex and then you get the people that look fine, say they’re gonna die and then do exactly that, which yes is creepy as hell. But you can’t fake crapping your pants- it’s always a bad sign whether asthma attack, heart attack or trauma, it means the body is giving up less essential functions to concentrate on the only ones that matter.  The mom came running up a second later. The boy laid out on the stretcher, gasping and started turning blue. I mean, the kid literally used his last drip drops of life force to  make it to us and then everything started giving out.

Moments like that, the world goes into slow-mo. Actually, we were moving pretty fast, but it felt like hours as I moved across the bus and pulled open our medicine kit to find a syringe and the epinephrine. My partner was dealing with the oxygen, setting up an albuterol treatment, and I’m wondering if the kid’ll even be breathing by the time we get it to him, but I can still hear his tight little gasps and his mom sobbing for us to help him. 
The stupid epi comes in stupid little vials that you have to crack open and extract the liquid from painfully carefully with a needle. It sucks. drip drip drip. 0.1 mgs and I need 0.3. Drip drip drip. Gasp…gasp…gasp. “Please, he’s turning blue! Help him!” I hear the shushhhh of the oxygen (Finally…only seconds later though…) and Mike straps the mask onto the kid’s face as the treatment seeps out in a little cloud. It’s a start, but epi is the real turnaround medication. Finally I hit 0.3 mgs, grumbling, and I stab the kid in the arm and push the meds in and exhale.

But he’s looking worse. “I think we’re gonna haveta tube,” Mike says. I nod, throwing the defibrilator pads on the boys chest so we can get a read out on the monitor and shock if we have to.  A tube is a last ditch effort for someone in respiratory failure. It’s for when the body simply can’t breath for its self anymore and so it allows us to do the breathing for the person. His heart rate turns out not to be so bad- it’s 110, which is about normal for someone having an asthma attack. (Kinda bad woulda been much much faster that, 140 or 160 but really really bad woulda been slow, anything below 70 would signal him sliding straight down the drain at any second.) His oxygen saturation is crap though. That’s the percent of o2 that’s gettin to his blood. It’s normally %97-%100. Someone struggling to breath might be down to %80something and we’d be pretty concerned. This kid’s is %54.

Mike opens his mouth to intubate but the boy is clenched up. It means he still has some fight in him, but still…I take a quick look to see if there’s an IV to be gotten, but he’s large and nothing popping up. The moment to move has come. The first lines of medicine are onboard, the oxygen is flowing. Stay and play is over. I put on the machine gun scatter siren and blast off to St Johns, giving the notification breahtlessly as I go (“13 year old…male…(pant pant)…imminent respiratory arrest…(pant pant)…vital signs are as follow…(pant pant)) and make it there in 2 minutes flat. Mike has popped an IV and some more meds in on the way, bless his soul. I can tell the epi has done its thing before i even get out of the driver’s seat- the kid is coughing and crying. People who are about to code don’t cry. He’s moving air. I hop out and by the time we roll him inside Little Big Man is actually talking, almost in complete sentences.  “Jesus Christ!” he pants. “I almost fuckin’ died!!”

LEMME JUST TAKE THIS CALL

I guess if I’d been shot twice in the face there’d be some people I’d like to call too, but if the paramedic told me to lay down and stop moving that’s what I’d do. Not this dude. This dude is too busy cursing someone out on the other line and swatting off the EMTs while they try and fit a c-collar on him.
I hop on the bus and put on my I’m-not-kidding voice: “Sir, you have 3 bullet holes in your face. That means 2 went in and only 1 came out, so there’s a bullet rattling around somewhere and if you move too much it very well might dislodge and end up in your brain.”
“But…”
“And then you’ll be dead.”
He relents and lays onto the board, lookng irritated at me . (I’m not the one that shot him…whatever…) the emts collar him up and strap him down and I yell to the driver to take a not-2-crazy ride to King’s County. If you don’t say that you end up hitting a bump at mach 7 and all kindsa mess can ensue. Especially because when the ambulance roars off me and my partner grab the biggest needles we can find and start poking the patient with ’em. To get the IV of course- not cuz he’s being difficult.

The first bullet entered the ridge of his cheek bone just below the eye, transversed his face somewhere between his eyes and nose and exited through the opposite cheek. The second bullet entered slightly lower than the first and is who-knows-where. Miraculously, the dude’s vital signs are all stable, he’s mentating perfectly well and the only bleeding is a little clottiness around his nose. Still…trauma patients and kids (see next post) can look perfectly fine one second and die the next, so we keep a steady eye on him.
Before we get to County he swears he doesn’t know who shot him, gives a false name and fields two more curse-laden phone calls.

In 2 Ze Bone!

Been on a little blog vacation- ok a bigass 1 actually- while i concentrate on some fiction but it’s a slow ass night 2night and may actually have a second to knock 1 out.

I can’t remember if I’ve been over the criteria for True Death on here yet, but anyway it bares repeating cuz it’s morbidly fascinating and that is the theme of this blog.
If you die, the job gets entered into the system as a CARDIAC ARREST, which just means your heart stopped. Doens’t matter if it happened today, yesterday or 12 years ago, you still have to get evaluated and pronounced and/or worked up by EMS. The other day we had a dude that died in a shelter, got pronounced by EMS cuz he was QUITE dead but never got picked up by the morgue so 3 hrs later they put the job back in the system hoping to get the ME guys 2 show up and take the body but got us instead. The bunk room was cleared out, all the guy’s roomates standin irritably off to the side waiting to get back to bed, and lo and behold the dude was still dead- it was a guy I’ve had several times as a patient actually, a real ornery cat that always refused 2 go to the hospital no matter how messed up he was. There was nothing to do, because we don’t take bodies to the morgue (usedto though) so we got back in the truck and went our way, much to everyone’s disappointment.

Anyway, what is the criteria for being SO completely dead that we don’t even go through the motions of trying to bring you back? There’s 5:
Rigor Mortis, which is when the body becomes rigid, usually several hours after death.
Dependent Lividity, which is the pooling of the blood at the lowest point of your body and basically looks like a huge grimy stain.
Decomposition, which is….gross. And you can usually smell from a block away.
Obvious Death, which covers everything from splattered across the pavement to decapitation.
And having a Do Not Resuscitate Order, which doesn’t happen nearly enough, in this medics opinion.

If you don’t meet any of those criteria, we’re gonna be intubting you, putting an IV in with load of medications and possibly shocking you and dragging you to a hospital while some grumpy fireman pumps on your chest. This lady we had the other day didn’t fit any of the criteria BUT she was quite large and didn’t have any available IV access. When you have a cardiac arrest with no kinda veins to put your meds in2 there is now one other option: the bone.

Right below the knee cap there is a flat plateau along the humerus. I place my fingers along it, pushing through layers of fat and muscle until I’m sure I have the spot. Lather it up with an alcohol swab and place the tip of a largeass needle against it, my hand gripping the blue plastic handle. Around me, the typical cardiac arrest chaos is swirling- partner intubating, EMTs sweating as they bounce up and down on that chest, nursing home attendants blabbering about how they just saw the patient a few minutes ago and everything was fine, lieutenant gazing at the lovely trees outside the window… I push the needle into the flesh, twisting in a screwdriver motion as I go. It slides in without much resistance till i reach the bone, then i have to push harder, put some back in2 it before the satisfying (yes I said satisfying) POP! comes and I know I’m in. The needle has entered the marrow. I pull out the needle, leaving the catheter in place and attach up the IV line, adjusting the flush to gush full blast, which will push fluid through to the bloodstream and give us the access we need to get medications on board.

We push our meds and when there’s no response from the patient make a phonecall to our medical control doctors to get a Time of Death. We’re wheeling the empty stretcher out towards the elevators when the lieutenant looks up from her window gazing: “You guys think that tree out there is fake? It’s so pretty!”

DANCING W/ DEATH

I’m a little tipsy right now, which seems like the best time 2 write a blog about death.
Imma also tryn write this as quickly as humanly possible with minimal thinking involved cuz i suspect that if I even slightly overthink it, the shit’ll come out all crapademic and corny.

Death isn’t the tragedy, from where we stand, its the perpetual slow state of constantly dying that really sucks. I’ll tryn explain:
I usedta work Transports- that’s as opposed to 911. Transports means ur bussing the same sick and dying folks back and forth day in and day out btwn nursing homes, dialysis centers, crappy little apartments, ICU units…watching limbs rot off one by one, mental statuses decrease into total vegetation. THAT shit, is depressing.
It’s also the polar opposite of ‘Emergency,’ which is why most of us got in2 the field, to deal w/ emergencies, right? Right.
We’re good w/ the acute: u about having a heartattack? we got nitro to spread those veins open and keep the blood flowing. Not breathing? Here’s a tube and some oxygen to keep things moving.
In 911, things move fast. Within a 45 min job, a patient can go from about to die to dead to back alive and kicking to dead again. Or vice versa. And that’s when we are most alive, jumping in and out of protocols, stepping back to assess and reassess, checking in w/ each other, staying light on our feet, planning thinking moving working…
What it comes down 2 is this: Trauma lives in the body. They say it again and again in all the books and lectures, but what does that really mean? It means that when your body is all up in that trauma, when you are literally entwined with the heart and lungs of the patient, connecting IVs to veins and plotting exit strategies and busting ass to hospitals, the experience of someone else’s effed up situation is completely different than when u are walking by, helplessly witnessing it.

This is why we sleep at night. Because whether the patient makes it thru ok, ends up a vegetable for life or dies completely, we have played our part, added our small piece to the puzzle of their survival, with the knowledge that we do what we do and the rest is in God’s hands.

THE WANDERER

She’s 42, passed out on the floor in her own vomit and barely breathing.
Damn seems like all my blogs start this way…I have one about to happen about dealing w/ trauma and death on the job but interesting shit keeps happening, so that’ll be next weeks…
Annnnyway: she’s 42, etc etc etc has no medical problems and no signs of trauma. According to her husband, she just took a pain medication from the Dominican Republic- some ish I never heard of- felt itchy, groggy, puked, passed out. The itchiness speaks to an allergic reaction and the pain meds speak to a possible overdose; both could cause vomiting, syncope and respiratory arrest, but neither is a sure shot answer. First of all she’s not covered in hives, in fact there’s none at all to be seen. It doesn’t sound like she took enough to OD though, unless she had something else on board, which the husband swears up and down that she doesn’t. So, the EMTs are giving her ventilations, my partner sets up his tube and I get the IV ready. On our EKG monitor she’s a normal rhythm at a healthy 60 beats a minute, she’s breathing intermittently, only barely, and occasionally moaning and writhing.
You don’t see the best veins for sticking a needle in, you feel them. They bounce gently against your finger in a way normal skin doesn’t. When you have a somewhat plump arm that’s not showing you anything vein-wise, you’re usually better off going by touch. If you know the body you know where to look: usually at the little depressed area along the wrist, just below the thumb or on the reverse side of the elbow are the best spots. On a really tough one, sometimes you can get lucky with a little veins swirling around the knuckles. This lady’s got some flesh to her, but my finger bounces off a nice one running along her forearm and the needle goes in with no trouble.
I push 2 mg of narcan, which will block her opiate receptors and break her out of an OD. The EMT tells us he can’t hear her blood pressure so I hang a large bag of fluid, run the line through and attach it to her IV. At this point, my partner decides to intubate. I’ll be honest, it wasn’t the move I woulda made. It wasn’t wrong either- she was only barely breathing and she had vomited so her airway was definitely compromised, and the best way to secure a compromised airway is to put a tube in it. On the other hand, the EMTs were moving pretty good air into her with the ventilations and most of all, when they tried to put in the plastic piece that slides into your throat to help the air in, the patient gagged. If she gagged on a little piece of plastic at the base of her tongue she was def gonna gag at a tube reaching all the way into her lungs. Also, if she was an OD, the narcan will bounce her out, and the last thing you want to do is wake up in withdrawal, puking and with a tube down your throat.
She gags on the tube, pukes again and then her heart rate drops from 60 to 50 to 40.
“Shit.”
The EMTs go back to giving ventilations. Her oxygen saturation is fairly high but she still has no pressure and now her heart is waaaaaay too slow. I push an amp of pure sugar into her, just in case she’s a secret diabetic or somehow dropped her glucose level, and then some more narcan. Nothing’s working. Generally, when young, healthy people’s heart rate’s start spiraling down its because of a respiratory issue, but also from stimulation of certain nerves, which I’ll get into in a minute. As long as there’s no underlying situation keeping their rate low, a few minutes of good solid ventilations should bring them up to speed, with or without a tube.

We start packaging to get moving, keeping an eye on the monitor. She slips up to 48, 52 and then falls back to 44. We musta looked like we were watching a sports game, the way our eyes followed those numbers on the EKG. My partner and the Lt on scene wanted to push atropine, a drug that suppresses the body’s ability to slow its heart but I wanted to give another minute or two to let her resolve herself before we shoved any more drugs in her. Atropine’s no joke, and if you give it too slowly it can actually do the reverse of what it’s supposed to and drop her heartrate even further, which would definitely kill her. I drew up the medication to have it ready, we lifted her up to the stretcher, explained the situation to the husband, sent someone to call the elevator up for us so everything was ready.
Her rate evened out at 42. I pushed .5 mg of atropine (quickly) and stepped back. Nothing happened. Then it went up to 50. Then 54. Long as it stays over 60 its ok w/ me. 58. Then 64. We all let out a sigh of relief and start wheeling her out. 68. In the elevator, the rate stays a steady 70 and our lady opens her eyes and pushes the oxygen mask out of her face irritably. In the bus, she tells us her name. By the time we in the ER she’s more concerned with how her husband will get home from St Lukes then the fact that she just basically died and came back.
“I was with it the whole time,” she tells me. “Praying. I could hear everything you were saying. I just couldn’t speak. I just prayed to the Holy Spirit to keep me around.”
So: wtf happened? I’ll tell you what I think.
There’s this nerve that runs from your brain down behind your eyes, past the back of your throat and into your heart. Because of its long, winding path, they call it the vagus nerve (as in vagabond, wanderer, vague, vagrant) . The vagus nerve slows your shit down. When you yawn you stimulate it, but most notably, and this usually happens to the elderly, when you bear down, like when dropping a deuce, you stimulate that thing like crazy. It’s called a vaso-vagal response and is responsible 99% of old people that we find unconscious on the can- they bare down, trigger the vagus nerve, slow their heart which drops their blood pressure and they pass out.
Probably, our lady had a mild allergic reaction to the painkiller, which caused the itchiness and nausea. She vomited, vaso-vagaling herself out. When the EMTs arrived and put the plastic piece in to keep her airway open, she gagged, stimulating the vagus even more. Then the tube added insult to injury, PLUS the painkiller may have already been boosting her parasympathetic system, which keeps everything depressed. The result: respiratory arrest, no blood pressure, unconsciousness, low heart rate.
Of course, it’s easy after the fact, when husbands and lieutenants aren’t running around screaming and women aren’t not-breathing on the ground in puke, to see all that clearly. What the job presented, much like the dude last week who coded, was a fluid, ever-changing situation. As a medic you’re constantly weighing what your options are, what the consequences of each one is vs the consequences of inaction. There’s a million different subtleties in between over-aggressive treatment and doing nothing, and somewhere in there is the path to reversing an imminent cardiac arrest. In situations like these, when there’s no one clear pathology or treatment plan, it takes a cautious trial and error to proceed, which sounds iffy from the outside but ultimately saved this woman’s life.