Closest I've Come To Passing Out

My blog doesn't have any stories in it before my paramedic internship started. For good reason. It was started for me as a way to document my internship and to share some of my stories with my friends and family. I've since taken it over (cue evil laughter). So every once in a while I'm going to start sharing stories of when I was an EMT. This one comes from my clinical rotation during medic school.

I walked into one of the busiest trauma centers in Los Angeles county (and probably the world). It was my very first shift as a paramedic intern. I had to put in 240 hours in the ER and do several rotations through other specialties (OR, OB, Peds...). I was assigned to an RN and was basically told that I would be assisting her the entire shift. She gave me a quick tour of the ER and then showed me where the supplies were that I might be using. She then tossed me into the proverbial water so I could learn how to swim. She asked me to go start an IV on the woman in bed 23.

Up until this point all of my IV starts had been on mannequins. Not the ones you see in the department stores. These had simulated veins and were supposed to prepare us pretty well for the real thing. Most paramedic programs have you practice on each other (which seems like some breach of the 8th amendment) but ours didn't citing that their insurance wouldn't let them. I didn't complain while I was in class but now that I was about to start my first IV and it was on an actual patient I wasn't very happy about it.

I was a nervous wreck. I went to the supply room and slowly gathered everything that I thought I'd need including lots of 4x4's. I then stalled by double checking that I had everything. I was mildly freaking out.

As I walked up to bed 23 I noticed that my patient was a black woman, in her 50's and she was overweight. Quite a bit overweight. I walked up to her side, introduced myself and confidently told her that I was there to start her IV. She could obviously tell that I was anxious because she informed me that she had been a heroine addict for 30 years so needles didn't bother one bit.

I fumbled around and got the tourniquet on her arm. I then went to the antecubital spot on her right arm and started searching, in vain, for a vein. I then tore open the alcohol wipe and proceeded to wipe down the area hoping that a blood vessel would magically pop up.

It was then that my patient did it. She grabbed my hand, the one with the needle in it, and said that I had to get in there and just dig around. As she was telling me this she forced me to plunge the needle into her arm. She then started moving it around deeper and deeper as if the vein were hiding behind her bones. After what seemed like an eternity she stopped and directed me to the other arm. The scenario played out the same with no luck starting the IV.

By now I was sweaty, pale and defeated. I went and found my RN and told her that I was unable to start the IV. The only thing that makes the whole experience sting a little less is that 3 nurses could start the IV either. Eventually the MD had to come in and do a surgical cut down to get vascular access.

Wet Stuff On The Red Stuff No Longer?

While wasting time I found a very interesting article on firefighting on Fire Rescue 1's website.

Firefighters know that in a structure fire there are other things that damage property besides fire. Smoke gets everywhere and causes almost everything with which it comes in contact to be ruined. Then there's the knuckle dragging hose jockeys. We break down doors, cut off security bars, rip out cabinets, cut holes in the roof, tear out dry wall....basically we make a giant mess. Then there's what we use to put out the fire.

I'm sure most of you have seen what happens when you spill a glass of water on a book. We do that writ large. Another issue with water is the sheer weight of it.

Temperature - t - (oF)	Density - ρ - (slugs/ft3)	Specific Weight - γ -
		(lb/ft3)	(lb/US gallon)
32	1.940	62.42	8.3436
40	1.940	62.43	8.3451
50	1.940	62.41	8.3430
60	1.938	62.37	8.3378
70	1.936	62.30	8.3290
80	1.934	62.22	8.3176
90	1.931	62.11	8.3077
100	1.927	62	8.2877
120	1.918	61.71	8.2498
140	1.908	61.38	8.2048
160	1.896	61	8.1537
180	1.883	60.58	8.0969
200	1.869	60.12	8.0351
212	1.860	59.83	7.9957

So it weighs roughly 8 1/3 pounds. At my department we flow 150 gallons per minute onto a fire. That's 1250 pounds a minute of water (if we only have 1 hose line flowing) going into your house or office. That's a lot of destruction.

In the fire service our mandate is to preserve life AND property. That's why we fight structure fires. To limit the damage caused by fire, we put it out. To limit the damage done by smoke (and to help with fire suppression) we ventilate the structure. As far as the damage we cause we only do what we have to, to stop the fire and to make conditions safe. We are actually quite good at limiting the damage that we do have to cause. Up until now all we could do to reduce the damage done by water is to use less of it. That may be about to change.

At a meeting of the American Chemical Society, in Anaheim, a new way to fight fires was demonstrated. Magnetism. They focused a magnetic beam onto a fire and extinguished it. Ludovico Cademartiri, a Harvard physicist, says that they aren't sure exactly how it works but "it appears that carbon particles, or soot, generated in the flame are key for its response to electric fields. Soot particles can easily become charged. The charged particles respond to the electric field, affecting the stability of flames."

Looks like scientists have figured out how to stop the continuous chain reaction part of the fire tetrahedron. Sounds promising. It would be nice to have yet another tool in our arsenal.

We're Going To Open Up The Lines

When dispatch told us that we were headed out for a 20 year old with back pain we all groaned a little. 99 times out of a 100 this would be a total BS call.

We walked in to find our 20 year old patient writhing in pain. Her mom told us that she had had thyroidectomy done about a week before. She had no other medical problems other than that.

My patient mostly just cried. It brought back bad memories for me. She looked like I had felt. We got a quick set of vitals. Her BP was 151/90, pulse 150, respiratory rate about 30 and shallow but she still had a pulse ox of 99%. She was very warm to the touch and said that she had been nauseated and had been throwing up now for a couple of days. When I asked her where it hurt she said her back. I asked where on her back. She replied that it felt like someone was scratching out her entire spine from top to bottom.

My engineer was impressed that I started a line on her in one attempt since she had no veins. That's one of my mad skills as a medic is my ability to start an IV. You could see the relief ripple through her entire body as the morphine started to act on the pain receptors in her body. Unfortunately moving her brought back all of the pain. Once she was in the back of the bus I gave her some more 'candy.'

My question for all you medically trained blog readers out there is this, what was the pathophysiology behind her spinal pain. I thought meningitis but there was no head pain or stiffness in the neck. Is there some sort of infection (or was the fever unrelated) that she could have gotten (maybe in surgery) that affected her CSF but not given her headaches? I'm just curious. I don't think it would have changed my treatment at all.

Panicked Father

While we were at the grocery store the radios crackled to life. We were being dispatched for a medical aid, a 6 year old overdose. Any medic that tells you that a potentially serious pediatric call doesn't speed up their heart rate a little is full of it.

While riding backwards in the engine I went over the normal vitals for a kid of that age. I also figured out what his weight should be and did some calculations in my head, just to get the cobwebs out.

Once on scene we found dad with his son, who appeared to be sick. The father told us that he had found his son playing with a now empty bottle of Children's Tylenol. He had no idea how much was in the bottle before his son got to it.

Arriving at the house just after the ambulance, much to her dismay I'm sure, was mom. She came in slightly flustered until she heard what was going on. She then told us that the bottle was empty and that she had just gone to the store to buy another.

Disaster averted. Another life saved.....by not doing anything.

Family

We were dispatched to a 50 year old male with abdominal pain. I remember in medic school we were told that there were a lot of potential causes of abdominal pain. Even more vivid was was my recent bout with cholecystitis where I became very acquainted with dilaudid. Needless to say, I'm very sympathetic to my patients with abdominal pain.

We walked in to find our patient laying in bed, in very little distress. He had, in the last week or so, undergone a  duodenal switch surgery in order to lose weight. The patient denied any complications or recent illness. The man said that he had experienced excruciating abdominal pain on four separate occasions today, the longest lasting about 30 minutes. He wasn't in much pain at that point and the only other thing wrong was his BP, which was really high.

While I did my assessment my captain dealt with the mother. She was being rather stubborn. Her son had had the surgery at a hospital over an hour and a half away. 'Mom' had talked to his surgeon and was directed to bring her son to the hospital. We tried to explain that we couldn't take her son past 20+ hospitals that were closer just to take him to the one where he had the surgery. We tried to explain that we'd send him to the closest ER where he would be evaluated for any serious problems and then transferred, if needed, to the hospital of his choice. Evidently she wasn't having any of that.

Meanwhile, while this was going on I simply talked to my patient and explained the situation. Funny thing, he completely agreed with me that going to the closest ER was the wise thing to do. After all, it might be something simple like gall stones.

So while my captain and the B@#$% were arguing (she was simultaneously talking on two cell phones and the house phone trying to find a family friend that was a medic....he later told her we were right) we loaded the patient into the ambulance.

After we were done with the call my captain decided to go back and try to smooth things out. Unfortunately it just made things worse. Sometimes I can't stand family members. At least my captain took that one for the team.

Additional Dangers Of Obesity

As we were walking out of one of the local SNiFs our dispatch hailed on the radio. "Engine 51, status?" We informed them that we were available. "Engine 51, respond to room 179 for a 65 year old female, possible stroke." At least we didn't have far to go.

As we walked into the room we were met by the RN. She said that her patient had, in the last 10 minutes, started slurring her speech and began having facial droop. CVA's (cerebrovascular accident), more commonly know as strokes, are very time sensitive. Just like a heart attack, the longer the brain goes without oxygen, the greater the damage that is done. There is a small window of opportunity for stroke victims where they can receive clot busting medications, only 4 hours from when symptoms start.

My patient did have progressively worsening facial droop and slurred speech. What she had going for her was a nurse that noticed this and immediately called us. We would have been able to get her to the ER well withing the prerequisite time frame except for one thing. My patient didn't fit on the gurney. She weighed over 600 pounds.

While being obese does place people at extra risk for all types of medical conditions I don't think people realize that it can also delay your much needed treatment. We had AMR respond with their bariatric gurney. Meanwhile we waited. And waited. We talked with our patient. We learned all about her and what lead her to be there under those circumstances.

About 15 minutes after our arrival my patient appeared to stabilize. She still had the drooping face and slurred speech but she wasn't getting an worse. Other than those two minor things she said she felt great. No headache, no weakness.

After an hour of waiting another crew showed up with the super sized gurney. Seven of us moved the patient over to it and got her on her way to the hospital.

I hope that, when further tests are done, they find that it was only something like bell's palsy. If it was a stroke, I think we still got her to the hospital within the time frame for drug therapy.

Fire Ops 101

One of the departments in the bay area took part in IAFF's Fire Ops 101.

The program is designed to allow political leaders and the media to have a glimpse of what it's like to do our jobs. One of the main goals of the program is to show the importance of having 4 firefighters on an engine. Most departments now, because of budget restraints, are unable to staff fire engines and trucks with more than 3 firefighters. While we as firefighters understand that this is not going to change while the economy is in the toilet, we like to remind people that what we do is more difficult and dangerous when we don't have the right amount of people for the job.

The firefighters-for-a-day took part in several different stations which included fire attack, search, ventilation, auto extrication and EMS. The entire event was planned and run by volunteers from the department with the support of the department.

Here are a couple of news articles written participants in Fire Ops 101:

http://castrovalley.patch.com/articles/fire-ops-101-crawl-into-burning-building-smash-car-windows

http://newark.patch.com/articles/a-day-in-their-boots

And here are a couple of videos showing how it went and what our elected officials thought of it.

Fast forward to the 2:10 mark for the piece on Fire Ops 101.



If you get a chance to participate in Fire Ops 101 in your area jump at it. If you work for a department that isn't currently participating in it I would encourage you to look into it.

Sleazy Motel

Anyone that has a cheap motel in their district knows that they are good for all types of calls. Anything from AAA (abdominal Aortic Aneurysm) to Zygote Intrafallopian Transfer (infertility). Ok. I looked up medical conditions and picked the first and last one alphabetically. But there really is a wide variety of calls at places like this.

The tones went off about 10 minutes after I had drifted off to sleep. We were toned out to the E-Z 8 Motel for a man having a seizure.

We arrived on scene to find the girlfriend waiting for us outside her second floor room. When I walked in I found my patient laying on the floor, almost unresponsive. The woman told us that her boyfriend had had a seizure that lasted about 2 minutes. Evidently he just sort of slid to the floor so there was no trauma.

We gave the patient some oxygen to help bring him around while we continued our assessment. After a few minutes he was able to tell me his name but was still a little fuzzy on any other details. A few minutes later we were trying to get him to go to the hospital. He was now probably as alert and oriented as ever. As soon as he figured out that we were trying to take him to the hospital he tried to tell me that he was just sleeping. That's when I tossed the proverbial BS flag.

I asked him if he thought I had just become a medic yesterday. He looked me up and down and shook his head, "No, I guess not." So I asked him why he was trying to sell me that line about sleeping. He sheepishly agreed that it wasn't a smart thing to do. He still didn't want to go to the hospital.

I ended up making him a deal. I'd let him sign out AMA but if I had to come back that night he was going in without so much as a whimper.

Thankfully, I slept the rest of that night.

Seroquel

Seroquel is a drug used to fight depression. While watching TV I noticed that they rattled off a long list of side effects. What's worse is most antidepressants have adverse sexual side effects, SSRI's being among the worst according to the Mayo Clinic. If I had all these symptoms I'd be depressed too! This is a list of side effects from Seroquelxr:

• Neuroleptic malignant syndrome (NMS): 
• high fever
• stiff muscles
• confusion
• sweating
• changes in pulse, heart rate, and blood pressure. 
• These may be symptoms of a rare and serious condition that can lead to death. Stop Seroquel XR and call your health care provider right away.
• High blood sugar (hyperglycemia):
  Call your health care provider if you have any of these symptoms of high blood sugar while taking Seroquel XR:
  • feel very thirsty
  • need to urinate more than usual
  • feel very hungry
  • feel weak or tired
  • feel sick to your stomach
  • feel confused, or your breath smells fruity.
• High cholesterol and triglyceride levels in the blood (fat in the blood): Increases in total cholesterol, triglycerides and LDL (bad) cholesterol and decreases in HDL (good) cholesterol.
• Increase in weight (weight gain)
• Tardive dyskinesia: Tell your health care provider about any movements you cannot control in your face, tongue, or other body parts. 
• Orthostatic hypotension (decreased blood pressure): Lightheadedness or fainting caused by a sudden change in heart rate and blood pressure when rising too quickly from a sitting or lying position.
• Increases in blood pressure: Reported in children and teenagers. Your health care provider should check blood pressure in children and adolescents before starting Seroquel XR and during therapy. Seroquel XR is not approved for patients under 18 years of age.
• Low white blood cell count
• Cataracts
• Seizures
• Abnormal thyroid tests
• Increases in prolactin levels
• Increases in liver enzymes
• Long lasting and painful erection
• Difficulty swallowing

These are not all the possible side effects of Seroquel XR.

I'm not singling Seroquel out, they just happened to have the commercial that saw most recently.

Distractions

In the past couple of weeks I've noticed that my blogging has slowed down quite a bit. I thought I'd share my new distraction. We're in the process of buying a house.

We've spent a lot of time researching homes and then touring them. We've found a bunch

And so I've been very distracted.

Now we're in escrow and I think I can start blogging again with a little more regularity.

So stay tuned. More to come very soon....probably.

Doh!

Usually, sometime around 4:30 in the afternoon, whoever is cooking dinner gets started. Every crew is different. Some have a resident chef that always cooks. Most have some sort of rotation where everyone gets a chance to cook. This tour, my engineer was cooking.

He decided that we would be doing pizza that night. So while I was doing EMS reports (yes, even we get inundated by paperwork) he prepared the pies and placed them in the oven. It was about this time when his wife called.

 

While he was talking on the phone and I was on the computer some cheese melted and slid off the pizza and onto the bottom of the oven. We, of course, did not realize this until we heard the loud electronic warble of the fire alarm joined with an annoying strobe light flashing. It really is effective at getting your attention.

I ran upstairs to the kitchen to find my engineer at the oven pulling out a piece of charcoal that was meant to be his pizza. While my captain headed to the panel to shut off the alarm we opened up all the doors and windows. The chef then tried to salvage what was left of his pizza.

Even firefighters are not immune from torching dinner. Oh well.

KaBoom!

We were doing our morning checks on the apparatus when we heard a big boom. Over the roar of the engine and power tools we didn't hear the screech of tires or the second crash. We peered around the corner of the station and could see one vehicle with moderate damage up against the utility pole and another vehicle in the middle of the intersection.

I ducked into the engine to grab some gloves and headed over to the wreckage. My engineer informed our captain and then pulled the engine around to block traffic in an attempt to make things a bit safer for us.

I stopped by the first vehicle I came to, the one up against the pole, and checked on the driver. She was a elderly woman that was shaken but did not appear to be injured. I then turned my attention to the car in the intersection. In the drivers seat sat a young woman young enough to make me wonder why she wasn't in school. She was complaining of head and neck pain.

About this time is when my engineer got big red in between the wrecked sedan and traffic. He jumped out and grabber the c-spine equipment. I grabbed a c-collar and directed him over to the other patient. the biggest problem with having an accident happen in front of your station is that there aren't enough EMS personnel to go around.

As soon as the first police officer showed up I had him help me with my patient (I'm sure there's a joke in there about cops wanting to be firemen but I'll let it slide this time). Soon we could here the truck coming from the next station over. Two minutes after their arrival we had an ambulance on scene, plenty of manpower, and a patient just about packaged to go get checked out.

These types of accidents really demonstrate how for passenger protection has come in vehicles. More than likely both patients that day were able to have lunch with friends and talk about their experience. 20 years ago a t-bone accident would have been a lot worse.