¡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.

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.

SUDDEN DEATH

The guy is almost fifty, skinny and white, tatted up w/ Buddhas and Asian letters and all in all has the general affect of an angry teenage hipster.  He’s squirming and whining, and I’ll be honest, truly irritating the shit outta me and my partner. There’s a younger Asian girl there that he’s bossing around and that’s grating me even more. Also: there’s nothing apparently wrong with him. His pressure’s 158/90 his pulse is 70, he’s breathing regular, has no chest pain, no signs of trauma, hasn’t been pissing blood or puking excessively. Nothing.  That much is fine, we get patients w/ nothing wrong with em all the time. But this dude won’t sit up. Then when he does he’s slouched over so we can’t get the EKG on him properly. Then he wants to put his feet up even tho he’s in a chair and clearly can’t.
We being calm, mind you. The curseout I had waiting in the wings remained lodged in the back of my throat, even when the guy decides to lay down on the floor and starts grabbing my partner’s arm and screaming “Why won’t you give my something for my legs!? My legs are tingly! I don’t understand why you won’t help me!”
I was sharp w/ him, as I pried his hand from Mr. C, but I kept it basically cool. We lift him up, put him on our chair and cart him out. The Asian chick looks anxiously after us but doesn’t come with.
Ok. Reassessing as we wait for the elevator: he has no medical problems, no allergies, takes no meds. Has no complaint of pain beyond his legs feeling funny, but he clearly feels it when we pinch him to make sure there’s no nerve damage. He’s moaning still. When we told him we don’t give anything for funny leg feelings he apparently ignored us, cause he’s still asking for something. He denies any drug use, not sure if I believe him or not, but he’s alert, oriented to where and who he is, knows his birthday, etc and his pupils are normal.
Something happens between the elevator and the ambulance. It’s a subtle thing, very hard to describe if you’ve never seen it, but at some point, a small change in his body motion sets off little alarms in me. I can tell Mr. C sees it too, the way he eyeing the patient and then looking back at me. The guy’s still talking but his motion is more sporadic. His arms just flop loosely up in the air every couple seconds like he’s a marionette being jerked around by some sadistic puppeteer.
When we lift him from chair to stretcher there’s no question something’s wrong. He has enough energy to grab my arm and make it more difficult to move him, but that’s about it. And he’s talking less. When people who won’t shut up suddenly shut up you need to pay attention- (unlike the non-asthma attack having lady who was so busy cursing us out we couldn’t listen to her lungs, but we didn’t have2 anyway, cuz if you can curse us out w/out taking a breath for five min straight you aint having an asthma attack…)
At this point, I’m thinking hemorrhagic stroke and I’ll tell you why: The typical stroke, the one they tell you about in all those PSAs with the droopy one side of your face and slurred speech and can’t raise one hand- that presentation is more commonly for what’s called an ischemic stroke . Basically, a bloodclot is cutting off flow to one part of the brain, much like the way a heart attack works. But when the blood vessel bursts, either from trauma or high pressure or whathaveyou, its called a hemorrhagic stroke and you’re head fills up with fluid, increasing your intcranial pressure sometimes to the point that the brain tries to escape through the hole at the bottom of your skull. These kinda strokes don’t often look like the other kind: the pressure doesn’t neccesarily go as high until later on, there isn’t always one sided weakness and one thing I’ve noticed time and again with these, the patient won’t slur their speech so much as speak in tongues. It’s like the way a baby will talk utter gibberish but with total conviction, and they look like they think they really saying something that makes sense, but they just saying “Blarga blarga blorp blaa! Blarg! Blegh!”  and so on. And they get irritable.  Now this isn’t all that different from the way certain people look when they drunk or hopped up on some bullshit, mind you, and so it’s easy to miss. (Diabetics when their sugar drops tend to moan more and are usually sweaty and cool to the touch.) The only difference is that certain something, a kind of lethargy that takes over that is really a grim late sign- the body is giving up.
When we load him into the ambulance he’s pale as shit, still mumbling and squirming but looking otherwise very corpselike.  I take a blood pressure while Mr C drops a line. Well- I try- but there’s nothing to hear.  A very late sign. The last thing I notice before I slam the back doors closed is his respirtations- his body can’t be troubled to open his mouth any more, so they come out in a rude snoring kind of way, all spittely and loud.
I jump in the front, let the hospital know we comin and blast off down Dekalb. When I open the back in the ER bay Mr C says: How fast can you set up my tube? And indeed, I see the patient has stopped breathing. His heart rate has dropped down to 40. I jump in the back, pull out the tube kit, throw him the laryngescope, which he uses to hold open the guy’s jaw and get a look at those vocal cords. I screw the syringe onto the little attachment on the tube and pass that over as the heart rate dips down to 20.
“Uh…tube quick he’s checking out.”
But Mr. C is no fucking joke with a tube, before I can count to 10 he’s slid the thing in, confirmed it with the stethoscope and I’m passing him the platic device that holds it in place.  The heartrate slides back up to 50, then 70. “Ok, we straight,” he says, but then the lines on the EKG go all squiggly. “He’s in V-fib,” I say, going for the pads and thinking if this dude takes one more damn turn for the worse… Before I get a chance to put the pads on the rhythm straightens out back to 50 and then starts dropping.
We load him out the bus and hustle him into the ER, yelling out the presentation to the docs as we go.  His heart’s at 20 when we wheel him in and stops completely as we reach the crash room, where they work him up for another half hour before pronouncing him dead.
Ok, a couple things w/ this job:
It startled the shit outta me.  I’ll be honest- it didn’t really bother me so much as it just caught us off guard. In the end we moved with what happened, didn’t get caught up in the tunnel vision and what it started out as vs what it became. It was definitely a solid reminder to stay flexible: even when something looks, smells and sounds in every way like a basic bs anxiety attack, some real shit can be lurking.
Was there anything we could’ve done to stop what happened? Nope not at all. What this dude had going on was beyond anyone’s capacity to stop. He didn’t show any hints to what might’ve been going on before he started crashing and once he did it was waaaay to late to stop. Plus, we have nothing with us that would’ve stopped it.
Sometime I’ll blog about dealing with death on this job, but that’s for another day.

‘TIS THE SEASON TO BE…DEAD

Apparently. Cuz people always in bad shape during the holidays. Folks with families get stressed by their families. Folks without ‘em wish they had ‘em. Everyone’s stressed. It’s like your birthday, when you spend so much trouble tryin to have fun that it sucks, except the whole damn world’s doin’ the same way.
So last week was the triple shooting and the crazy come-back arrest. Then Saturday at 5:40 they wake us up for an “UNCONCSCIOUS” call up the block, but you can tell within 2 seconds of walking in the door that she’s dead. She wasn’t the kind of dead that comes back either: 76, morbidly obese, a million medications and disorders, living in utter squalor and sitting up in a puddle of her own pee. The folks around her thought she was still alive, which is always unnerving, so we cleared the room and started working.
My partner intubated while I poked around for an IV. She had big veins but they wound in crazy angles all up and down her arm, none long enough to really land a catheter in. I put one in but it was reeeeeeal tentative, like the slightest jolt would knock it out of place, which is exactly what happened after I got a few rounds of epinephrine and atropine in her.
Meanwhile, the EMTs arrived and started pumping on her chest- ribs cracking, the smell of pee and stickiness underfoot…you just learn to ignore it. The monitor’s showing us nothing- just that flat flat flat line that means the heart isn’t even considering doing anything different than being still. I’ll be honest people, I don’t like disturbing the dead. I believe in giving people the best chance they got and I wanna keep my job so we work up anyone without Rigor Mortis or other signs of Obvious Death, but the least amount of intrusion I can do on a body the better, and it seemed to be this one’s time to go.
So we get on the phone, make a call to our medical control docs to see if they want us to do anything else. It’d been 45min or so and the time had come, and just when we’d dropped in an amp of dextrose and two of sodium bicarbonate, lo and behold, the lines on the monitor go all squiggly wiggly- v-fib. A shockable rhythm. But still – even that…well: we shock (“bla bla bla I’m clear, yer clear, we’re all clear…KAZAM!”) and lo and behold once again, she has a nice real normal rhythm and—check a pulse: a PULSE, a bounding pulse no less, to go with it.
“I’ll be damned…” I say out loud, cuz I really was caught off guard. We roll her body over to one side, shove a sheet underneath, roll her back over. 1, 2 ,3 and heave ho all that dead but alive weight up and on to the stretcher. As we clamor out the cluttered apt door, the lieutenant’s explainin’ 2 the family what’s going on, and their squinting at her like- the fuck you talking bout lady! And I would be too, quite frankly.
I truly don’t expect our lady to last very long and that may seem negative, but consider that most folks who do make it end up purely vegetative, especially after being down for so damn long- it was literally and hour and a half from the time we arrived when we rolled her in2 Long Island College Hospital, (still with a pulse)- and I wouldn’t wish that on anyone endless alive but dead nothingness on anyone. But there it is.

Then on Sunday it was a super rich doctor dude on the Upper East Side. Lord, I’m talking doorman, massive lobby with a fountain, the full spread. The guy’s layin on the carpet, had just vomited, pale as shit, sweatin’ and was having a sudden onset of crushing chest pain. AND then we put him on the monitor- his hearts going a sluggish 40 beats a minute (should b btwn 60 and 100, and this dude was no athlete…). His pressure was 92/60, probably on the way down as he decompensated from such a slow heart rate but he’d also just taken ahem, a you know a, um…
“A WHAT?!”
a, er, y’know a, well, wanted to have a good night…and…Levitra…
Ah- erectile dysfunction medications don’t mix well with nitroglycerin, by the way, cuz they both drop yer bloodpressure out. He hadn’t done that but his low bp meant we prolly wouldn’t be giving him any nitro either, which once we checked his 12 lead, we saw he badly needed. Once his heart sped up some. Too much going on with this dude, I thought, setting up the IV for my partner and eyeing the monitor like it was an nasty little creature about to attack. Jobs like this can go sour so damn fast you won’t even know what hit you. His 12 lead- which is a more indepth EKG that shows the heart from various angles and tells you if there’s any damage from oxygen deprivation, i.e. heart attack- looked like ass. It was ass. Besides his heart rate being slow as shit, his 12 lead was ass.
“fuckshitass,” I said under my breath.
“What?” The doctor said, grabbing his own 12 lead from off the floor and tryin to read it.
“Nothin,” I said, grabbing it back. “You’re have elevations and your bradycardic, but you’re not treating you, I am.”
He smiled. “Fine. What’re you gonna give me?”
I don’t like to treat any more than I have to. We were setting up to give him atropine, which would bring his heart rate up, but if that didn’t work and he stayed shocky we’da had to sedate his ass and send little electrical volts through him to stimulate each heart beat. Which I really didn’t wanna do.
“I’mma give you some fluid first, and some oxygen, and take it from there…”
“Ok,” he said, like I need his fricken signature to do it. But I just went about my business.
We attached a fatbag a fluid to his IV and squeezed it in hard. The stretcher was set up and ready to move, and we were about to drop the atropine in him when those effed up little complexes of his started coming faster and faster across the monitor. Now 52, now 56…
“wait for it,” I said, my partner with the full syringe poised over the hub.
60. Beautiful. We held off atropine, the rate evening out at a steady 64.
“How’s the pain?”
It’s gone, he said, almost laughing.
I gave him some baby aspirin to chew on- not 2 b condescending, that’s really what we carry, and we wheeled him out the door.
By the time we rolled him into the hospital even the 12 lead was looking better. He was pain free, had a solid bp and was ticking away at a healthy 70 beats a minute.

CLUSTERFUCK 1

MAKE MY FUNK THE…

Last Saturday:This dude was 60 and totally out- speaking garbly gook like he might have a head bleed but the also kinda had that o.d. look to him. Or maybe his sugar dropped. The thing is, for a medic, the most useful skill we have is our ability to get the story. The best ones are like medical Sherlock Holmeses- can figure out the whole damn scenario from getting the history. New guys always gush about the skills: can u get an iv, how many tubes have you done, etc etc but bottom line is that if you don’t know what to do with that iv when you got it, it aint worth shit. But then there’s dudes like this, who can’t tell you what’s going on cuz they’re just going: Blarga blarga blarga and the cracked out middle age ladies who were with him were either clueless or withholding info.
All they would tell us is: he’s hopped up on p-funk.
What’s p-funk?
They didn’t know. His pressure wasn’t high enough to really look like a stroke and he didn’t respond when we put an amp of sugar in him, which he would’ve if he was hypoglycemic. He doesn’t look much like a standard narcotic OD either- pupils aren’t pinpoint and he’s not in respiratory depression, but he could have any number of things on board, so we push a judicious little squirt of narcan in him to see how it settles.
Full body seizure. Not even a fake one.
This’ll happens sometimes with addicts, because the narcan puts them into such immediate withdrawal their body rebels. But this wasn’t enough to do that and it seemed unlikely that he was that far in anyway. He came out of it on his own as we sped off to the hospital, where we found out from google that p-funk is a saucy mix of powdered heroin and crack-cocaine…. Which makes me think the seizure happened when the narcan zapped the heroin out of the equation and left him suddenly full of pure crack.
Sometimes all you can do is shake yer head and sigh…

CLUSTERFUCK #1

Yesyes, clusterfuck, but first, this:
It’s pouring rain in that weird semi-suburban part of East New York where the mafia used to put all their dead. We’re backing up a BLS unit on another nonsense DIFFBREATHER. You can tell it’s gonna be no big thing from the call description on the monitor: FEMALE, 48, UPSET, NO MED HIST, DIFFBRTHR… and the EMTs are already inside so I tell my partner to wait in the bus, I’ll just take a quick looksee. When I open the door to the little ramshackle house I find a lake in the living room. The water is easily knee deep. A little electric pump is at the entrance, frantically scooping water up, but it’s facing the wrong way so all the waters’ splashing back into the house. An old blind guy is sitting on a mattress that’s floating in the middle of the room. He’s propped up on his elbows, looking around curiously.
Uh- sir? I say.
Eh?
Sir? Someone called EMS for trouble breathing?
Eh?
I gingerly wade thru the domestic tide pool to a back room, where the EMTs are chatting with a crying lady.
What’s wrong?
She didn’t take her psych meds for three days, the EMT reports
She’s not upset about…, I nod my head towards the disaster area behind me.
The EMT shrugs and the lady sobs.
Any chest pain, ma?
She shakes her head.
Any medical problems besides the psych stuff?
Another shake.
I make my “you good?” face at the EMTs and they nod (because EDPs get EMTs). I slosh back out into the living room, past the little floating old guy who says “eh” and out into the rainy Brooklyn night.

Ok now the story, and this people, is 1 of the ones that comes to mind when people go ‘Oh what’s the most fucked up shit you been in on the job?’:

Big T was grumpy that night, which usually meant that any little thing could ignite a rambling curseladen monologue that would eventually lead back to his wife. Always amusing, once you got past the fear that he might stab you up. But still- one of my all time favorite partners.
You can tell a shot is gonna be legit when it comes in a whole bunch of times in a whole bunch of different ways. This job came in on three different corners, once or twice as a shooting, once a stab. It’s not because there’s so many patients (usually), but more a hint of the clusterfuck that awaits us: shit is so chaotic and everyone is going batshit so everyone calls 911 with a different batshit story. As we start heading in the job becomes a CARDIAC ARREST, which doesn’t even mean he’s dead, just means more insanity. Now an arrest by its very nature requires two units, an ALS and a BLS, so the EMTs can do CPR while we start the ivs and intubate and shock and all that. But tonight, all the east new york EMTs were busy taking stuffy noses and stubbed toes to the hospital, so they had to send a unit from Crown Heights to back us up.

The night was thick with chaos. Even before we get to the job someone’s trying to flag us down cuz he’s getting his ass kicked over some petty robbery shit. Cops are flying around in all directions like dogs chasing their tails. It’s hot as shit out. We have to park at the top of the block because the whole thing is covered covered covered in people who spilled out of a houseparty whn the shooting went down. Everyone already wants to kick our assses the second we get there, and the only back up we have is a bunch of surly Long Island firefighters, who aren’t world renowned for easing the community’s aggression. They do help us cleave a path through the crowd though, and we finally get to our man.

BUT- there’s a chick clinging to him. They’re both covered in blood, who knows whose, and she’s screaming for us to help him but won’t get the f out of the way.
We erupt into a chorus of: lady, you gotta get off the dude so we can help him, lady, miss, seriously, now, lady, get off the dude NOW RIGHT NOW YOU’RE NOT HELPING.
And she’s screaming: HELP HIM MY GOD PLEASE OH HELP HIM PLEASE…
And believe me people, I wanted to physically detach her myself but i already had a large angry crowd looking for a reason to whup my ass and touching the screaming lady was not about to 2 be that reason. Meanwhile, we still have no BLS to back us up and the Fire dudes are looking pretty iffy about the whole thing.
Lady: HELP HIM! SAVE HIM! PLEASE!
Us: Get…OFF…THE SHOT DUDE…NOW!
And the guys barely moving at all.
It takes FD, PD and us to convincer her to get the f off him AND THEN: (and i don’t even like using capital letter but if i was telling u this in person I would be raising voice plenty, because although this happened a few years back when i was a new medic, the trauma of the night lingers. In a healthy way) Aaaaanyway: AND THEN: it turns out the lady didn’t even know our guy. Did…not…even…know…the dude….Damn. Just rolled up on the scene and jumped right into the action. Covered herself in his blood, delayed his medical care- which in any other circumstance would land yer ass in central booking, and he a total stranger. Well…sometimes you just have to move on.

EMTs showed up and I swear I’ve never been so happy to see them. Situations like this- you need as many hands as you can get. When we get him on the bus they get a blood pressure and cut off his clothes while i set up an iv and my partner does a full body super fast assessment. He’s got one thru the hand, one in the left chest and one in the gut. The chest one turns out to be a problem because it’s pierced his lung, collapsing it- that’s why he’s not talking. This is the most pressing issue he’s got, will kill him quickest. Second most pressing is the gut shot, because you can easily bleed out and/or later on, toxify your system from that. Those are eerie because you may not even see a drop of blood, but it’s all gathering in the abdomen somewhere and then they’ll suddenly have no blood pressure and crash, just like that.

For his bleeding out gut, we have a big bag of saline, attached through a drip set which is attached to HUGE ASS IV that I stick into his arm. The collapsed lung is more complicated: I pass my partner an equally hugeass needle, which he inserts into the third intercostals space, meaning between the second and third rib. With the needle removed, the open catheter allows the extra air that’s built up in the chest cavity to escape so that the lung can reinflate. It did and the guy started talking and looking a little more alive as we rolled into the er bay.

Unfortunately, that’s when things started getting really ugly.
We musta caught em off guard, cuz it was a hosp i’ve seen work miracles in some f’ed up situations. We definitely told the dispatcher to let them know what we were coming in with, but maybe they never got the message. Either way, they weren’t ready for us, which led to chaos: nurses and doctors running around, paging trauma teams, screaming back and forth. You know things aren’t going well when you have to repeat the presentation like five times to different people. In the midst of this, homeboy’s lung recollapsed right in front of me, so I re-decompressed him, using my partner’s needle hole as a marker. Then someone pulled out that fat iv i’d worked so hard to get, and a scramble commenced to get another. Then suddenly everyone disappeared for a haunted few seconds, but not for an x-ray, maybe just to huddle and try a new approach, cuz then they were all back with renewed chaos. I should’ve known just to do my job and back away, but like i said, i was new, and we’d worked so damn hard on this guy, i wanted to see what happened. He could see things weren’t going well, was yelling and screaming for them to help him and then finally, out of breathless and hopeless, just looked at me, dead in the eye actually, and said goodbye. Then he dropped his head back on the stretcher. They tubed him but didn’t have a oxygen ready to push into the tube, and by the time they got it his pressure was bottoming out and they whisked him away to surgery, where he died.

The Ungrateful Suicide

Saturday Night. Gentrification has created these weird pockets of extreme wealth in that ambiguous part of town where Bed-Stuy and Prospect Heights overlap. Me and C wind our way through the corridors of some converted warehouse. It’s dim and dank and smells funny until we step suddenly into an ornately decorated apartment with frilly columns, oriental rugs and wall-to-wall theater memorabilia. A distraught, exhausted middle-aged woman ushers us into the bedroom where we find cops and volunteer EMTs swarming around a fat white male, obtunded like a goddamn beached whale and not breathing on the floor beside his king-sized bed.

My partner C was here last time this guy tried this, and he’s asking the wife what our patient took tonight but she won’t say. The EMTs get the bag-valve mask on to giving him respirations and I’m driving tonight, so i set up the IV while C gets down to where the patient is and starts looking for a vein. The guy’s teenage son is coming in and out, I’m trying to get a coherent story while squeezing saline into lines and ripping open plastic bags, but all we can get is that the guy was drinking all night, has been depressed, has tried this before, etc etc. There’s a not that says “Dear so-n-so i love you and i’m sorry’ and then it’s all garbly chicken scratch. PD was here a few months back cuz our man locked himself in a room with a gun (a BARRICADED EDP- more on that some other time…). He’s h e a v y like you wouldn’t believe and out like a pile a rocks. I pass C the tourniquet, then the catheter (a smallish one, cuz the fellow’s fat so he’s a tougher stick and there’s no reason for anything big), and when he reports that he’s in i hand over the iv lock and a flush of saline water along with the stickies to hold it on.

The pupils are pinpoint and his respirations are still almost none, so we have good reason to suspect a narcotics overdose. I pass C a needle with 2 mg of narcan- a medication so notorious in the heroin circles all you have to do is mention it and many addicts will come jumping out of their stupor just to beg you not to give it. Basically, it blocks all the opiate receptors in your body and completely and utterly deprives of you of any possible high you mighta had. Then, you go into instant withdrawal which can mean anything from extreme irritability to severe hibijibis to simultaneous shitting and vomiting to seizures. That’s why, to avoid prolonged cleanup/resuscitation sessions, narcan is best given a) in small polite doses and b) no more than two seconds before the patient gets moved out of the ambulance and into the er.
The Dreaded Narcan…

But a suicide is a horse of a slightly different color than a typical addict OD, especially when the guy is HUGE, has taken unknown mountains of unknown narcs and is already pretty far gone. So we drop in the two mgs, enough to make your average user do the shitnpuke right quick, and it doesn’t even touch him. Practically bounces off the guy. He’s still pinpoint, obtunded, not-breathing. A hot mess. And we’re all still wedged into this awkward space between the bed and the wall. I pass C an amp of dextrose, sugar water, in case on top of everything else he happens to be diabetic and hypoglycemic as well, and then another 2 mg of narcan. Then we start packaging to go, cuz he’s still not responding and we’re reaching our limit of options. It takes about five of us to get him, strap him to a board and get him moving. We’ve all carried some fatties, but this guy is solid, dead weight and managed to collapse into a particularly un-reachable corner of the master bedroom. So we heave and ho and finally begin carting him through the windy passage ways back towards the street.

Just before we make it back out I see his arm start to raise up, and slowly he blinks back into consciousness. He looks around groggily. His hands are taped together to keep them from flopping out of the stretcher. He has an iv in him. He’s surrounded by cops and medics. He looks each of us in the eye and says:
”Fuck you guys, why didn’t you leave me the fuck alone…” and then falls grumpily back into his stupor. Then he wakes up again as we loading him up. “Damn you. Damn you all. Motherfuckers…”

What do you say to a dude like this? I mean, none of us are really in it for the thank yous, but shiet- if yer gonna be hufuckingmongous and a big a-hole to boot, yer ass can walk to the ambulance or just keep it to yerself. But in the end, you say nothing. You chuckle. Brush it off and take homeboy to the hospital, where he proceeds to curse out each and every one of the nurses, security guards and techs and then falls back asleep.
And then you go get dinner.