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Friday, April 23, 2010

Trust Your Heart Monitor?

We got a call during our morning check out for a 26 year old female having chest pain. I'm pretty sure that everyone on my crew was thinking the same thing...BS.

As we pulled up to the apartment building we were greeted by close to a dozen kids all excited to see the fire truck stop at their place. We walked upstairs and past the kids to apartment C. The front room was totally bare with the exception of 3 pregnant women. One of them pointed towards the back bedroom.

As I walked in I found my patient laying down in bed. As reached for her wrist I asked her what was going on. While talking to her I noticed that I couldn't feel a pulse. My engineer quickly got her on the heart monitor and started working on a blood pressure. I assumed it would be low since I could get a pulse at her wrist. My patient told me that she woke up with this chest pain and that it had happened once before. It was a tightness in her chest that didn't radiate. She wasn't able to rate her pain but it appeared to be in moderate distress. No history of recent illness or recent stress. The pain did not increase on palpation or inspiration.

She was supposed to be on some medications but didn't have them. Last time she felt this way she was transported to the hospital where they gave her something to make the pain stop. The patient was also experiencing shortness of breath and general weakness.
The rate is wrong but this rhythm strips show basically what I saw.

On the heart monitor she appeared to be in SVT at a rate of about 230. Her systolic blood pressure was in the low 70's. Shocking. As I started an IV my engineer shot a 12 lead. AMR showed up just as I finished starting the IV. I gave a report and my engineer finished up the 12 lead. My heart monitor was telling me that my patient was in atrial flutter not SVT. It didn't look that way to me. Since we don't carry anything in my county that would work on atrial flutter part of me wanted to go ahead and give the Adenosine and see what it would do.
Once again the rate is wrong but this is what the monitor was telling me it saw.

And for the record, I did have the patient try a couple of Valsalva maneuver but those didn't work.

I ended up trusting the heart monitor. I recently read a book about the mistakes we make in medicine. It talked about a study in which a cardiologist went head to head against a machine in determining which patients were having an MI. While the computer was not correct all the time it did better than the cardiologist...and faster. I have to assume that my heart monitor was able to read things in the 12 lead that I just couldn't pick up on with the naked eye which made it determine it was a-flutter and not SVT.

I should have followed up on this patient and found out what they did for her in the ER.

So just curious, would you have given the Adenosine?

Wednesday, April 21, 2010

There's Only Room For One Rooster

We recently had a call at a local clinic.Local clinics are not on the top of our favorite places to go although  every once in a great while you can get a good call out of one.
As we entered the rear of the clinic we were greeted by one nurse sitting in a chair and 9 others gathered around her. As I approached my patient my captain asked what was going on. What he got for an answer was a cacophony of answers from all 9 nurses. He immediately started clearing the room of all but one nurse for questioning.

I let my captain deal with that. I went straight to the source. My patient was a...and I assume still is a woman in her early 50's. Being a nurse she was able to give me just the sort of answers I needed during my assessment. She told us that she had been driving in when all of the sudden she felt some chest pressure and shortness of breath. We quickly followed our guidelines and treated her chest discomfort.

By the time AMR arrived we had just finished with our 12 lead ECG and and a line established. A fairly straight forward call, once you let the nurses know who was in charge.

Monday, April 19, 2010

Feelings of Helplessness

As a firefighter/paramedic there are not many situation in which I feel helpless. My crew and I are highly trained for all manner of emergencies and, if we can't fix it, generally know someone to call that can.
Just before dinner we were toned out for a woman in labor.Several things go through my mind on a call like random order.

"S**t! Do I remember how to deliver a kid?"

"It's a BLS skill, let the EMT do it!"

"Women have been having kids forever without help, how hard can it be to play catcher."

"I was right there when all of my kids were born, it's not so bad. I got this."

"Hehehe! This could be a fun call."

Like I said, some variation of these thoughts went through my head on the way to the call as well as the actual procedures for delivering a newborn.

When we arrived on scene we found a 34 year old woman laying on a couch in the garage surrounded by her family. First impression, she's not far enough along to be in labor.

She informs us that she is 21 weeks and 4 days along and that she was just discharged from the hospital 4 hours prior to our arrival. She had started dilating prematurely and had had to undergo surgery to put a couple of sutures in her cervix. She called us because while she was going to the bathroom she felt a rush of fluid. Sounds like her amniotic sac ruptured. She wasn't complaining of any pain or desire to push. She had no abnormal bleeding.

After running a quick set of vitals and a thorough assessment there wasn't a lot we could do. And AMR still wasn't on scene. Enter the feeling of helplessness. My engineer started a line on her since she would need one in the hospital.

Still no AMR.

We explained why we were just waiting and she understood. She had taken an EMT course and now worked for a hospital. She was amazingly calm.

Still no AMR.

After what seemed like an eternity AMR finally showed up. We gave them a quick report and got her on the way to the hospital.

There was nothing for us to do except be caring and supportive. This poor woman was probably losing her baby and we were completely incapable of help. I hope that everything turned out well for her. Maybe her amniotic sac didn't rupture and a couple of months from now we can go back to deliver the little girl.

Thursday, April 15, 2010

No Gear Left Behind

One of the firefighters at my station left at the end of his shift for a 10 day vacation. In his excitement (an assumption on my part) to get away he left his turnouts right next to the rig. Seeing as how firefighters are such a helpful and friendly lot someone decided to hang them up for him.
Hang them way up.
They made me laugh every time I saw them.

Tuesday, April 13, 2010

Bad Dinners

I recently read a post by another blogger that talked about some less than stellar meals at the firehouse. It immediately brought a couple of meals to mind....from the same "chef."

The first time I had his cooking the firefighter decided to cook meatloaf. His variation on a theme called for string cheese to be placed in the center. When asked how long it would be until dinner was ready he replied that it needed to cook for 20 minutes. That was our first warning. 25 minutes later he was slicing the meatloaf...
...which looked nothing like this. It was completely raw in the middle. So much so that the string cheese was still cold. Due to the late hour of the failed feast, we went out to eat.

The second (and last) time that we let the "chef" cook he said he was making stew. He put everything together and let it slow cook in the crock pot. During the meal the "chef" informed us that the mystery meat (at that point what we did not want to hear was that there WAS a mystery meat) was Elk.
 It actually didn't taste that bad. But, my guess is that the elk was a little too old because within 30 minutes of dinner every one of us was in the bathroom.
I'm just glad that we didn't get a call right then. He never got the chance to redeem himself on our shift.

Monday, April 12, 2010

The Seldom Seen Firefighter

A couple of shifts ago we had a ride along. She happened to be the wife of one of our soon to be retired ranks.
Since she has been the wife of a firefighter for many many years she has had the opportunity to visit the station and be with the guys quite often. She has been able to see how the young firefighters grow and mature both in the department and with their own families.

She has had a front row seat to a strange, and at first glance, an almost darwinistic culture. We aren't exactly known for sympathy. As mentioned on other blogs the time to start to worry is when the other firefighters stop making fun of you.

She has seen how we can laugh at anything and everything. We are seldom serious. And we love practical jokes.

So it was interesting to hear her what she thought about her ride along. She was simply amazed at the transformation that takes place as we walk into an emergency scene. She said that we became professional and courteous. We quickly examined and treated the patient. It's something that I haven't thought about much. When I talked to my wife about it she wasn't surprised at all. She said she has seen it at the scene of traffic accidents that I have stopped at while off duty.

Luckily they haven't picked up on our subtle games that can be going on even while we are on scene.

Boys will be boys.

Monday, April 5, 2010

Legality vs Morality

I recently came across a news story from Pittsburgh where a man died because paramedics didn't get to him....within 30 hours. That's what I said, HOURS! Not minutes.

The man had severe abdominal pain (after having had cholecystitis I have a new found respect for abdominal pain) and was not able to walk. His girlfriend later told CNN that her boyfriend "couldn't walk or move, and had to lie down with stomach pains."

The problem with the response was that Pittsburgh was having a heavy snowstorm. They received almost 2 feet of snow in 24 hours. This delayed the response. In fact, on three separate occasions, ambulances were dispatched to the home of this man and all three times they never got closer than "two to four blocs from the house." Three of the city's 13 ambulances got stuck in this snow storm.
Now I understand that weather conditions can make 911 calls challenging. I've been in a very similar call. But I don't understand why the crews gave up. Doesn't the writing on the side of the ambulance say paramedic RESCUE? Maybe they just didn't think they had enough manpower or equipment....
So would this be more manpower and equipment? It's even designated as RESCUE 1!! Maybe they mean rescue if you aren't really trapped. Or maybe we'll rescue you if it's not too cold or wet. What the hell?!?!

Now if the patient had died in 30 minutes of the original call (the girlfriend called 911 ten times during the 30 hours) I would not even be writing this post. But while I was sitting here I put myself into their shoes. What would I do if I were unable to drive to the patient?

My first instinct would be to hike in. Been there done that. The Pittsburgh Public Safety Director Michael Huss said it perfectly, "You get out of the damn truck and you walk to the residence."

Let's say that for some reason you can't walk. Try calling for additional resources. We're not talking about some small town like Monowi, Nebraska where there is no one else to call. Pittsburgh has a population of over 1/3 of a million people. 

So let's see. First, call for a snow plow.
I find it hard to believe that they wouldn't have one within a 30 HOUR drive but for arguments sake we'll say there wasn't one. 

Let's not just give up. Call for a could have called and had one transported from Colorado and still had time to spare.
...or get creative. Local citizens love to help.
Hey! Call the military. Put your defense dollars to work. With the time that they had the military could have flown it in from Iraq!
Call a redneck...There's got to be a few of them around.
Try calling for a helicopter to come in and do an aerial rescue. I ended up having to do this on my snow rescue.
If all that fails, grab a couple hundred volunteers and some shovels and dig.
How long would it really take a group of determined people to shovel enough snow to get an ambulance 4 blocks?

I guess the thing that bothers me most about this story is that the emergency responders gave up. And now that someone lost their life because of it they are arguing that they didn't do anything legally wrong.

This man and his girlfriend called 911 in their moment of need and we did not answer the call in an expeditious manner. It makes me sick.

I don't want to be associated with fire and EMS crews that give up because the call isn't an easy one. Or because they won't be held legally responsible. It wasn't as if their lives were in immanent danger if they continued on the call. No one was going to shoot them. They might have gotten a little cold and wet. I was fairly hypothermic after my snow rescue. But we still got to the patient, treated her, and got her out.

To the crews that were on this call (and those who sympathize with them), find a new profession. You may not have been legally liable but you sure had a morally duty to act. You Fail. Go become a waiter or something. Get out of my profession. You embarrass me.

I can't get over 30 HOURS!! Sad.


(I realize that I don't have all the information as to what happened on this call. The information I did get is from a few articles on the site. If you agree with me or, more importantly, if you don't, let me know. If you have more information I would love to have it)

Sunday, April 4, 2010


We got a call for a woman laying on the floor of her living room unable to open her front door. Something a little different. Fun.

When we arrived on scene we were greeted by the neighbors who informed us that the old lady that lived in the apartment next door was unable to unlock the door. They were under the assumption that she had fallen and hurt herself.

My engineer and I grabbed some tools and started looking for a good spot to do some breaking and entering.

We found that all the windows and doors locked so we decided to make our entry at the sliding glass door. We simply popped the sliding glass door off the rails and tried to lift the door over the locking mechanism. Instead I broke the screw that was holding it together. The repairs cost the owner only 35 cents.
We found our patient, a 76 year old woman with dementia, laying on the floor next to her couch. We quickly determined that her hip was dislocated or broken. We don't know how long she had been there but she was unable to make it to the bathroom. She tried to tell me that she just wanted to lay there a while and that she would get up later. She was very vocal about not going to the hospital. We found out later that she had run away from her daughters house to come back to her old place. Since she wasn't all together there (because of the dementia) we couldn't leave her. We kindly informed her that she had to go.

Still no dice. She wasn't going.

So we told her that if she chose to not go the police would have to get involved since she was obviously unable to take care of herself. She didn't decide to cooperate until PD was called.


We cleared that call to take another one, just around the corner. This time it was a 51 year old man that was a little out of it. His family was sure that he had taken some Valium and/or Vicodin but couldn't figure out where his stash was. He was able to answer our questions with a lot of prodding and patience. He just didn't seem right even though all his vitals checked out.
His family, bless their hearts, kept trying to explain that he was going to die if he didn't go with us. Almost as if it would happen the second we drove away. After being there a while his mental status had deteriorated. He was no longer able to tell me what day it was or why we were there.

At that point he had to go.

Of course, he didn't want to go. And this was a big guy. Finally, we explained the same thing to him that we did to the old lady on the previous call...go with us or the cops. We ended up calling PD. Then one of the family members suggested bring the gurney up close and just telling him to get on. It worked, sort of. He tried to stand and couldn't without assistance. Once we helped him to the gurney PD arrived. The officer that showed up had, for one reason or another, been on every call we had had that day.

Both patient had blood sugars of 98. The amount of similarities between the calls amused me, if only for a second.

Thursday, April 1, 2010

Do You Sign?

The call came in for a fall victim at the community center. It was one of the best times of the day to get a call there (this last statement is dripping with sarcasm). It was during the senior citizen's activities. This would turn my ordinary call into a spectator event.

When we arrived we were informed by a staff member that my patient, a 70 year old man, had fallen and may have lost consciousness. She wasn't sure how it happened or if he hit his head. Apparently there were no witnesses to the fall but a lot to the aftermath.
To make matters more difficult we quickly discovered that our patient was deaf. Luckily, my engineer knew enough ASL (American Sign Language) to be able to spell out a couple of simple questions. It was seemed clear that our patient was grateful that we were there but that he didn't want to go to the hospital. But since we couldn't talk to him we were stuck and had to assume he was injured.

After my engineer had ascertained that the old man hadn't hit his head, and had no head, neck or back pain, we cleared c-spine. One of the overly helpful old ladies in the peanut gallery proceeded to inform us that he may have a neck injury and we should do something about it.

I asked her if she had seen the fall? No. Did she know the man? No. Why did she think the man had a neck injury? He fell and that can happen.

I though she was going to say that she had seen it on TV.

As AMR walked onto the scene I flippantly asked the medic if she spoke sign language. To all of our surprise (including her partner) she said yes. She started to sign with the man and discovered that he doesn't speak ASL, he speaks RSL (Russian sign Language). Fortunately the two languages were close enough that the two could communicate.
We left the patient in the care of AMR who had decided to wait for his daughter to come get him.

I'm still amazed that we were able to talk to the guy at all.
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