MEGACODE

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

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

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

CALM THE #%&*! DOWN

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

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

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

A FAT GUY DAMN NEAR DIES

Some jobs you walk in and know exactly whats goinon and what’s gonna happen next and all the things you’re gonna haveta do etc etc. You can see the whole thing wind out in front of you like a damn roadmap, and you quickly fall into the rhythm and BAM it’s over before you know it.
This wasn’t one of those jobs.
A bigass dude, and I don’t mean big boned (all though he was that too) but Large and In Charge, looking a little worried and breathing kinda heavy. Our guy’s sitting on his bed in what’s called tripod position, leaning forward with his hands on his knees, puffing in and out like he just spent 20 minutes underwater. Still, I’ve seen much worse and he’s not blue, not lethargic, not gasping. At this point, could be a anxiety attack, a mellow dramatic head cold or a bad breakup.
He’s only 34 but has an enlarged heart- damn near the size of my head, the x ray later reveals- and i literally coulda crawled into his belly and taken a nap it was so effin huge, probably from the excess fluid buildup from his backed up heart.
When your ventricles are that gigantoid, they don’t work right. Sometimes they work so asscrappily that the blood doesn’t fully make it out and stays backed up, which causes the bodywide puffiness. That’s when the right ventricle backs up. When the left one goes the fluid ends up in your lungs, and that’s when you start drowning in yourself.
Neither of this dude’s ventricles were working well. You could hear the excess blood lapping up against his lungwalls, a rising inner tide.

Jumped into action. Checked his ekg (predictably fast but otherwise ok), found a vein and put an IV in. Put some nitroglycerin under his tongue to open up those tightly clenched blood vessels, lower that pressure some and get the blood flowing. Got ready to move.
Now there’s something bout moving patients that completely fucks em up. Even a relatively stable patient that we’re literally lifting up to put on the chair and carrying the whole way, no exertion whatsoever, can still end up like 5 degrees more effed up by the time you get em on the ambulance. It’s just the stress of moving, being moved, I suppose, plus the sudden rush of cold air when they get outside never helps. But it’s something you count on, so especially when it’s a dude like this, you treat a little aggressive before you move just to pre-empt the inevitable decline.
The problem was, this dude was getting worse and worse even before we started moving him. His mild discomfort had blossomed into a full blown freak out, which was causing him to stress his already taxed heart even more. The fluid was rising steadily higher and higher with each passing moment. My partner and i were doing the everything’s cool routine, without lying to him about what ws going on mind you, I’m just sayin we weren’t panicked, but there was no mistaking how fast we were moving. Dude was agitated.
So we get em on the chair but when I tell you I was eyeing it to see if it’d give out…Anyway, the other problem was that he lived DOWNstairs, which meant we were gonna havta heave him UP ‘em to get out. Plus he was in some weird basement complex, so we had 2 wind our way through a weird atrium, back into a building, over cracks and bumps and through a little tunnel b4 reaching the stairwell. And lemme tell you: the only thing worse than lugging hugeness is lugging hugeness that is freaking the fuck out and about to code. By the Grace of God we got to the stairs and then I swear it was like some serious epic shit, every single step. I was on the top part, yelling in Spanish at the patient “Tranquilo, papa, ¡calmate coño!” and a cop had the bottom bar, and he was just lookn copconfused and sweating. We heavehoe’d each step, letting out some real Neanderthal-ass grunts and there was a couple times i really didn’t think it was gonna happen but it did and we loaded him up in the bus and reassessed.
He was still bad, flopping and flailing bad, but not quite as bad as he coulda been. We’d pushed lasix earlier, which drains you out and makes you haveta pee something mean, and a few more nitros were working their way thru his system. My guess was that he’d make it (he did). Hopped in front, came up on the radio to let the hospital know were coming and what we had, drove the fuck off in a blur of blasting sirens and flashing lights.

THE SINGING HEART ATTACK

Fire men were standing in their usual confused huddle around a bench outside the Myrtle Ave projects. One of them came and met us on the walkway. “Um, he’s having chest pain, we think and he had a…seizure…maybe…”
And?
He looked nervous. “And he’s…singing.”
Indeed, the slurred, drunken strains of I’ll Be There were wafting out from the center of the firemen’s circle and we knew it was Singin’ Joe.
This dude calls every couple days when he’s lonely or cold or just too drunk to get home. He was sitting jauntily on the bench, looking back and forth at the confused FDNY dudes, singing at the top of his lungs thru his oxygen mask and punctuating his song with the occasional scream of “OH MY HEART!! OW! OW!…I’ll be thaayayare!!”
“Whatsa matter Singing Joe?”
“Oh I was at dis ol party on the second flo’ and I caught a heart atta- no wait I caught seizure. I caught a seizure. JUST REMEMBER…Yeah!”
“So you came down stairs?”
“Uh huh, I’ll be thaaaayaaaree!”
I wave at Fire. “You can take that oxygen mask off.”
One of the boys goes to pull off the little plastic piece and Joe rolls his eyes back and starts twitching, his great big fro waving back and forth like a peacock tail. The fireman jumps back, horrified. “I’m ca-a-a-tchin a see-e-e-e-iz-ure a-a-a-aga-a-a-ai-n!!! Oh my chest, FUCK!”
I’m biting my finger not to laugh. “Just get on my stretcher, Joe. Seriously. You can finish your seizure on the bus.”
He obligingly brings his shaking to a dramatic close and climbs up onto our stretcher (Singing Joe is fucking tiny, by the way- more fro than dude.)

All the ER nurses turn and smile when we wheel Joe in. He’s crooning at the top of his lungs again, waving at his adoring fans like the drunken king of Brooklyn.

STAND UP SIT DOWN LIE DOWN DIE

The next night, after lots of ridiculous little jobs (“my elbow hurts” and “I can’t find my psych meds!”) I was workin with newguy and we walk into a fancy Spanish Harlem apartment to find a little old guy, surrounded by gawking firemen, about to die. Dude was pale as shit, gasping for air, flailing his arms around like he was drowning and couldn’t get more than a word or two out. He definitely had fluid in his lungs, you could hear that raspy gurgling from across the street- the real question was his blood pressure. If you have fluid in your lungs and your pressure’s skyhigh, which is usually the case, it’s very bad- your veins are clenched up tight, you’re heart failing miserably and you’ll eventually drown in yourself. But if you’re ful of fluid and your pressure’s low: you’re fucked. Unless someone puts some dopamine in you quick it’s all over. It’s called cardiogenic shock. That was this guy. To top it off, there was no way for us to give him the dopamine, which tightens up your vessels enough to keep your heart pumping and your pressure up, because the guy had no veins at allll. Nada. I took one look and knew it wasn’t even worth trying.
Here’s the quandary with this situation: no blood pressure means you can’t sit up- any fluid you got needs to be pooled at your upper body, vital organs, so if you sit up it’ll drop to your lower extremities and you’ll die. That’s why people in that situation, including trauma patients who’ve bled out and internal bleeders, all get transported with their feet up, lying flat on their back. On the other hand, people with fluid backing up in their lungs can’t breath, and the last thing you want to do if you can’t breath is lay back- the fluid floods right up your airway and drowns you. That’s why asthma attacks and pulmonary edema patients lean forward in what’s called tripod position.
So here we have a dude with both: no blood pressure- it was like 80 over 50, and can’t breath, and he’s anxious, freaking out, won’t tolerate even the oxygen mask that he so badly needs. So we have the scoop to lay him down in and the chair to wheel him out in but it’s a no win situation either way. He was in a sitting slouch when we got there, so I watch him sit up some and ease onto the chair. He doesn’t look much worse for it and I can tell that laying back further is increasing his agitation, and him getting more upset means his poor failing heart has to work even harder and will sooner collapse. I decide to chair it but have the fireguys walk along side with the scoop just in case he codes and we have to start doing cpr.
He’s spiraling down in the elevator, arms flailing madly like he might take off at any second, water rising higher and higher up in his lungs and everything seems to be going in slow mo, but not in the badass matrix way, only in the whytheFUCKthistakingsolong kinda way. Finally we outside, I toss partner my keys so he can set up the stretcher while I cart homeboy out. Firefighters are scurrying all around me in a frantic escort as I heave ho thru two sets of project doorways and out into the street. We do a quick 1,2,3 evaluation: dude’s still fucked, and then I jump into drivers seat and come up on the air to give the notification: 12xray (that’s our unit number) with a note to Saint Lukes.
I’m throwing into drive, restraining a hot seething curseout as the firetruck that’s blocking us in takes a few milliseconds longer than I want it to to get the f out my f’ing way.
-Go head with your notification, 12xray.
-we have a sixty three year old male, eminent cardiac arrest second to cardiogenic shock, blood pressure 80/50 heart rate 120 respirations 28 be there in 2 minutes.
In my rearview, I see my partner flittering around like a desperate little toothfairy in the back. He’s brandnew and truthbetold, I don’t think the patients gonna make it through the night, but I know the best I can do is get him to the hospital fast as humanly possible so he doesn’t have to get worked up by brandnew dude all by himself.
The *%#*&&#?!! Firetruck has pulled off now and I’m airborne through the windy upper west side streets, winding round the park, hauling ass along 110th and screeching around onto Amsterdam. My sirens are having a temper tantrum, my lights playing rude games in red and white along the Chinese restaurants, coffee shops and saint johns cathedral and then we’re there, breathless, weary, but the dude’s still alive, if only barely.

He didn’t make it through the night tho.

A Dream, A Drunk, and A Few Things You Do When You Die

Before I begin- before I forget, lemme let out something I been meaning to mention since i started this blog: if you and me are walking down the street one day and- god forbid- some nice little old lady gets steamrolled by a mack truck, or some dude decides to check out off a building ledge or any of the other imaginative-ass ways people find to get themselves collected into the underworld takes place- it’s not gonna be a whole heroic rushing to the rescue situation. Music won’t swell. I won’t be pulling any granny’s from flaming cars and I definitely won’t be sticking pins into people’s throats and breathing for them. Probably, I’ll tip my hat and walk away, because without a bag of equipment and some gloves, I’m just another dude on the street except I would be able to imagine what I would do and not be able to do it. Which would suck. For me and the unfortunate patient.

Having said that, there are 2 exceptions. The first is non traumatic cardiac arrest- cardiac arrest because CPR only requires hands- (the American Heart Association recently took mouth to mouth out of the equation cuz no one wanted to do it and compressions work well on their own. holla. ) and non traumatic because traumatic cardiac arrests usually involve lots of blood, and I love humanity and all but not enough to catch something nasty from some stranger. Aaaand traumatic cardiac arrests rrrrarely make it anyway.
The second exception would be the choke and by choke I don’t mean the guy holding his hands to his throat going Oh my god I’m…I’m choking! I’m choking dammnit! Because someone who tells you they’re choking is like someone telling you they’re in cardiac arrest- it means they’re not. Real chokes don’t talk, they’re too busy turning blue and coding and I’m too busy getting my forceps out and putting em down their throat. They don’t turn red. They don’t cry and moan. And usually, they were eating right before it happened, not talking on the phone with their ex like most CHOKE calls we get. But yes, for the real legit, bluefaced not talking not demand making not EDP or recently dumped choke, the good old heave ho on the tummy will do the trick most of the time and make all the difference.
So there you have it.
Now on to the subject of tonight’s pleasant/gruesome chat.

1.
I was pleasurably napping on my couch yesterday when all the sudden I was downstairs in a strange duplex and people were filing out of some meeting on the second floor. An old scruffy fellow with a beard came up to me and sort of collapsed onto me, getting his drool all over my shirt. I lifted him up and he puked on the floor and looked like he was about to check out as I was waking up.
Damnit- I thought, back to work already…

2.
Later that night:
You can tell this job’s gonna be retarded from the way it comes over on the screen. It’s an UNCONCIOUS and the text says “FEMALE CALLER STATES MAY HAVE LO BLOOD SUGAR” so you already know the lady is not unconscious at all, but lucid enough to be already trying to rationalize Why she called 911 and told the operator she wasn’t conscious. And it’s at a bar. Any UNCONSCIOUS at a bar sucks on principle cuz it automatically means the patient’s having more fun than we are.

When Mr C and I pull up outside 1 of these new trendy spots on Myrtle, a short white guy approaches the bus. He has thick glasses and a little hair left and carries himself like he owns the place but doesn’t want to throw it in your face but wants to make sure you know but doesn’t want any trouble either. The creases on his forehead say that he’s gonna try to maintain calm and keep control even though he’s very fucking concerned about how this looks for the business. He immediately irritates the shit outta me so I open the window just a quarter of the way. He wraps his anxious little fingers around the edge of the window and gets up on tippytoes to peer in at us.
Um- excuse me…
Yes, can we help you?
Yes, um, there is a lady inside, she was shaking, and she said that um, her sugar might be low, and um so now though she’s like, unconscious and so we you know called and she’s inside so maybe you could you know…um. Yeah.
Okay.
I roll up the window.

The bar is all wide eyes and whispers. The unconscious lady has decided to stay in the back area and she’s moaning and carrying on, waving her hands in the air in the midst of a small crowd of onlookers. She’s middle aged and fattish with an indigo girls haircut leftover from 1992. Predictably, she’s trashed.
Oh god! She’s yelling in a thick british accent. God, this is- this is so Not Me! I just- I don’t know what’s wrong with me, it’s like…I’m like…It’s like I’m perhaps I’m or my sugar is low!
Are you a diabetic? Mr C asks.
No, but I mean, oh it’s crazy, I’m so, I’m so embarrassed. I mean…
Ma’am, could you hold still a second?
I mean, I’m so- this is so not me. I can’t even, oh godddddd
Ma’am, stop writhing please and sit in this nice orange chair.
(Patience waning, waning away)
It’s like…oh! I’m so embarrassed. Perhaps it’s you know, something menopausal, you know, like I don’t know, I feel so weird, perhaps it’s something with menopause…
Perhaps, I suggested, it’s that you’re drunk.
At this point her friend chimes in helpfully- Oh, she wasn’t drinking tonight!
Mostly without meaning to, both me and my partners’ eyebrows raise with wonder.
I say that I think maybe she was, just a little.
Just three vodka tonics, says the patient, but that can’t be it…

Everyone stares as we wheel her out, which usually bothers me, but this one’s still moaning and carrying on so much it’s hard not to think that she’s feeding on the attention. When we load her into the bus she enters the apologizing drunk lady phase, starting with a thick round of Oh god, I’m so sorry boys, I’m really really really really- uh sorry. Oh, I think I’m gonna be sick again, oh my god- like, i”m really really sorry, guys. I’m really embarrassed and I really think this is the menopause, you know, and maybe my sugar.
Must be some combination, dear, -the friend offers reassuringly. Some combination of chemicals, you know, in your body. Reacting to each other, you know? Not to worry- this isn’t you, darling, this isn’t you, just some combination of chemicals.
Yes, I think: alcohol and blood.

Drunk people l o v e to repeat shit, just in case in the retelling some new detail will emerge that makes it all make sense in that satisfying drunk way. And when you add a mostly drunk person to a completely drunk person, they usually end up repeating themselves and egging each other on to repeat things even more, ad nauseum (literally). So I was happy to be driving last night, and not sitting in the back listening to the pissfaced brit fest skip back to the beginning of the monologue again and again.

At Brooklyn Hospital, she decided that she needed a cool room please, and a clean bucket to be sick in, and that perhaps it was actually, you know, food poisoning.
Perhaps, my partner said, it was alcohol poisoning but she’d already cycled back to the low blood sugar theory and her friend was nodding enthusiastically.

some douche bag took this photo in Cali. Im not for this voyeuristic crap but im not against ripping it for my blog, especially when it’s SO exactly what im talking about. Notice how the new guy looks like he’s thinking about maybe treating her and the old dude in back is like “Don’t even fucking consider it, a-hole.” Classic. And that chair is HUGE.

3.
Even later that night:
Our EMTs are dealing with a drunken head trauma when another guy approaches them to say he’s having trouble breathing. So they call us to come handle it while they continue longboarding and collaring their guy. Our guy is outside on the stoop, puking and yelling that he can’t breath. It’s dark, so we don’t really get a good look at him till we’re inside the ambulance and starting the workup. He’s 59, a diabetic and has just been having shortness of breath all day but no chest pain, no bleeding, nothing else unusual at all. When he takes a breath you can hear the rustling of excess fluid frothing in his lungs. It sounds like someone sucking the last bits of soda out of a cup of ice and it means his heart’s failing.

There’s a few things I tell my students to look for when they’re trying to assess whether a respiratory distress patient is about to check out. They’re not medically proven and you won’t find them text books, but as someone who sees people on that gray breathless line between alive and dead fairly regularly, i can tell you they are almost without fail warning signs of someone looking to not make it.

The first is Non-Tolerance of Oxygen.
I can’t breath I can’t breath!
Ok, Here’s some oxygen, this’ll help.
No! I said I can’t breath damnit! Ah!
When someone’s so deep in their hypoxic stupor that they can’t even bear to have the O2 mask strapped to their face, I start looking at my tube kit.

The second sign of imminent respiratory and then cardiac arrest is the Toilet Spin- they start making crazy circles with their upper body like someone just flushed them down the big linoleum bowl of death. Their eyes stop looking at anything at all because the patient’s too busy trying to breath to bother seeing. It may be why we call it crapping out.

Finally, Everything That Once Was Fast Gets Slow, real slow. That fast thing is how the body compensates: They can’t breath, so the heart beats faster to pump more blood to the lungs and other vital organs. The respirations speed up to try and get more air in, but adds to the hypoxia and franticness. Sometimes a patient can keep going like this for a long time, their chest muscles flexing in and out in a desperate attempt to keep breathing, but eventually, exhaustion will kick in from all that hard work, and that’s when Everything That Once Was Fast Gets Slow. They’ll go from “OhmygodhelpmeIcan’tbreath

pleasedosomething” to “…uh…” and from gaspgaspgaspgaspgaspgaspgasp to gasp……………….gasp………………….gasp…………………gasp……………………………gasp.
That’s endgame.

This fellow had all that going on within minutes of getting on our ambulance. AND he had no veins for me to put an iv into. AND his lungs were quickly filling up with backedup fluid from his failing heart, so he was literally drowning inside himself, which is only a deep concept when you’re not watching it happen to someone right in front of you. Now, usually folks in this condition, it’s called Acute Pulmonary Edema, have extremely high blood pressure, which sucks a lot for them and could quickly kill them, but suck tho it may, it’s still much better than the ones with fluid filling up their lungs and NO blood pressure at all. Those guys are in whatscalled Cardiogenic Shock, and they’re fucked. That was this guy. He was cold to the touch. No one could find his blood pressure. His veins were collapsed. It was the kinda guy that you keep looking up at to make sure he hasn’t coded yet, even if he’s talking to you.

And he was talking away at first, while we were digging around in his hands for that lucky little flash of blood to tell us we had IV access and could get some life-saving meds in him. Then he got agitated, and started taking off his O2 mask, and me and Mr C exchanged a glance. Then we still couldn’t get a blood pressure or an IV and he started getting quiet, which is when I said “Imna start rolling.” As I hopped out of the back I saw him make a little sightless spin with his upper body.

When you’re a paramedic and the man you’ve been assigned to keep alive is about to die and you don’t have an IV, all you have left is you’re lights and sirens (this is why I don’t mess with patients when I aint working). I fucking flew to the hospital, my siren turned up to an ear shattering, frantic splatter that makes yuppy scum jump the fuck out the way and then look on irritably. Made it there in a minute and a half and by the time I opened up the back our man was in cardiac arrest, intubated and lifeless. Can’t say I was surprised. The only thing that didn’t fully add up about the situation was no chest pain- for someone to be in as much cardiac distress as he must’ve been, judging from his EKG and symptoms, he shoulda felt it, but diabetics are known to have whats called silent heart attacks, meaning you can catch and not know it.

In the hospital they put a central line in and got him back for about ten seconds before he coded again. They shocked him more than a few times, brought him back again, lost him again and last I checked he’d coded and revived a total of five times but was still alive and ticking all by himself.
What’s the story with this guy? The doctor wanted to know.
No history, I said, except the diabetes. No chest pain, he was just sitting on his stoop vomiting and looking like he was about to check out.
Then I remember my dream.

5 Flights or Patriarchal Dumbassery Claims Another Victim

A five story walk-up on the Grand Concourse. Why do folks who need to be carried always live on the fifth floor or higher with no elevator? The patient’s wife opens the door and she looks like she’s not sure whether to be irritated or worried. (Strange to have our own expressions mirrored back to us for once.) She leads us inside where we find a pale, sweaty, agitated, half-drunk 40 year old with bags under his eyes, clutching his chest and yelling that he’s fine and he doesn’t need to go to the hospital so dejame en paz, carajo!…

We finally coax him to calm down and sit down and usher his teenage daughter and five year old son into another room. Turns out, the doctor told him that he ever drank again he’d have another heart attack.
And?
And I jus had a drink.
And?
And I’m fine. I’m- AAAAH MY CHEST!!! (Sweat sweat, clutch clutch…) But is not that bad, I swear!

It’s funny because…wait a minute, in writing that I realize that a lot of you might not find anything funny about a man having a heart attack in front of his whole family. And you’d be right not to. But in reading ahead i would encourage you to let go of preconceived notions and all that right/wrong junk and just appreciate what a pleasurable thrill the twisted disasters of life and death bring. That’s all. People die in horrible and ridiculous ways day after day and when you’re there to see it, well, sometimes all you can do is laugh- once all the busy work is done of course, and you’re having a cup of strong black coffee at the Lechoneria around the corner with your partner. It’s not that if you don’t laugh you’ll cry, it’s that if you don’t laugh you’ll become a fucking shell of a person who can’t function.

AAAAaaaaaaaaaaaaanyway, it’s funny because we spend SO Much time, Most of our Time, dealing with people that have no business at all calling 911, or even 311 for that matter, but really just want a little human touch. Okay, I’m full of sidetracks tonight, but I’m restless so bare with me- like the lady last week who said: “I was opening a window and I think I pulled a muscle and then my whole left side of my body went numb.”
And then what happened? (because you could tell there was more coming..)
So then I took my asthma pump and…
Wait, why’d you….nevermind
And it worked!
It did?!
Yeah, I can feel my left side again. But my pulled muscle is still kinda bothering me.
You wann go hospital?
Yeah!
(Later in the elevator)
By the way, ma’am, how long ago was it that you tried to open the window, an hour or two?
No, it was like three, no four day ago.

I really enjoyed that call, actually, because it really truly had me laughing. Like LMAO kinda laughing, not just a sardonic chuckle.

AAAaaanannnnnyyywayyyy again- back to the story at hand:
Where was I? Ah yeah- it’s funny Because: we spend all this time with folks that truly don’t need us, or our 40 pounds of equipment, and then here we have what turns out on the EKG, the 12 Lead and in every possible way to be a bonafide Myochardial Infarction AKA The Big One AKA a fricken heart attack- and homeboy has no intention of letting us treat him. We practically have to beg him to let us put an iv in, and all the while:
I’m fine, I’m fine, I’m fucking AAHAHAHAHA MY FUCKIN CHEST OH CONO CARAJO MY CHEST JESUS MARY AND JOSEPH!!!

When we finally convince him to come with us to the hospital and not commit suicide by stupidity in front of his family, he want s to walk down the 5 flights. Now, believe me- just about any other patient I would’ve actually hid the stair chair from so they didn’t get any dumb ideas about being carried, but the Llaaaast thng you wanna let someone having a heart attack do is walk down 5 flights of stairs. BUT- one the other hand, the last thing our patient wanted to do was get paraded out in front of his whole building looking weak and being carried in a gimpy EMS chair by another man. So we were at a standstill.

My partner and I wasted many graphic explanations of how the heart crinkles up and dies without oxygen and what it feels like when you’re lungs fill up with fluid and you drown inside yourself (more on that in some other posting, I’m sure…) trying to reason with our dude but it was no use. He didn’t even seem to be listening, mostly just sat there sweating and clutching his chest and whining that he was okay leave me alone, papa, estoy fucking …bien… (ow! Shit!…ow!)

Finally, I lost my patience, my temper and my cool all at once and launched into a satisfying, curse-laden tangent, (any of you who’ve seen my do a workshop…like that, but without the stupid smile…)…(why should patients be the only one’s who get to curse?)…

DUDE, I said, yer gonna die. In fact yer gonna fucking die, more than likely, on this staircase, in front of your family and it’s gonna suck AND me and my partner gonna haveta stick a tube down yer throat and pump on yer chest. . It won’t be poetic, it’ll just be ridiculous. I don’t like carrying people down 5 flights of stairs, but for you it’s how it has to be. Sit in my chair. Put this sheet over your head. And stop screaming in pain and saying you’re okay, cuz you’re not. Then, we go to the hospital. Okay?

I knew he would concede when he looked at me the way I look at some EDP’s (like the one hiding the rock in his sock). It’s a look that says: Are you gonna kill me or am I gonna kill you? Or are we just gonna fucking pretend to be friends and go to the hospital without a problem?

BUT…oh, the but.
Before he could go, he had to have a pep talk with his successor. And this…really, this was one of those moments that I could kinda feel civilization crashing around me.
Before I go, he said, Bring me my boy.
Someone brought the boy (age 5 remember).
Boy- he said. He said, Papi’s going away for a little while. You da man of the house now, hear? You in charge.
His grown ass wife and mostly grown ass daughter looking on, traces of embarrassment plain to see.
You running things round here, he continued. You the boss. Okay?
The boy nodded but his face said WHAT THE FUCK IS WRONG WITH YOU DAD?

And with that, we draped the sheet of shame over his head and carried his ass down the five flights to the ambulance.

THE BABALU AYE SPECIAL EDITION: 2 BACK FROM THE DEAD STORIES (sorta)

Well: I was really planning on the next piece i wrote being about all the mundane bullshit we do, which is like 90% of the job, especially cuz now i got fricken jud and saraivy telling me how i’m just trying to show off on facebook with all the gory shit we do…BUT, f them- cuz this week was Babalu’s day, and in his catholic form, Babalu was Lazarus, who Jesus famously raised from the dead, and in honor of this I somehow ended up with 2 Babalu-relevant jobs, and I’m sitting here bored out my skull so I will now share them with you.

1.
There’s this crackhead motel on 125 and Park. Everytime we go there it’s some scene out of The Wire or Pulp Fiction. Job comes in as first DIFFBREATHER, then UNCONCSCIOUS and then, inevitably, ARREST. Means the guy’s supposedly dead. We get there, walk up the rickety stairs and our dude is laid out doing a very loose impression of a dead person, surrounded by a swath of mortified and confused cops and fire fighters.

On a sidenote: this is a classic firefighter maneuver called The Circle Of Death: it’s when they get there first and form into a small circle of curious white faces looking down at the patient. It’s FDNY sign language for ‘what the fu-u-ck?’ Many a time we roll up on scene to find this peculiar huddle and it’s usually not a good sign.

Anyway, if you’re any kind of medical personnel you get good quick at knowing the difference between a true cardiac arrest and a guy that wants attention (the best are the fake seizures, when they go “I’m having a seizure!” and squirm awkwardly till they realize you’re not buying it). But firefighters and cops are not trained in this art, so they really were convinced. O and I took one look at the man and O set up the stair chair and i said “Get…up!”

First he squirmed and moaned and the firefighters all gasped. “Get up and get in my chair,” and reluctantly, he struggled to his feet and planted himself in our chair as the room fell completely silent.

We had ourselves a good chuckle driving back to our spot when it was all over. Not so much at the fireguys’ expense (a little though…) if not at the whole situation in general: here we are again in the midst of this whole huge bureaucratic clusterfuck, dozens of different agencies and crossed lines and legalities and so much work done covering ass and so little done treating patients, between dispatchers and insurance companies and godknows what kind of existential spiritual lifendeath tug-of-war, and right smack at the center of it all is five guys with helmets standing in a circle around one old bobo trying his best to look dead so he can get a night of sleep away from the other crackheads.

2.
That was Wednesday, December 17, sacred to San Lazaro, who shocked everyone by

emerging out of his grave on Jesus’ request and hobbles around town with his crutches and pack of dogs. On Saturday, the night of the annual Babalu cleaning ceremony, we had two back to back cardiac arrests.
The first was a 96 year old lady who was clearly well past gone, but when we walk in the fire guys go “oh! She was up and talking just before you walked in!” like it’s all our fault. This is pretty standard procedure especially when it comes to nursing homes- we get there, the patient’s rock solid with rigor mortis and the staff is talking bout how she was laughing and chatting not seconds before and how they can’t believe it, in fact she was walking around, walking I tell you! Playing freeze tag even! Lord- look how quick she went!
This lady was, as i said, gone but she didn’t fit the criteria for us to leave her in peace (rigor mortis, decomposition, dependent lividity-which is the pooling of fluids at the lowest point in your body, or a grim catch all called Obvious Death, which is for those guys that are just DEFINITELY not coming back, i.e. decapitated) . So we went ahead and started working her up. It ended up messy, firstly cuz she was old and must’ve had a terrible case of osteoporosis, because literally all of her ribs collapsed on my first round of cpr. Secondly, she had zero veins for iv access, (and we tried plenty) except as it turned out, a nice solid 1 going right down the center of her forehead, and that is exactly where the iv ended up. It seems crude, it is crude, i guess, but this is what it is: if you’re in or about to be in cardiac arrest, having a little saline-lock antenna popping out your head is not what matters, all that matters is that you have one. In that iv goes all the good medicine that we carry around that will bring you back, directly into your bloodstream and all across your body. So in retrospect, or from the comfort of all of our not-imminently-to-die selves it’s easy to squirm at the thought of all these gruesome details and invasions, but I’m telling you them precisely because that is the very heart and soul of emergency care. It’s by definition a sticky mess of bloodied gauze, discarded syringes and stained suction tubes matched only by the colliding and collapsing human disaster zones that it’s created to revive.

Which brings us to the second cardiac arrest of the night.
No wait, first, another sidenote:
Approximately 100% of the recently dead on tv and movies who are treated with a touch of poorly performed CPR come springing right back to life and go back to killing bad guys. Most notably, James Bond, who just one movie ago defibrillated himself back from the beyond and then went on playing poker straight away.
Yeah- that’s not how it works. First of all, it’s literally about 1-2% of people we get in arrest ever get a pulse back at all. In my five year career I’ve gotten 2 maybe 3 pulses back total. Second of all, and maybe most importantly, of those few the vast vast majority of them are total vegetable matter from then on out. You just can’t deprive a brain of oxygen for that long and pop back around like nothing happened, it doesn’t work that way. In NY the situation’s complicated even more by tall buildings, projects, traffic and numerous other obstacles delaying patient contact.

So, so so so, that means when it’s your time it’s your time, and most guys that’ve been working the field long enough know better than to walk into every arrest that comes over and raise the dead.

I was particularly feeling that way on Saturday, not just cuz of the first messy arrest, but because i was working with, oh let’s call him Gerk- a certain medic that I just wouldn’t trust giving treatment to anyone i knew or cared about or had ever met. At all. I mean- well his name says it all. And then I was even less thrilled, you can imagine (maybe…) when the second arrest of the night came over not long after we finished cleaning up the first one. Oh lord, i said to myself, this poor whomever, wrong night to flatline…

Whomever turns out to be a 72 year old Indian gentleman lying flat on his back in his underpants with a bright red flare of blood at his lips and nostrils and a burly EMT thumping up and down on his chest,. He has no signs of trauma and appears to be in good health except for a large unsightly triple bypass scar stretching across his chest (and the fact that he’s dead).

Our monitor says he’s flatline, so there’s no movement at all in the electricity of his heart, nothing to shock in other words, so I start looking for a place to put my iv while Gerk prepares his tube kit to get an airway. This guy has only slightly better veins than the last lady, and having no heartbeat doesn’t help, but i manage to sneak one in right along the top of his left hand. Gerk’s having trouble with the tube, to his credit the blood in the airway means he’s just staring into a dark tunnel of fluid, with surely no vocal chords in sight to pass the tube through. Eventually, we do get it though, and just when I’m thinking the EMT is gonna have his own cardiac incident from how hard he’s pumping and sweating, someone announces that they felt a pulse.

No shit, i think, but there it is- a vigorous thump-thumping along his carotid artery. There’s some excitement now as the crew shifts course, one EMT running off to get the stretcher, the other taking the blood pressure, Gerk on the phone with our on-line medical control to get more meds, me and the lieutenant prepping the patient for transport.
The family’s all there screaming and praying as we load up our post-arrest patient and stick him in the ambulance, and though I’m trying to be pessimistic I’m feeling good about this one right up until he arrests again as we’re flying along to the hospital. He’d come back strong with a solid blood pressure and the pulse way up in the high 140’s but halfway to Wyckoff his heart dropped back down to the 60’s, then 30’s, and while we’re frantically working on him he loses pulses again completely and we’re back to thumping his chest while trying to keep balance amidst the tossing and turning of Brooklyn streets.

As we pull up I check again and miracle of miracles, there it is, that rhythmic murmur of pressure against my finger… In the ER bay they do their usual half-joking complaining about how we have all the fun and get right to work on him, setting up a dopamine drip, getting a ventilator set up, etc. I can’t help but feel good, and I’m literally typing the first words of a jubilant text message to Gabi when I see all the nurses run over and a doctor start compressions again.
Crap! I shut the phone right quick and walk over cringing. For a third time though, our man decides to live that night, and this time he stays for good. When we leave the hospital he’s pumping away all by himself, but he’s still, and maybe always will be, a vegetable.