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.

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.

THE MOST SKEEVED OUT I’VE EVER BEEN

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

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

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

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

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!”

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.