This Week In Other People’s Disasters

There’s an ebb and a flow.
months and months will pass and you’ll only bring in chronic neck pain, chest colds, the occasional migraine and the same five drunks again and again. A minor MVA will seem exciting. These are the months i want to quit and never see an ambulance again in my life. Then, just when you’re starting to drop your guard and accept that you’re really just a glorified taxi for the inept and accident proned and chronically vaguely unwell, some real ass shit goes down.
And while you’re still marveling that anything worthwhile happened at all, it happens again. And then you’re pivoting and splicing your way through a whole barrage of megacodes, epic disasters, medical mysteries and whatever other series of other people’s misfortunes the world has to offer. Fun!

These past two weeks were in that vain. First a perfectly healthy looking fifty-year old just up and died for no apparent reason in the West 4th Street train station in the middle of the mid-afternoon rush home. So death became a spectator sport because let’s be honest, who wouldn’t stop and stare at such a sight: A team of firemen, EMTs and medics pumping up and down on the guy’s chest, yelling commands, disagreements, possibilities, drug administration numbers, semi-coded curseouts, intubating, sticking in IVs, glancing at monitors…All that. The gapers irritate me, but the truth is i’d watch too.

He came back. And well he should’ve, young fellow like that, plus he dropped in public, which means everything happened fast and speed is everything in those situations. Still, you never presume someone will come through. Well, I don’t. But yes, there was that bounding pulse at his neck and then we heaved him up four flights to ground level and loaded him onto the bus and lo behold, the pulse was gone. Crap. Did some shit, got things ready to move and enroute he came back, good strong pound pound and a solid blood pressure to boot and last time I checked he was still at it.

Then some dude who’d been coughing for like six weeks called from around the corner from the hospital because he was “coughing a lot.”

Ok.

Then was the 40 year old that nearly passed out in a swank uptown bistro. She’d had a sudden bout of unfathomably intense abdominal pain ( did she say “unfathomably?” maybe not. But her face did. ) and when she went to the ladies room everything got bleary. She slid down the wall and we found her sobbing, holding her tummy and with no blood pressure at all. No blood pressure, unless there’s a good healthy reason for it like you’re an athlete or extraordinarily chill or a yoga master, is a very very bad thing. It usually means you’re about to die. Your heart should be zooming at that point, to compensate, pumping as much blood as it can and if it’s not you’re really really about to die. So, her heart wasn’t going that fast, another bad thing.
Why do people have no blood pressure? Either their blood vessels have suddenly opened up wide to fight off a perceived threat, like with an infection or a allergic reaction, or the heart isn’t pumping right, usually this would be a massive heart attack or someone with a cardiac problem already in the works, or you’re losing blood or massively dehydrated. Since she’s not febrile or breaking out in hives it’s not the vessels, and she’s not having chest pain or a cardiac patient so it’s almost definitely not cardiogenic shock, so we’re left with the fluid. She’s not visibly bleeding out, she hasn’t been shot, so the bleed is internal. Usually, these are in the GI tract and they eventually find their way out in the form of blackish tarlike poop. No fun. Sometimes it comes out all fresh and bri…you get the point.
Anyway, ok, that’s a good possibility here, but there’s another piece of the puzzle to consider. The patient’s last menstrual period was two months ago — she could be pregnant. Anytime you have a hypotensive, almost passing-out woman with sudden onset lower abdominal pain and any possibility at all of being pregnant you pretty much have to assume she’s having an ectopic pregnancy. This is when the egg fertilizes in the fallopian tube and then ruptures, causing massive internal bleeding. Which is exactly what happened with our lady.
There’s not much we can do for that prehospital. We put a huge IV in to replace as much fluid as we can as fast as we can. We throw an oxygen mask on her, we lean her back and move fast, plowing rudely through the shocked diners and whispering waiters. We haul ass to the bus and then haul ass to the hospital and let ’em know what we comin’ with so they have fluids and surgeons standing by.

Then some lady called for her grandad, he was having “chest pain”, even though he hasn’t spoken or moved any of his extremities since 1998, still, he was having chest pain. And difficulty breathing. And he had to go to the hospital. Right.

Then a slew of drunks. All familiar.

Then an old guy laid out in his own piss, squirming, moaning, writhing. Home Health Aid epically unhelpful, but still, he’s a diabetic so we just go head and check his sugar figuring that’ll be that. And it’s low! So low the monitor just says “LO” which is great for him, because sugar is a thing we can fix up, so we do. Except then he’s still not with it. And his blood pressure’s insanely high, 240/130 or somesuch disasterness. This is all very bad. It means he’s having a stroke and there’s absolutely nothing we can do except move fast, and even in the ER they’ll be pretty helpless because with stroke treatment, timing is everything and since we can’t get a straight story from the HHA, who’s probably high and definitely…not bright, we don’t know the onset time. So, grandpa is basically on his own as far as healing. We package him up, drop a most difficult and delicate IV in one of the meandering little slipstream veins hiding along his forearm and go go go, knowing all the while the deal is basically done.

Dead Guy In An Elevator

maybe I should start having more chipper names for these posts… Maybe that’d be deceitful though. I dont want people coming here thinking it’s gonna be all care bears and unicorns and then getting traumatized when people keep dying. Yeah, okay. *keeps title*

ANYWAY: job comes in as “MAN ACTING WEIRD, DIZZY IN ELEVATOR” and the address is an old people home on East 128th Street. Apparently by “acting weird” they meant “dead” because when we get there there’s a crowd of geris staring at an open elevator door and inside there’s a guy lying there on his back, dead. Well, damn near dead, I should say, because just as we roll up he takes one, final gurgly breath (gurgley? Gurgle-y? …whatever) and then he’s really dead. 
Oy. 
We gently, respectfully and very quickly drag him out because when you’re working up a cardiac arrest the last place you want to be is in a cramped little elevator. We park him right in front of the door and start a round of compressions.
Now normally, i think i’ve probably said this before a bunch of times here but there it is, normally when you have a cardiac arrest they send two units so the EMTs can pump away at CPR while we get our advanced life support on, intubation and IV meds and electricity, but here since the job came in as “acting weird” they just sent us. So, there’s a lot going on. I can’t even tell you the exact order of things happening, because there’s a few moments in there where your hands just move in automatic pilot, compressing the chest and tearing open packages and setting up IV lines and tubes and compressing the chest more and getting the oxygen tank and tube in order. At some point the elevator door opened again and a gaggle of elders was traumatized and then the elevator door closed and we pulled the guy a little further into the lobby.
We called for backup but they were still a few minutes out. The only other person around with less than a century of living was the security guard and he was about 12 with the wispy beginnings of a ‘stache just starting to make an appearance at the edges of his mouth. 
I ask him if he knows CPR.
“No,” he squeaks. 
“Well, time for a free lesson, c’mere.”
I gotta give the kid credit: he jumped in even though he was clearly boggleyed at the whole situation. 
Push right here, I said, pointing to the sternum. Just like on TV.
He did some kinda timid, halfassed finger dips and I told him he had to put some back into it, which he did. The ugly truth about CPR is that usually if you’re doing it right it means you’re breaking some ribs, a dull crunching with a little extra give that you actually get used to pretty quickly, but probably less so when you’re bar mitzvah age and have never done it before. 
Cardiac arrests always feel like you’re fourteen steps behind, because every second that something isn’t done yet is another second that the guy is dead and not getting the oxygen or circulation he needs. Still, it’s not stressful in the way paperwork or organizing concerts or meeting deadlines is. You know you can only move so fast with precision, and you move just that fast. Yes you feel behind but once you’ve done em for a while you also know you’re never nearly as far behind as you feel. It always starts with a flurry of movement: There’re so many things that needs to happen right off the bat and then as shit falls into place I always take a second to step back and say out loud what’s going on. 
75 year old male — i mumble — cardiac arrest, asystole on the monitor IV in place with cold fluids running and epi, vasopressin and dextrose on board intubated with CPR in progress for 10 minutes no change on monitor unknown history allergies meds…hmmm…
By this time the EMTs have arrived and relieved the anxious security guard just when he was getting the hang of things. I’m thinking we might have to call this one. There’s no point in transporting a dead body to the hospital just so they can pronounce him there and he hasn’t had any changes in his rhythm since we started. Plus he’s old, and the older you are the smaller you’re chances of popping back around after you code. I tell them to hold compressions and check a pulse. One of the EMTs is getting into it with the cluster of ancient onlookers, (“Keep it moving people, nothing to see here” riiiiiight…whether from Alzheimers, non-English speaking or just not giving a fuck, they all just stand there, mouths hanging open). She gives up and puts her fingers on the guy’s neck and says “Oh! Pulse!”
We recheck and indeed, the man has his very own pulse and, it turns out, a halfway decent blood pressure to boot. Then things happen fast. They have to, because people don’t necessarily stay back when they come back and we’ve already emptied half the med kit into this guy. We do a cursory wipedown/cleanup, load the guy onto the stretcher, careful not to pull out any IVs or disrupt the tube and take off in a blaze of screeches and lights. 

MEGACODE

Spoiler Alert: The patient in this post does not make it. I want to get that out of the way because there’s some ups and downs in how it plays out and I don’t want to put y’all through the emotional manipulation of wondering if she’ll get through or not.

We show up on a DIFF BREATHER call and find a 70 year old woman flat on her back with no pulse. She’s a dialysis patient and has pink frothy sputum lining her mouth so it’s a safe guess she went into fluid overload from kidney failure and her lungs filled up, effectively drowning her. A FDNY chief has decided by chance to show up on the job with us and she has one of the Medical Control doctors along with her, so we have a physician on scene along with the Fire Fighters helping out with CPR.
This turns out to be cool and works in our favor because the Doc is actually very laid back and not trying to run shit – we’re able to circumvent the annoying process of calling Online MedCon to get permission for certain medications. Sometimes, when too many authority figures and egos get on scene together there’s an inevitable clusterfuck to be managed, but fortunately that wasn’t the case here.

So we put our monitor on the patient to see what rhythm her heart’s in. What we see looks like a regular old heart rhythm, a little slow perhaps but basically could be a perfectly healthy person. Except she has no pulse. This is called Pulseless Electrical Activity and happens because sometimes the heart has a little life left in it, just enough for the electrical impulses to keep flickering away but they’re not getting capture with the actual musculature of the heart, so there’s no beat, no movement to speak of, just a parade of ghost complexes marching past the monitor screen.
So we start CPR, i set up the intubation kit while my partner prepares the IV and the Chief gets the woman’s basic information from her son. I’m trying a new technique with intubation, just a simple adjustment on how I grip the handle of the tool we use to open up a patient’s airway but it works like a charm: I can see straight down her throat and the two diagonal white lines of her vocal chords open up in front of my eyes, a perfect view. I slide the tube in, we confirm it’s in place by listening to her lung sounds and my partner gets the IV as the Chief comes back in to inform us the woman is a leukemia patient, besides the kidney failure.
We stop compressions, check a pulse and low behold, there it is, thumping away a little weakly but still: there. So we start setting up to transport her and are trying to check the blood pressure when she loses pulses again, we jump back into CPR, start pushing medications. When we stop the next time she’s in Ventricular Fibrillation. Commonly known as v-fib, this is when the ventricles are just jiggling away uselessly, not pumping blood, not doing much at all but sending crazy wavy lines on the monitor. I charge up the paddles, an alarming wail climbing in pitch till it’s a squeal, make sure everyone’s clear and then shock – the patient’s lifeless body jolts once and we start CPR again.
It happens again- four more times in fact, till we’re all looking back and forth at each other like “Really?!” because v-fib is not a rhythm that tends to stick around. When you shock your effectively jolting the heart with the intention of restarting and usually it’ll either come back as some living rhythm or just flatline out and that’s that.
We’ve already pushed four different medications into her, meds to stimulate her heart, meds to preserve her tissues, meds to balance her electrolytes, meds to keep her sugar levels up, and now we push another that reduces the irritability of her cardiac cells to keep them from fibrillating. When we check again it’s in an extremely rare form of v-fib called Torsades de Pointes (here’s another Torsades case i had with a happier ending) which is actually quite beautiful, a spiraling double helix kind of pattern on the monitor and gets a whole other medication to try to tame it back to something healthier.
Nothing works.
After we shock her five times the squiggle steadies out into flat with only occasional, large messy blips. This is called idioventricular and it’s the end. It means the ventricles have all but given up and are just sending a last, useless series of impulses out. We keep pumping the chest, keep squeezing oxygen into her, keep giving meds but finally the last squiggles pass by and the line is fully flat. At this point, the patient has been down over 45 minutes and we’ve given her every medication and treatment possible to keep her alive. It’s a moment when a medic has to understand that the time has come, our resources are exhausted, we pronounce the patient and begin the careful process of undoing the past hour of messy interventions, pulling out IVs and unsticking the shock pads, finally lifting her lifeless body onto the couch and making her look as peaceful and presentable as possible for the family.

CALM THE #%&*! DOWN

Seems the most common way for people to almost die is Acute Pulmonary Edema (APE). This, as I’ve blogged a lot about already,  is when the heart isn’t pumping adequately enough and fluid backs up into the lungs, essentially drowning the person inside herself. It can happen over the course of days, a gradually rising tide, or it can flashflood and kill someone in seconds, pink frothy sputum coming all the way up their airway and out their mouth. Usually folks show some signs as it’s approaching, something called othopnea which means they can’t lay all the way back without getting short of breath and is measured by how many pillows you can sleep comfortably with (six pillow orthopnea would be a very bad thing). Another sign is Paroxysmal Nocturnal Dyspnea – a fancy way of saying sudden late night breathlessness, (which now that I think about it sounds like a fancy way of saying something else altogether…)

Anyway, Congestive Heart Failure is the chronic condition that causes this, but it can come from a sudden heart attack or fluid overload from kidney failure or massive hypertension, among other things, but basically, it’ll kill you. By the way, i just made up the term “massive hypertension” do NOT use it if you want to impress people with your medical lingo.

When a body is starved of oxygen, there’s a period where it just goes batshit before it gets exhausted and starts giving up. So batshit could be described as a latesign, something foreshadowing total respiratory failure and then cardiac arrest. this is bad news because getting all worked up increases demand on an already taxed heart and makes it very difficult for us rescue folks to do complicated things to you like start IVs and put on oxygen masks. In fact, as I’ve said before, not tolerating an oxygen mask is almost always a sure sign someone’s about to go down the tubes (unless they just broke up with their girlfriend and they’re trying for attention). It means the body is SO confused, the brain is SOO starved of oxygen it can’t even figure out what it needs to get better any more.
This lady we had last week (betweeen the 2 arrests I blogged about previously) was already at that point when we got there.
She was also a fighter, so not only would she not tolerate the mask, she was throwing old lady punches every which way to keep us back. And here we are with needles in our hand trying to be like, “Ma’am…ma’am…we’re here to *ducks*…ma’am!” and my partner trying to get near enough to put the oxygen mask on…not happening.
Fortunately, her daughter happened to be an EMT so she got in close and tried to calm her with a mix of loving caresses and CalmTheFuckDownCoños. Grandma didn’t calm down but it distracted her long enough for me to grab her arm and put the IV in, but then of course she started flailing again, so I had to hold the arm still with everything i had to keep the catheter secure while I with one hand undid some tape and mummified that shit tight so it wouldn’t go anywhere.
Meanwhile, my partner wants to put her on CPAP, which is an even more intense kind of oxygen administration, basically a reverse vacuum cleaner strapped tight to your face, shoving air down your throat. It’s a lot to take even if you’re not panicking.
She’ll stab you before you get the first strap on, I mutter beneath her screeches.
that may be true, he says, putting the mask down.
Thing is, she does need it. Lack of oxygen is what’s making her crazy and CPAP is the best way to get her lots of oxygen fast. But not if she’s too busy tearing it off her face throwing it at us to get any good from it.
At this point, our IVs in but I’m really looking at this lady like she’s going down at any second, from the sheer amount of excitement her heart might damn well explode. Okay, not really, but it will continue to suck valuable resources from her body, and she can’t maintain for long.
We call for backup, on the premise that if she codes, we will need more hands to do it all right, and put some energy into calming her as we start setting up to get moving.
I think it must’ve been the daughter’s helping out, because slowly, gradually, the screaming and yelling subsides and we’re able to get close enough to give some medicine. That one thing, the calming down, sets of a chain reaction of events that basically guarantees our patient will get to the hospital without indrowning or even a tube down her throat. The medicine opens up her blood vessels some, dropping her blood pressure, relieving more burden from her heart. She finally lets us put the o2 mask on her, raising her oxygen levels and calming her down even more.  By the time the EMTs arrive she’s so quiet I actually have to check a pulse, but then she looks up at me, still with defiance and her eyes but mercifully calm, and takes a breath.
I put the daughter on keep-her-calm duty and we zip off to the hospital.

THIS WEEK IN DEAD PEOPLE

Lord my blog is morbid! i forget sometimes, because it all’s become a pretty harmonious aspect part of my everyday life, but then I scroll down the past bunch of entries and make boggly eyes at some of the shit that’s come up. Anyway, for an ongoing collection of stories that are so much about death, the thruline really is Life: sustaining life, living life amidst death, letting go of life when the time is right. Alladat.
aaaand, this week is no different. It was a morbid ass week, i won’t lie, but only in that tumultuous, joyful, challenging way that it so often is in my job.

Started with The Stench. Never a good job to get. I think PD gets it as the FOUL ODOR, for us it’s a CARDIAC ARREST because if something smells SO bad you have to call 911, it’s probably dead. Fire trying to get themselves canceled the second they get there- “Um, you really gonna need us? It says Possible DOA in the job descrip…” which is an absurd excuse to leave because “possible DOA” can mean anything from dude taking a nap to…well, to what we ended up finding.  So i tell Fire no, y’all comin up there with us, possible DOA or not. As I’ve said before, the main thing you need on a Cardiac Arrest is enough hands to have CPR ongoing while we do the other stuff, and I wasn’t about to be the jackass that cancels Fire only to have a just-died dude on his hands and no one to pump the chest.

When the elevator door opened on the third floor, the whole Fire crew literally took 1 step into the hallway, did an about face and went poof. And at that point, I couldn’t blame ’em. The smell of human decay is singular, unmistakable, unshakable. Some EMT showed up out of nowhere acting all cocky and loudmouthed about something, I don’t remember what, so we let him go in first. He opened the apartment door and then we all had to move out of the way while he ran retching in the other direction and then was never heard from again. Poked my head into the apartment, not breathing through my nose at all. Didn’t see anybody, just a dingy old onebedroom, cluttered with old magazines and piles of clothes. I peeked alittle further in, but the door was one of those swings shut quick behind you joints so I kept one foot blocking it. The air was thick and nasty and ahhhhh yes, there on the couch was the gentleman, lying peacefully on his back in a state of total Indiana Jones style decay/damn-near mumification. I hadn’t noticed him because he was so perfectly still, obviously, and so many different colors that a human being should never be. 
It’s possible that I said “Where’s the dead guy? Oh.” But I can’t confirm that.
Anyway, we made a quick retreat, ganked PD’s paperwork so we could write the guy’s info down from the safety of our air conditioned ambulance and then went out to breakfast.

The next night we started out with a 55 year-old dementia patient who’d turned up dead on the floor of his nursing home room. He was on the young side, but otherwise, it was the same nursing home “we just saw him alive 5 minutes ago” routine, when clearly he’d been down much longer. It’s maybe one of the saddest parts of my job that I’ve come to expect that kind of utter-incompetency and negligence from nursing homes, but that’s what it is. He probably didn’t have a chance but we did what we could. The family showed up halfway through, and we tried to have them stand outside but the son, a tall cat in his late 20s who was fasting for Ramadan and had been an EMT for a few years, just stood there shaking his head and saying he’d seen it all before. Family reactions are hardest when the death comes out of the blue, there’s no time to brace for the impact and it just seems to sweep people up and knock them over like some angry wind. The son stood there solidly while the patient’s wife bawled on his shoulder. I don’t like prolonging the uncertainty. As long as we’re working on him, all that maybe maybe shit gets drawn out, when really, it’s not a maybe maybe situation. So i call, get a time of death and that’s that. The son thanked us and then swooped around his mom like a big bird and the true mourning commenced.

Then some lady called us because her back had been hurting for like 18 years and she just couldn’t take it anymore.

At six or so that morning, an asthmatic woke up barely able to breathe. He told his brother to call 911, put himself on a treatment and died. We got it as a DIFFBREATHER first, “…unable to speak in full sentences…” (never good) and then as we approached it became a CARDIAC ARREST. The brother had started CPR right away, and the EMTs were doing those real good ribcracking compressions, and the guy was only fifty-something, so everything was basically in place for him to pop back around, but still, he was flatlined, which is the deadest rhythm your heart can possibly be in, and he didn’t change in the first 20 minutes of working on him. I did a round of compressions, felt the crunching of breaking ribs beneath my hands, then handed it off to fireman and stepped out the room to call Medical Control.
Passed the guy’s ancestor shrine on the way down the hall. I was on hold with telemetry, so I just gave them a nod and mumbled ‘go take care your homeboy,’ and then the doctor picked up. Laid the presentation out to him, got a few more medications to give and came back in the room. The EMTs are still pumping on his chest. I push the meds, we do some more CPR and then stop to check a pulse.
“Pulse!” the EMT yells. “Strong one!”
Indeed it is – a good solid pounding up his carotid artery. His blood pressure’s a healthy 148/72, his heart’s a little fast, but that’s to be expected considering everything. Okay. now we have to move. People that come back like that can look really really good until all the sudden they’re not, and then there’s a tiny window when you might be able to get ’em back stable but it’s real touchy, and really, they need an ER at this point. So we scoop him up, gather our shit, carefully carefully lift him on the board, because if we dislodge the tube right now it’s a wrap, and bustle him off to the ambulance. Downstairs we recheck everything: his heart rate is still good but his pressure’s diving. The recently-undead can be so finicky and unpredictable with their blood pressures! It’s not low enough to intervene yet, and given said finickiness I tend to be a little tentative about putting major gamechanging medications on board prophylactically, which is what the lieutenant on scene thinks we should do.
So i hold back on the dopamine, and sure enough when we get him in the ER and they take his pressure it’s through the roof high, 180/100 or something, and any kind of intervention would’ve skyrocketed it into guaranteed stroke territory. We give the report, the doctors are always a little wideeyed that such things happen outside of hospitals, and they take over. Before the shift ended we check on him up in the CCU and he was in an induced coma, his body being inundated with cold fluids to preserve the tissue, but he was still alive.

3RD PARTY CALLER NOT ONSCENE

I was sleeping on the stretcher early this morning and the rain was falling in sheets on the roof of the ambulance. The job they woke us up for, sometime before dawn, sounded like either nonsense or a complete mess: “FEMALE 80 DIFFBREATHER 3RD PARTY CALLER NOT ONSCENE.” that usually means someone somewhere doesn’t know what to do with their grandma so they call EMS and say she’s having trouble breathing and let us handle whatever family crisis was going down. Usually.
In this case though, the patient had called her daughter, gasped “I can’t breathe!” and hung up. The daughter was on the way but when we got there it was 4:30 am and no one was answering the door. We buzz, call dispatch for a callback, buzz some more, wait. Nothing. Finally, the daughter shows up, lets us in and there’s her mom, laying facedown on the kitchen floor. You can tell right away when a body’s a corpse. It’s not just that they’re not breathing, there’s something else; a total inanimate quality to a dead person that even the comatose don’t have. She was quite dead, but had been alive at least 15 minutes earlier, so we brought her into the front room (because there wasn’t enough space to work her up in the kitchen) and began CPR.

If you’re gonna work up a cardiac arrest, the thing you really need that’ll let you do your job is more hands. This is because CPR has to be going on throughout, and meanwhile you have to be starting IVs and intubating and pushing medications and all that, so really it takes at least 4 people to do it right, but preferably more. Since this job came over as a DIFFBREATHER and not an ARREST, it was just us. I come up on the radio to call for our backup, as I’m pumping up and down on this woman’s chest, and nothing happens. No staticy reply, no other units chattering. Nada. My partner tries too and gets nothing. One radio keeps shutting off and the other gets no signal whatsoever.
Mumbling and grumbling and still pumping up and down while my partner gives ventilations, I call the dispatcher, but of course, the number i have in my phone still goes to the Brooklyn desk, and for whatever stupid reason they won’t transfer me.
-i can give you the last four digits of the number you need, the dispatcher tells me helpfully.
How bout you go ahead and give me all ten?
-Oh, I don’t know them.
There was a pause then as a million unfathomable curses swung through my head.
Meanwhile, I’m panting, and the phone is cradled in my shoulder and I’m trying not to let it slip and fall onto the patient and the daughter is watching from the kitchen, trying not to burst into tears.
-But I can tell you the first six numbers are the same as the ones you just called for the Brooklyn board.
what. numbers. are. they?
-Oh! I don’t know. Whatever you called!
I think I growled at that point. Fortunately I had been repeating everything back to her throughout the whole conversation, including the last 4 digits that we needed, so my partner took out his phone and put everything together.
“We have a cardiac arrest and we need backup…”
In the meantime, I get busy with the IV, which involves doing a whole bunch of chest compressions, stopping to put on the tourniquet, a whole bunch of compressions, finding the vein, which is all the harder when someone doesn’t have blood pumping through them, compressions, swabbing the site with alcohol, mad compressions, tearing open the plastic wrappers on the saline lock and the syringe, pushing saline into the lock and unwrapping the catheter, mad compressions, and finally putting in the line, compressions, and securing it down with tape. Whew. Fortunately, backup showed up right around then so I was able to go head and push the first line of medications without stopping every five seconds.

Amidst all this, I’m trying to explain, without being too grim or falsely hopeful, to the daughter that her mother is in cardiac arrest and what exactly that means. I do this because all too often, people believe the crap they see on TV with dead folks popping back alive every time someone bounces on their chest for a few seconds. Without obliterating all hope, I want the family members to understand the gravity of what’s going on. It can get even messier when we’re forced to transport the patient, for one reason or another, and then people really believe they’re going to make it, when in reality they so rarely do. So, I’m panting away, holding the calmness in my voice, and the daughter is taking it really well, nods, seems to get it, although I do see the moment of painful realization flash across her face and for a second she looks like she’s going to break but then she pulls it all together.

I start running the cold fluids, part of the new hypothermia protocol we do for cardiac arrests patients now that lowers the core body temperature with a flush of near frozen saline to preserve the tissues. But when my partner goes to intubate he finds the airway full of pink, frothy sputum. The patient had been in pulmonary edema, a fluid overload in the lungs. Pumping more into her at this point will only aggravate the situation that caused her death so we discontinue and move on to the other medications. 

At some point the daughter remembers there’s a Living Will that specifies the patient doens’t want to be resuscitated. Technically, we can only accept a true Do No Resuscitate order, but at this point we’ve already pushed all the first line meds and are ready to call the online telemetry doctors for a consult anyway, so I make the call, give the presentation and then let the doc know about the will.
The patient’s been flatline the whole time, hasn’t shown any change towards making a comeback and the will speaks for itself, so when the doctor asks if I’m comfortable pronouncing I tell him I am and he gives me a time of death.
And that’s that.
We extubate, pull out the IV, slide a sheet under her and heave her onto the daybed in an adjacent room. One of her cats comes out to see what all the fuss is about and then somberly walks away. We close her eyes, tuck her in and leave her be.

It takes a while for PD to show up, again because the job didn’t initially come over as a cardiac arrest, so I end up sitting at the kitchen table with the daughter, sipping water and chatting about life, death and cats. She’s calmed down a lot, made a quick peace with it, perhaps to grieve later. Her husband showed up and took on the grim task of alerting her estranged sisters about the death of their mother. Outside the rain is still coming down and the sun is just beginning to rise.

TO TUBE OR NOT TO TUBE

The guy’s ancient, all flaky skin and withered bones, body permanently contorted like a gnarly tree. Plus, he’s in a nursing home, and quite frankly when we get any job in a nursing home we’re surprised to find the patient alive at all. This fellow is indeed alive, but only barely. His lungs are gunked up with pneumonia, his blood pressure’s low, his temp is high and his heartrate is all over the map. He’s septic and probably has been for a while. Sepsis becomes lethal when the body feels so threatened that it opens the entire vasculature up nice and wide in an attempt to flush out whatever nastiness has entered. The blood pressure drops and the heart eventually gives up when it can’t find anything to pump. It’s similar to an allergic reaction but the patient’s already in a weakened state and becomes febrile and lethargic.

To top it off, our guy had almost no oxygen saturation. That means the percent of o2 getting to his blood stream, which in a healthy person is upwards of 96%, was down around 82%. This number is complicated by the fact that he suffered from chronic lung disease, which keeps your sat numbers down even when you’re not acutely ill. He’s moving air, although not much, and his mental status is impossible to really gauge because according to the staff he’s either agitated or vegetative but never makes sense. Right now, he’s agitated and makes no sense.

So what we have is a decompensating patient. We have a few things we can do for him to keep him from checking out on the way to the hospital but really he needs lots of antibiotics and to have his position in bed changed more than once every couple days. To keep his pressure from bottoming out, we put two of the biggest IVs we can on him and start dumping fluid through them. This helps fill those wide open vessels and gives the heart something to pump.

His breathing though, is another matter. Even with a mask blowing high-concentration oxygen straight into his face, that sat is still hovering in the mid eighties. By some standards, that number alone would get the guy intubated but most medics know better than to treat a patient by numbers or monitor readings. The problem is this: intubation is an invasive, complicated procedure. When you do it on a live patient it often requires sedation, which means further depressing his respiratory drive and mental status. If he’s far enough gone to be intubated without sedation, you still need to lay him supine, which is a bad position for patients struggling to breath, open his airway enough to see those vocal cords, wait for them to open when he takes a breath and then put a tube between them, all the while depriving him of oxygen. Either way, you risk stimulating the all important vagus nerve, which runs behind the throat and slows the heart rate. In such an unstable patient, vagal stimulation could easily spiral them into bradycardia and then death. Also, intubation comes with added risk of infection, especially in the pre-hospital setting.

Of course, a tube means a secure airway, and this patient’s breathing is far from stable. Once the tube is in your pumping oxygen directly into the lungs. The question then becomes: is his situation unstable enough that it’s worth risking tipping things even further with intubation or will he hold out to the more stable environment of the ER, where they have paralytics, other airway options, bright lights, non-swerving through traffic surroundings, etc etc…? Of course, it’s case by case, there’s no one answer.
I try to gauge how acute a situation is based on how the patient responds to our lesser invasive treatments, how the pathology changes in the short time we’re one scene. A lot can happen in 10 or 20 minutes. Someone in Acute Pulmonary Edema, for example, can go from mild distress to having fluid filling up to the top of their lungs and coming out their mouth in a matter of seconds. Or it can take hours, days even. With septic patients, especially in nursing homes, it’s particularly hard to get a good history because they’re often not with it enough to tell you (and neither is the staff).
So you look at what you have. If I’ve been on scene for half an hour and the patient hasn’t declined sharply I tend to cautiously put more aggressive treatments to the side. I say cautiously because an unstable patient is an unstable patient, so the tube kit is never far from my grasp.

My partner wanted to intubate this one. I see where he was coming from but to me, it was an unnecessary risk. I’ve seen medics go to tube very similarly situated patients and ended up pumping on their chest. We went back and forth a few times in that respectful, quiet way that you have to use when you’re on scene and there’s other people around. I had a sense that the patient wouldn’t put up with much tinkering around since he kept pulling the oxygen mask off; we agreed my partner’d take a look and see how it went but not push it. When he went to open the airway, the guy slapped him across the face. Sometimes, the patient will tell you all you need to know about a situation. If they’re messed up enough to consider tubing but strong enough to deck you, they’ll probably make it to the hospital, which this dude did.

¡ECLAMPSIA!

I was working BLS this weekend, which basically means I’m lugging 30 lbs less equipment and they send us the stupid nonsense calls on purpose instead of by mistake. Except this one: comes over as your average boringass ‘SICK’ call, which can be anything from ‘My nose hurts’ to ‘I’m upset.’ This one was 23 year old female with headache. No further information. Fine. When we get there a dude’s flagging us down from outside the building looking real urgent. “She’s having a stroke or a seizure or something! Come quickly! Please!”

I’ve already mentioned that people love to hurry us along for even the lonliest little toothache or whatever, but as time goes by you can kinda distinguish between the guy that is just wants to someone around and the person who really and truly fears for their loved one’s life. This guy was definitely the second. Then he mentioned, as we hustled through an outer open area and up some stairs, that his wife had just delivered a baby five days ago.

Now here’s where any medic or EMT worth their salt should have the word ‘eclampsia’ dancing through their mind. Not as a definite, cuz we gotta wait till we see the patient and all that, but between the call information and the husband’s story, you have a pretty textbook eclamptic patient. What it is is an obstetrics disorder where the blood pressure shoots through the roof causing blurred vision, massive headaches, edema in the extremities and sometimes blood backing up in the lungs. All that is pre-eclampsia, when the patient actually goes into a full tonic-clonic seizure it becomes eclampsia proper, which is gets its name from the Greek word meaning “shining forth.”  It’s rare we see even a pre-eclampsia in the field and rarer still to see a fully seizing pregnant woman, but sure enough when we walk in we find the patient just finishing her last convulsion and settling into a postictal stupor complete with snoring respirations, drooling, rolling eyes and occasional tremors. (I’ve heard varying reports but apparently it can happen up to 4 weeks after delivery.)

So, like I said, I’m BLS and don’t have any medicines with me and really there’s nothing worse than being at the scene of some magnanimous disaster and utterly helpless to do anything about it (See previous posting for more on that…) The family is going through all the motions of utter freakout, from screaming that she’s going to die (her mom) to trying to shut the gloomy screaming lady up (her husband) to bawling and pointing (her nieces and nephews). The pregnancy wasn’t high-risk, plus it’s over, and she has no medical problems so you can see they were all taken totally off guard when she suddenly seized after complaining of headaches and blurred vision all day. I call for a medic bus to back us up and my partner and I start getting her ready to go. Baby’s sleeping quietly in her crib the whole time.

The medics are waiting for us downstairs. I give the story as I’m fighting the stairchair with the lady in it over some bumpy pavement, praying she doesn’t seize again and topple. We’re on the bus and let me tell you, when I’m working BLS and medics show up I generally make it my business to be quiet and stay out the way, mostly because the worst thing in an emergency is three alpha medics yelling three different things. Plus, the guy working was a friend of mine and knows what he’s doing. HOWEVER, just when it seems like we’ve fallen into the whole swing of the job and everything’s moving along smoothly, he goes for an utterly different medication, Dextrose in fact, which would infer a treatment modality for a whole other situation than what we’re dealing with.
“Wait!”
I really don’t like doing that, especially when there’s a student, another medic and an EMT all right there. The guy looked at me cock-eyed. I ran down the list of symptoms and watched it dawn on him. “Why didn’t you say all that when we got here?”
“I did!” I had!
“Oh! I didn’t hear you. And I figured my partner’da given me the story.” She hadn’t.
A moment went by where we all kinda looked at each other. Then I don’t know if anyone said anything or what but we all just fell back into the business of treating the patient, now truly on the same page. Magnesium Sulfate relaxes the smooth muscles and can ease/prevent the eclamptic seizures. We also treat asthma with it and a rare form of v-fib called Torsades de Pointes. You have to mix 2 gms of it up in a 50 ml bag of saline and set the drip rate to deliver it over 10 minutes, which is a little project unto itself, so while the other medic is doing that I get on the phone with our telemetry doctor to get clearance to give the medicine.
Talking to telemetry can be an outrageous experience. There’s a medic that you have to get through to actually speak to the doctor and he’s always angry about the fact that he’s wasting away in an office while you’re out there having fun in the street and he always manages to find something to pick a fight over. I brush through him as quickly as I can, doing everything possible not to take the bait of his irritability. Then some absurd pop song comes on, because I’m on *&*&#^#*! hold of all things and finally the doctor gets on. I spit the situation out quick to him and make it very clear with my tone that I know what I’m doing, because certain doctors enjoy verbally shredding medics when they smell uncertainty. “Alright give the mag,” he mumbles, hangsup and returns to his cave.
When I get back in the bus I see the medic has asked the student to draw up the 2 gms of Mag, which he’s done, but now he’s got the syringe full of medicine and is reaching for the patient’s IV, about to mainline it. I can’t say for sure that his would kill her, but anytime you dilute a medicine in saline and drip it over 10 minutes it’s for a reason. Both me and the other medic yell “NO!” and lunge at the student who realizes his mistake and cringes. We gank the syringe from him. “Sit down,” the medic says.
“But…”
SIT.
he does.
We put the mag in the bag and I hop in the driver’s seat while they set the drip rate. Get on the mic to give our notification as I peel off into traffic. She saves her last seizure for when we roll up into the ER bay, which makes getting her out of the bus and into hospital but we eventually manage and the doctors swirl in on her as we yell out the story once again. After some messiness, they break the seizures and she’s sleeping quietly when I leave, her worried husband holding her hand and shaking his head.

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!”

EMS WTF FAQ

Okay people- I realize as I’m scratching out all these stories that a lot of folks don’t have much idea what the this whole EMS thing is all about. So here’s a primer for those that’re interested.

Q: What the hell is EMS anyway?

A: EMS is the Emergency Medical Services. That’s the whole system. There’s the transport side, which is mostly when nursing homes, dialysis centers, etc have contracts with private companies and call an ambulance to get their clients towed back and forth inbetween, and then there’s 911- which is when you call 911 and someone at 9 Metrotech in downtown Brooklyn directs your call to EMS and a GPS system tells them which 911 ambulance is closer. 911 has private ambulance companies, hospital ambulances and FDNY ambulances in it, all doing the same job and each claiming the other is full of useless skells and lowlifes.

Q: What are you- EMT? Paramedic? What’s the difference?

A: There’s Basic Life Support and Advanced Life Support. EMT means Emergency Medical Technicians; they do BLS, which includes bandaging, immobilizing, bleeding management, delivery of oxygen and a few medications and transportation to the hospital. Paramedics (that’s me) do ALS, which involves more invasive procedures like giving IVs, intubation, needle cricothryoidotomy (putting a HUGE ass needle right below someone’s adam’s apple when they have an airway obstruction) and chest decompression (putting that same hugeass needle inbetween someone’s ribs to let the air out of their chest cavity when their lung collapses.) We also give medications, about 50 of them from Adenosine to Vasopressin, and are equipped to do for an asthma or heart attack what any Emergency Room would do in the first hour of treatment. If you call 911 and say you stubbed your toe they’ll send you EMTs. If you say you stubbed your toe and your chest hurts, you’ll probably get medics. If you tell them you stubbed your toe and now you’re dead, they’ll send both. It’s happened. Sometimes EMTs will get called for the sick and get there and find a heart attack, so they can call for us. You get shot, it’s EMTs unless you get so shot up your unconscious or dead. That’s why sometimes we medics keep an ear to PD radio and take a quick ride over when there’s a shooting. If you “feel weird” you get EMTs unless you’re especially old or diabetic, then you get us. It’s all a little ridiculous but also there’sa weird logic to it. I’ll just say, when the man called the other night to tell 911 that he was unconscious, they made the job an “UNCONSCIOUS” and sent us. If you just had a seizure it’s EMTs but if you’re having one, even if you’re the one saying you’re having one, it’s a “STAT EP” (status epilepticus) and it’s medics. Even the guy that calls every other weekend because he feels like he’s about to have a seizure, but never actually does, even he gets medics, even though he’s actually an EDP and EDPs get EMTs.

Q: What’s an EDP?

A: Emotionally Disturbed Person. Aaah we could go on for hours about the many wondrous events that happen when folks don’t take their psych meds or lose their shit for one reason or another. Any of us could go EDP at any given moment, far as I can tell, cuz they range the range across all borders. Many jobs will start as DIFF BREATHER and end up as EDP when we get there and patient says something like “I haven’t been able to exhale for like three days,” or “I haven’t taken my psyche meds and I want to fucking kill somebody.” Sometimes EDPs hide behind locked doors, which makes them BARRICADED EDPs, or hide weapons places (“that’s just my rock…i keep him in a sock…” which makes them VIOLENT EDPs. They can also stand up on high places, when they become the JUMPERUP, and then fall, when they become JUMPERDOWN.

NYPD is always getting into a hot mess over EDPs and then having to get retrained on how to deal with them. Usually its cuz they get confrontational with em, and the last person you need to argue with is someone who’s completely disengaged from reality (“Sir, you need to go to the hospital.” “I am in the hospital…” “uh…”). It’s like arguing with the last drunk guy at the party. (most recently see: Iman Morales, who was screaming naked on a Bed Stuy fire escape before PD tasered him, causing him to fall to his death.)

Q: Do you really drive the ambulance?

A: We do and yes it’s really cool but blowing lights and parting traffic jams like the red sea is really not nearly as cool as some of the shit that happens in the back of the ambulance. But people are usually more excited about the woop-woop.

Q: What’s like the craziest shit you’ve ever seen?

A: Why do people always ask that like they’re the first person to think of asking it? I dunno, depends on when you ask I guess. I’ll probably blog about it sometime…

Q: Do people really call for stubbed toes?

A: Stubbed toes, runny noses, burning genitalia, crying babies. “I feel: tired, sick, lonely, strange, different, okay, weird…” “I have an appointment at the hospital.” “I just needed to get out of my house for a while.” “I was bored.” “I hate my husband.” “Can you look at this huge cyst I have on my nuts?” “My tooth hurts since like, three weeks ago.” “I don’t want to talk about it.” “I’m bleeding from vagina, same as i was about a month ago.” “i can’t get out of my chair but i don’t want to got to the hospital, just help me…get…unstuck…”

Those are really the vast majority of our calls. About 80% let’s say is freakish dumbshit and then 15% is like mildly important medical situations and the last 5 is really good urgent crazy shit. Depends on the week though.

Finally, I’ll end with this one:
We were called for the CARDIAC- 78 year old with chest pain. We arrive to find a dapper little elderly gentleman sitting calmly in his East New York apartment.
Whats the trouble today sir?
My heart is broken.
Excuse me?
It’s broken I say.
Does it…hurt?
It hurts a lot.
How…long has it been going on?
Oh quite a few years now.
You want to…go to the emergency room?
Yes please.

And away we went.