Ahm not a smaht man, but I know what a trauma ee-is

Monday, September 19 2005

About two in the morning we’re toned out for a possible unconscious, “Caller reports patient lying in roadway”. We arrive to find an elderly man lying face-down in the thick mud between the curb and the sidewalk, where one day the construction company will place sod. His head, chest, and arms are covered with mud, but a ragged laceration in his forehead has bled much of the mud off his face. A baseball cap lies on the ground perhaps ten feet away.

Was this guy hit by a car and thrown onto the sidewalk? Was he mugged? Did he just trip? No way of telling. I take c-spine while the crew grabs backboard and cot.

“I’m okay, I’m okay,” the man says in a very weak voice. “Can I go home now?”

“No, sir, we need to check you out. What happened?”

“I fell, I think. Can I go home now?”

Backboard is ready, we roll the patient onto it and begin strapping him on. The whole time he’s whispering, “I just want to go home,” over and over. We place a collar.

The patient stops talking. And moving.

“Oh shit oh dear,” says DTs. “Sir!” No response. Sternal rub. No response. One of the crew takes the patient’s wrist, says, “I can feel a pulse.” Carotid pulse is present also. I look, the patient is indeed breathing – he’s just not responding. In EMS lingo, he’s DFO – done fell out.

DTs is precepting a young lady to become an EMT-B lead. She calls the county to ask if a medic is available for this call, and is told “negative” – all the medics are busy. Phooey.

Load and go. We grab a quick set of vitals, then the lead preceptee asks me to call the hospital while she and our third cut the patient’s clothing to check for non-obvious injuries.

“Charles Cullen Memorial ER.”

“Hi, ambulance 502, we’re responding to you with a male, 65, found prone on a sidewalk, periods of unresponsiveness, head lac, unknown mechanism, boarded, collared, vital signs BP 174/91, pulse 109, pupils PERL, Sa02 99% room air, dexy 120, see you in three minutes.”

“Okay,” says the ER.

The patient’s O2 sats do not warrant oxygen, but we give him a non-rebreather at 15lpm anyway – we’ve noted a tendency for his breathing to slow when he goes unresponsive, which he does twice en route. Each time, though, he pops back up within ten seconds and says, “I want to go home.”

We arrive, wheeling the patient into the ER. Recent construction has modified the nurses station to include partitions so they don’t have to see you when you walk in. Our driver wends through the mini-cubicles to the admitting nurse.

“Ambulance 502,” he says.

“Yes, I know,” she says. “Just wait.”

“Hey, we got this guy,” he says.

“I’ll be with you in a minute,” she says. The driver peers around the partition to give us a helpless shrug.

“Okay, put him in the hallway,” says the nurse.

“Hallway,” our driver says to us.

We move the patient on the board to the bed parked in the hallway. Another nurse comes up.

“What are his O2 sats?” he asks.

“99% on room air, but -”

“Take that thing off his face,” the nurse orders. Goddamn, I’m starting to get a bit pissed, here.

The admitting nurse comes around to the bed. Her eagle eyes miss nothing.

“This patient is on a backboard!” she says.

“Of course,” says DTs.

“And this patient has a collar!” she exclaims. “Why is this patient on a backboard with a collar?”

“He was found prone on a sidewalk,” I begin, but she’s cleverly deduced everything.

“This is a trauma patient! This patient should be in a trauma room!”

“Yes, yes!” says DTs. She’s getting it! There is hope!

“Did you call this in as a trauma?”

“Yes.”

“Where’s the medic?”

“There was no medic,” our young preceptee begins.

“Should have been a medic. Why didn’t you call a medic? You’re just a basic unit. This patient needs a medic…”

What this patient needs, I thinks to meself, is for you to STFU and call a doc; what this patient needed was our four minute transport to the hospital, versus waiting on scene 10 minutes until a medic was available. What this patient needed was to not wait five minutes until you graciously allowed us to place him in a goddamn hallway bed.

A doc arrives, gets things moving in the trauma room, then steps outside to get the story from the precepting lead. He nods his head a few times, says, “Okay,” then turns back into the trauma room.

Later, the doc pulls the preceptee aside. “You did exactly the right thing,” he says. The patient was suffering from ETOH mixed with a lot of heavy-duty prescriptions – not something a medic could have done anything about anyway, had they been available.

The next time we came in with a patient, the same nurse was there, and a sight more friendly and responsive. I wonder why?

Cameo of System Abuse

Sunday, August 21 2005

An auspicious start for a duty night. General tones dropped, and the station south of us is dispatched to an overturned vehicle, one occupant ejected. This is muy serious stuff. We follow the call on the computer aided dispatch (CAD) system, and the radios. An engine company is called to clear an LZ for a helicopter to fly out one of the victims. The nearest first-class trauma center is fewer than ten miles away, but that’s ten to fifteen minutes by ground – the victim just doesn’t have that kind of time. Both a medic and a basic unit are on scene, so it’s unlikely that DTs and his merry band will be needed.

But wait! Station tones drop, and off we go! The dispatcher relays the address as we pass through the vehicle bay and into the unit. The station doors roll up as DTs locates the address in the map book. Further details arrive as the driver rolls the unit onto the apron, hitting the lights.

“Turn left,” says DTs, “Then take the first right.”

“What’ve we got?” asks his partner.

“Adult female. Sore throat.”

“You’re shitting me,” his partner says. “We’re going lights and sirens, people are panicking to pull over, we’re gonna blow some red lights and make people stop on green – if they’re paying attention – for that?”

“Let’s pray we get there in time,” says our steely-eyed Hero.

“Yeah,” says the driver, “With the chopper busy, it’s all on us. Straighten your shoulders, DTs – they have become stooped with the Weight of Terrible Responsibility. I’ll grab the Lifepak when we get there.”

Could it have been “something”? Sure, if the sore throat was the result of Drano gargling. By all means, we make the bambulance go with blinkies and woo-woos, just in case. But one acquires a feel for these things, and it was what you might have guessed – what we in EMS refer to as System Abuse.

Now, kid calls are never system abuse, even if it’s simply a scraped knee that First Time Mom doesn’t know how to dress. I love it when kid calls are for “nothing”. It beats hell out of when it’s a kid call for “something”. And we carry little plastic fireman hats we give ‘em, which is always fun. But we’re talking about adults here.

Case in point, from the transport gig. We’re dispatched to Hospital X to take a patient home. Our patient is quite large. Each of her legs was bigger, and weighed more, than me. Best estimate from the hospital is 520 pounds, and it ain’t glandular. We load the patient into the ambulance and two ambulances (one for her, the other with personnel to help lift at the destination) are heading to her home.

“How far are we from Hospital Y?” she asks. “I should probably go to Hospital Y. My other doctor is in Hospital Y. Can you take me there?”

“No ma’am,” says the attending. “We’re taking you home.”

I’m having chest pain,” says the patient. “It’s radiating all through my right arm.” Ping! “radiating” pain is a possible symptom of a cardiac problem. But who says “radiating”? She knew the buzzword – but got the wrong arm. We pull over anyway and the medic from the other ambulance climbs aboard. As he climbs in, the driver from the ambulance comes over and tells me this patient was taken to Hospital Z just two days ago. Hmmm.

“I hear you have some chest pain?” the medic asks skeptically.

She senses he’s not buying it. “No, it’s my kidneys, they really hurt.”

“Kidneys,” says the medic.

She stares a second, then quickly says, “No, it’s my hernia. I have a hernia. I should really go to Hospital Y.”

“Ma’am,” says the medic, “Your doctor said you were well. His orders are to take you home.” He gets back into the first unit, and to the home we continue.

“I have to pee,” says the patient. The attending says there’s no way he can lift her to place a bedpan, she’ll have to hold it. No, the patient lets go with about two liters of urine onto the cot while maintaining a smirking eye contact with the attending. This is payback for not taking her to Hospital Y. When that doesn’t seem to faze him in the least, she lets go again five minutes later with another liter or so. Strong yellow urine is dripping down the cot onto the ambulance floor. She seems to be working on a bowel movement.

We arrive at her home, and DTs enters to see how many steps, and if we need to move furniture to facilitate the cot coming in, and so forth. The couch onto which the patient will be placed has half an upside-down pizza on it. DTs asks the husband to please clear the couch, then moves it to a better position. For a moment it seems I’ve knocked over a cup of coffee onto the floor, but it’s just a wave of disturbed roaches fleeing the vicinity of the couch.

Six of us manage to get the patient inside and settled on the couch. The children are happy because mom is home again. One of them brings a third of a cake in a plastic container from the kitchen and holds it up in both hands, an offering to us the nice ambulance guys for bringing his mom home. We politely decline, but it’s such a sweet gesture. Everything he’s been taught says food makes grownups happy, so it’s the most loving gesture he knew, and we respect that. Mom meanwhile is already complaining to hubby about the kids, the house, where’s food? We leave.

I hear she dialed 911 that evening and was taken to Hospital Z again. Food on time and someone to wipe you when you crap yourself, no kids pestering you while you try to watch your “stories” on TV. If you can’t afford Cancun, call EMS and let Medicare buy you a little vacation.

‘Cuz that’s what The System is for, ain’t it?

Abracadammit

Saturday, July 23 2005

Slow to post, because there really has been nothing “on topic”. Didn’t turn a wheel last two duty nights – not once.

On the transport side, there was a cautionary tale – as usual, some of the details have been changed to protect patient identity.

If you’ve ever been involved in even a minor fender-bender, you may have had to wear a cervical collar (or “c-collar”). This is an extremely uncomfortable device which wraps around your neck, below the chin, and rests on your shoulders. It keeps your neck from flexing.

Mechanically, your cervical spine is a segmented broomstick with an eight-pound bowling ball balanced on it. If you don’t have full muscular control of your neck, or have even slightly damaged the bony structures therein, severe injuries may result to the encased spinal cord. The c-collar prevents that bowling ball of a head from crunching the neck bones. Usually the collar is precautionary, and the hospital can X-ray or CAT scan you and remove it shortly after your arrival. Sometimes they leave it on, and so should you.

A young man, unrestrained (read, “no seat belt”) driver in an MVA was boarded and collared by EMTs and rushed to the hospital. The patient had stopped breathing and a tube was inserted. Died on the table but was successfully resuscitated.

ABGs came back – his BAL was somewhere near the 500 mark (read as 0.50, way the hell up there).

Some unspecified time later, the patient regained consciousness and was extremely combative. The details are fuzzy, but the patient did bite through the pilot balloon of his ET tube (deflating the cuff), and ripped off his C-collar. He was chemically sedated and a new breathing tube inserted and a new collar placed.

Later still, the patient again “came to” and again angrily removed his uncomfortable C-collar.

Presto-Chango! Like a magician whipping away a handkerchief to show the rabbit has disappeared, the patient whipped his collar off, and all motor function from the chest down magically vanished. He has only gross motor skills in his arms, no finger movement.

Whoops. A couple of fractures at C6 and C7 which, over time, would have healed. The patient can wave his arms in the air, somewhat. There is no control below that point.

“But DTs,” you ask between sobs at this tragic tale, “How can this poor unfortunate breathe?” Ah! The magic of enervation and some well placed nerves. Google “myotome” for the details. And for gossakes leave the collar on until the doc removes it.

Clever Ploy or Biting Criticism?

Saturday, June 18 2005

“Que pasa?” asks DTs as he identifies the patient in the group. “What’s going on?”

The patient glances around for support. “No hablo Ingles,” says the patient to DTs.

“Que molestias tiene?” asked DTs. “What’s bothering you?”

“No hablo Ingles,” came the reply. Various nods in the silent group. It is true.

“Ooookay. Um, donde el dolor?” “Where is the pain?”

“No hablo Ingles,” again.

“Habla Ingles algien aqui?” “Does anyone here speak English?” asks DTs plaintively.

Quoth the patient, “No hablo Ingles”.

Sigh. Is my pronunciation that bad? Must look up “I don’t care about immigration status” and keep that handy.

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