Stubborn Medics

Most of us in health care, especially emergency medicine, know that we make the worst patients. Even though we should know better we usually don't call 911 when we should. We wait until we absolutely have to. When I developed gall stones I was in so much pain I couldn't stand upright. I couldn't drive. I couldn't think straight. But did I call 911? Nope. Too stubborn. I didn't really want to ask my parents to watch the kids or ask my wife to take me to the ER.

So we got a call around 2 in the afternoon for a fall with injuries. When we arrived on scene we found a 60 year old man laying in a recliner. His wife informed us that he had fallen in the bathroom the day before and broken his hip. He had then crawled into the living room and into the recliner instead of calling for help. When she arrived home from work she found her husband pale with pain, but he refused to let her call 911.

She then told us that her husband was one of the first paramedics in Oakland some 30 years ago. He had had his picture in the paper and everything. That instantly explained his lack of interest in calling 911. She continued to explain his reluctance by relating the story of his last hip fracture 3 years ago. The medics just manhandled him onto the gurney with no pain medication. He didn't want a repeat of the performance.

I assured my patient that things would be different this time. I don't think the salty old medic believed me. I then started a line on him. His BP was borderline low so we only started him off with 3 mg of Morphine. We then used a KED to stabilize his hips. While we moved him onto the gurney (as smoothly as possible) we gave him a fluid bolus to bring up his BP with the hopes of being able to give him some more pain medication in the back of the bus.

Next time I hope that he will be a little more willing to call us.

Merry Christmas

I worked Christmas Eve. The firefighter relieving me came in a little early (thanks) allowing me to get home to the family for present opening.

Last night I was hoping for a shutout but we had a couple of calls. One guy couldn't breathe too well (fine, call us for something life threatening) and another was altered. I felt like telling them that I was out of it too at 4 in the morning. Oh well. At least they were legit calls.

Now, I think I hear a pillow calling my name.....zzzzzzzzzzzzzzz

For Those Supporting A Firefighter

My wife readily associates herself with my job by calling herself a fire wife. She caught a lot of grief because of that. It's not that she doesn't have her own identity. It has more to do with the fact that my job intrudes into my our personal lives a lot more than most jobs.

Because of my chosen career my life expectancy is shorter. My risk of getting cancer is increased (more than doubled in a lot of cancers), my risk of injury/death is greater, I'm often sleep deprived, the list goes on and on.

The other day I was on Fire Engineering's website and I came across an article written for the spouses of firefighters, What Every Firefighter's Spouse Should Know.

As I read through the article I started thinking that most of this doesn't apply to me (I'm sure most firefighters feel that way). But as I thought about it more I came to the conclusion that it must apply to a lot of firefighters. And there were definitely parts that apply to me.

So for those of you that support us from the home front, and for those that would like to have a glimpse at what we put our spouses through, enjoy the article.

Real Life Saver

The call came in for a choking patient. The house was just down the street from the station so it didn't take us long to get there.

We pulled up to the house and I noticed that there was no waver (someone frantically trying to get our attention). Inside, on the couch, we found a 75 year old woman. She was gently rubbing her throat. The story from family members was that she had been eating when she started choking on a piece of meat. Her daughter rushed over and did the Heimlich maneuver.

My patient said she felt as if something was still in her throat. I explained that that was a possibility, but it was more likely that the lining of her esophagus had been damaged (it's really sensitive) and that's why she felt that way. The same way you can "feel" a pill that you've swallowed without enough water.

After a thorough assessment (everything checked out great) she and her daughters decided that it would be best if they didn't go by ambulance but instead chose to take their own vehicle. We reassured them that if there were any more complications we were just a phone call away.

`Tis The Season

We were dispatched for a slip and fall. Nice and generic. I've been on "slip and fall" calls ranging from a person needing a hand to get up to a person on the third story roof that had a stroke and fell, and a lot of stuff in between.

This time we pulled up to find a waver. Someone, usually a family member, that is panicked and is out in the middle of the street to wave us in. Potentially a bad sign. In front of the one story house there was a ladder. Someone had been hanging Christmas lights. My patient, a man in his early 70's, lost his balance and took the fast way to the ground.

From 5 feet up he landed on the cement driveway but not before his head came into contact with the brick wall on the side of the driveway. He was alert and oriented and had some minor bleeding from the back of his head. His family, in a near state hysteria, explained that their father had been knocked unconscious when he fell.

We grabbed c-spine and applied a neck collar. We also placed some 4x4's over the wounds on the back of his head. The trauma assessment revealed that he had a couple of skin tears on his arm as well. Other than that and his head lacerations he appeared to be in stable condition.

The guys at AMR helped up package the patient onto a backboard. The last thing I remember after loading the old man into the ambulance was one of the sons complaining that he had told his dad to let him hang the lights.

Smell Of Smoke

The other day we were toned out for a possible residential structure fire. When we arrived on scene the occupants informed us that two day prior their landlord had had someone come out to work the furnace. This was the first time since then that they had turned it on.

Helmet covered in insulation after pulling ceiling.

A couple hours later they smelled smoke in the house. They did the right thing. They evacuated the house and called 911. On the way out the husband threw all the breakers killing the power to the house. When we arrived we found there to be a light smell of smoke with just a little bit of haze in the house.

Once we confirmed that there was no active fire we cancelled everyone but the engine and us. The BC decided to stick around as well. We used the thermal imager to check for hotspots throughout the house. I checked the attic in the garage and found nothing. I then went to check the attic in the house but I couldn't find the scuttle hole.

We searched the entire house (it was only a 1400 sq ft house). Every bedroom, closet, nook and cranny. There was no scuttle hole. By this time the landlord had made it to the house. He said that he had had some renovations done to the house about two years ago. He never noticed that the contractor had sealed the attic.

My battalion chief explained that we needed to check the attic to make sure there wasn't a smoldering fire and that there was no way for us to do that without a scuttle hole without making a mess. The landlord then looked at me standing there with a pike pole (and a grin). I told him that was my job to which he replied that I looked like I enjoyed my job.

The property owner decided to put his new scuttle hole in the hallway. We grabbed a salvage cover and placed it below where I would be working. I then used the pole to make a 18", mostly square hole in the ceiling. We figured that if I did it smaller than the normal 24" then it would be easier for a contractor to come in and convert the opening into a proper scuttle hole.

Once the hole was made I placed into it the attic ladder. I climbed up and was just able to squeeze in my shoulders. I looked around with the thermal imager and everything looked as it should.

Afterward we cleaned up the mess, turned on the power to the house and did a final check. Having not found anything burning we figured that the furnace was probably the culprit. We informed the residents to keep an eye on it and call us back if they needed us.

I needed to go clean my gear of all the insulation and to take a shower.

Miscommunication

We were dispatched for a man feeling ill. The RP was a home health care nurse that stated her patient had a low temperature. Yeah, I was suspect too.

We walked in the house and found an old man laying in a hospital bed in the front room. It was probably the only place they had that would fit the bed without some major rearrangement of furniture. At the head of the bed stood the wife of the patient. She appeared very concerned. At his bedside, the "nurse" (I'm not sure if she is an CNA, LVN or RN).

The home health care worker, as I will refer to her, informed us that the patient had a temperature of 94º F. I quickly placed my hand on the patient's head to see how he felt. He felt like someone with a normal temperature.

The worker then informed us that his blood pressure was low, 94/52. I again touched the patient. This time I checked for a radial pulse, which I easily found. Nice and strong.

While we were getting a proper BP the worker then explained that my patient was altered (our BP was 142/82 by the way). Knowing that that phrase can mean something totally different to someone that doesn't practice emergency medicine I asked for clarification (also because he seemed to be acting normal to me). I was informed that the patient had not been responsive for the last 30 minutes of the 90 minute visit. I then asked the nurse how well she knew the patient and she said this was her first visit.

At this point I turned to the wife and talked to her. The home health "professional" was useless. His wife said that he appeared to be tired. The nurse kept interjecting that she was worried about sepsis. Every time I acknowledged her concerns but she didn't get that (there was a major language barrier).

About then AMR showed up. The CNA/LVN/RN told the AMR medic that the patient was altered. He looked to me for confirmation and didn't get it. The transporting medic was again told that the patient was altered. He looked to me again and I did a quick eye roll. He immediately got the picture. We loaded the gentleman onto the gurney and helped the guys out to the ambulance. After making sure they were all set we headed out.

Car Crash

Just after dinner the tones went off. We were dispatched to the freeway with a neighboring agency for a single vehicle accident in the center divider.

Pulling up to the scene we saw several vehicles pulled over but only one appeared to have been in the accident. We nosed in Big Red behind the accident to give us a little protection as we worked. Some people are like moths to the flame with fire trucks.

We found our patient sitting and leaning up against the center divider. It was a chilly night and someone who had stopped had offered her a blanket. The victim said that she was cut off and had been forced into the median. She had been wearing her seatbelt and the airbags did deploy. There was only moderate damage to the vehicle.

The lady was initially complaining of pain to her right forearm and to the right side of her jaw. While assessing C-Spine I found that she had point tenderness around C4 and C5. As we were going through the process of placing her in full spinal precautions AMR showed up. While I finished strapping the patient to the backboard the AMR medic that was ready to strap her head down said alarmingly, "She's not breathing!"

We did a another check. She wasn't breathing, she did have a strong pulse but she wasn't responding to verbal or painful stimuli. I kept thinking, "Crap, what did I miss." While the EMT grabbed the BVM we loaded the patient onto the gurney and headed for the ambulance.

About the time that we had the BVM set up our patient started breathing again. She was also alert and oriented. The husband (who, from home, had beat the ambulance to the scene) told us that his wife had severe panic attacks and that she often passed out. I'm not sure if that was what happened here but it's something that I would have liked to know when I asked her about her medical conditions!

Before leaving I checked with the AMR crew to find out if they needed anything else. They had a paramedic intern there so they didn't feel they needed a rider.

Learning Curve

You gotta love frequent flyers. Ok, maybe not. Especially at 0430. But at least one of mine (featured in blog posts here and here) is learning.

In our most recent visit to her house she didn't bother to act like she was in severe pain. She complained more about nausea. But while we were waiting for AMR to arrive she asked if she could ask the ambulance crew for some morphine. I think she's finally learning that if she's not really in a lot of pain she's not going to get treated for being in a lot of pain....at least from us. I have no idea how successful she is at getting some of the good stuff from the medics at AMR.

What Changed?

I knelt down in front of my patient and gently felt for a radial pulse. "Hello, what's your name?" After introductions I asked her what was going on that day. She said that she was having "severe fatigue."

In just that short amount of time it was painfully obvious that she had some psychiatric problems. Her father said that she wasn't really able to take care of herself but wasn't bad enough that she was on a conservatorship. He had given her a cell phone in case she got lost while walking around the city but now she used it to call 911. Dad didn't seem too happy about that.

Severe fatigue, not just tired. Fair enough. Also generic enough to have all sorts of causes. My next set of questions changed my thought process. I asked how long she had been experiencing this severe fatigue. She stared at me blankly. I asked again, this time giving her the choices of minutes, hours, days, weeks, months or years (don't know why I stopped there, I should have thrown decades in as well). She thought for a minute and then said that it had been going on for months.

At this point I'm starting to see where this is going but I persist. I asked what made her call today, after months of severe fatigue? What had changed to make her call? Her answer....she had severe fatigue. That was about as far as that conversation went.

At this point I decided to backtrack a little. I asked her if she knew where she was (trying to determine if she was altered or not). She rattled off her complete address, zip code included. I then asked her what day it was. She immediately opened her cell phone, check the date and day, and repeated them back to me. I looked at my engineer and we both laughed. If she's knows enough to check her phone for the day and date I think I'll let it slide. I could tell you those things without doing the exact same thing.

Finally the ambulance showed up. We walked her over to the gurney and sent her on her way. What do you want to bet that we'll be back?