Fun with Blood

After a while at this gig, you get to where you can look at someone and tell things right off the bat. For instance, you’ll look at a patient and notice the jaundiced, loose skin and ping! you know you have someone who, whatever else is going on with them, has a problem with dehydration and liver function.

The same ability applies to EMS noobs (a class into which DTs still falls, somewhat). A major “tell” as to how long someone has been out of class is their use of PPE, or Personal Protective Equipment.

If your EMT-B partner has a still-healing paper cut from when he was trimming his certification down to wallet-sized, he will probably don lots and lots of PPE to your call, even if that call is nothing more than a ED-to-retirement-home transfer. Ms Picadilly arrived at the ED c/o “feeling slightly feverish”, was given a Tylenol and needs a ride home. The EMT noob will done Level A protective gear straight out of Michael Crichton’s “Andromeda Strain”. Full Tyvek body suit, airpak, the works, and only then approach the patient whilst making Darth Vader sounds: “<hhhhttt> Hello! <hhhhttt> My name is Bob! <hhhhttt> We’re here to take you home!”

As you may have guessed, there are diminishing degrees of PPE, Levels B, C, and D – which is just your uniform. Level E would be actually disrobing somewhat before patient contact, so counting shirt, undershirt, pants and socks, one would suppose that Level I would be wearing just your boxers. Since there are letters of the alphabet unused after “I”, one would suppose that around “M” or so the EMT is actually bathing in and gargling with the patient’s bodily fluids, but that just gets sick and we’ll stop there.

Anyway, gloves are pretty much always worn by everybody, no matter their experience (or perhaps because of it), but we tend to disregard the finer points of PPE unless we’re expecting a problem. For instance, goggles are rarely worn unless we’re working a delivery, tubing a patient, or getting our picture taken for JEMS.

Which all just goes to show how being “too experienced for one’s own good” can come about.

Our patient was a young non-English-speaking gentleman who had been pushed out of a car at the ED. The car sped off, leaving the patient on the steps as it were. Someone had it seems decided this fellow’s head was the wrong shape, and fixed it for him with the tools at hand, probably a baseball bat.

So here we have this guy who needs to go to a different hospital. We’re told CT has cleared his c-spine, but note that he’s still wearing a collar, but is not backboarded, so we board him up. He’s somewhat responsive but non-cooperative. One of his ears keeps filling up with blood – that’s bad – but it fails the halo test – that’s good. He won’t answer questions – that’s bad – but he nods understanding when we tell him we’re going to do something – that’s good. O2 sat at 100% on room air, add a 6L/min nasal cannula for giggles. We get this poor fella loaded and we’re on our way.

This being a blinkies-and-woo-woo kind of ride, and since we boarded him, I saved the detailed physical exam for in-the-box. The head’s the big problem here, but he may have soft-tissue injuries or broken ribs and whatnot, so I begin the detailed assessment.

Turns out, one reason that the patient hadn’t been verbally answering questions was he’d suffered some broken teeth. And bleeding into his mouth. And saving it up. And so he waited until I was checking his pupil response for the third time to become

Mr. Blood Vesuvius, meet Paramedic Pompeii. A loud blast of air and blood from the patient which (we found later) completely covered the cabinets, ceiling… everything.

Gurk! Damage report! Left ocular sensors offline, Cap’n! Lip shields unbreached! Nostrils at 70%!

Okay, left eye got a big clot of blood, probably all over my face, but with my RIGHT eye I can still check the patient’s airway and make sure he’s not drowning… nope, he’s fine and probably GCS 15, still protecting his own airway and spitting out more blood. I get to take a moment to clean out my eye a bit before finishing up the assessment – but first my patient gets his NC traded up to a non-rebreather at 15L/min. Slightly more cleanup so I don’t freak out the ED nurses when we arrive.

We transfer the patient to the ED RNs. One of them removes the NRB mask to ask him questions, leaning over solicitously to do so. “Sir, can you hear me?”

“Hey, you might not want to lean over him like that…”

The nurse straightens up to ask, “Why?” just as he erupts again. Unanimous decision by the half-dozen people in the room. Patient gets a mask.

And DTs gets a Ryan-White call an hour or so later. The ED has determined that this particular patient, this time, had no HIV, Hep-C, or any other cooties.

This time.

So what have we learned, kids?

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