In triage, I tell them low-speed accident, right hip and knee pain, and we are sent to the back, where we put him on a stretcher in the hallway. I give the report to the nurse, and wait while the nurse and a tech do their own assessment. The BP is still 140/80. He is having pain when pressing against their hands with his feet, and he can’t lift the left leg well. I can’t pinpoint what is bothering me, but I know something is. I am waiting for them to discover something I haven’t. I sense they are bothered by him as well. He gets moved into a room. The nurse can’t see any deformity. I leave a copy of my run report. I didn’t get a line, but the transport time was only a minute, so it’s no big deal. They haven’t put one in yet, and his pressure is steady.
I come back three hours later with another patient and learn the man has a fractured pelvis that was bleeding into him. They discovered it while doing an X ray.
It bothers me. I question how well I palpated his hips. I got pain, but I didn’t find them unstable. Maybe it was a hairline fracture or maybe his muscles were so developed they hid it. What bothers me is that I knew something was wrong but wasn’t admitting it. I have been doing so many BS accidents, I feel I have gotten lazy. My index of suspicion is just not there. Maybe I should have called for a trauma-room treatment of him. The mechanism of injury would have warranted it, but you don’t like to call for a Room 1 unless you are sure.
Maybe I did all right, but the call leaves me uneasy. I imagine Dr. Morgan reviewing the case and shaking his head. How could Canning have missed a pelvic fracture? Who let him out on the street? Other paramedics tell me it can be missed, but something bothers me about it. I need to be more thorough. I have been a paramedic only six months, and I can’t fall into complacency.
We respond to a cut finger, a cut elbow, a lady with the flu. Other calls go out—a shooting to the neck that Shawn and Arthur bring in on a one, a traumatic arrest. Joe Stephano does a code in Windsor five minutes after we are sent back to the city following an hour-and-a-half wait out there doing nothing. We get called for a broken leg. A guy on the fourth floor has a huge swollen ankle that he injured playing basketball. His buddies helped him up the stairs. We offer to help him down, but instead he hops on one leg down four flights, then keeps hopping like a bunny out to the ambulance. Glenn splints the leg in the back, while I drive to the hospital, no lights, no sirens. We do two BS accidents where people are looking for insurance money. I hear other calls go out. Good calls. Challenging calls. I think what am I missing? What am I not seeing for the first time? What am I not learning?
We’re waiting at Hartford Hospital in the triage logjam with a guy with a broken finger. A new basic EMT is asking his partner a question. She says why don’t you ask Peter, he’s a paramedic. He shows me two abbreviations. I tell him HTN means hypertension. The other abbreviation, AV shunt, I don’t know what it means. I ask Glenn, but he doesn’t know. Sorry, I tell him. He thanks me.
When I give my reports to the nurses, I sense they are listening to me. I’m getting good at giving concise reports. I usually have a saline lock in place and bloods drawn, which they appreciate. I hope they are saying to themselves, Boy, he’s a good paramedic, rather than yeah, yeah, yeah, right, right, right, right, right, oh, blood pressure 140/80, yeah, sure, gonna have to check on that, can you believe this idiot, yeah, yeah, yeah, right, right, right, right, now shut up so I can assess the patient.
* * *
Simsbury Ambulance calls for an intercept—this time for an eleven-year-old girl who has gone over the handlebars on her bike and been knocked unconscious for five minutes before awaking. The volunteers have her c-spine immobilized and on oxygen. A friend of the girl’s mother is in the ambulance with the girl and the EMTs. I check the girl over, put her on the monitor, draw bloods, and put in an IV. She is still a little confused about where she is and what happened. My guess is she has a concussion but will be all right. Still, since she is young and has been knocked out, I call the hospital to let them know we are coming in with her. This will assure she is seen right away. They put her in Room 2 and give her a full check over. When I stop by with my completed run form, the girl’s mother is there with the neighbor. “He’s the one who got on board,” the neighbor said. “He did a wonderful job.”
“Thank you very much,” the mother says, warmly clasping my hand.
“My pleasure, ma’am,” I say. I also compliment the Simsbury volunteers for making the right decision to call for a medic. I tell the mother that they served her daughter well.
She thanks me again.
“Glad to be of service,” I say. “Much obliged.”
Although the call was no big deal, I walk out feeling like John Wayne.
I believe I am doing okay. I don’t believe people are talking behind my back, saying I can’t believe he’s a paramedic. I wouldn’t want him treating my family. I think I have respect, but I am not revered. To be revered you need to have done the big bad ones and lived to tell about them with authority.
One of my favorite TV shows is The Simpsons. On one episode the bus driver, Otto, gets in trouble because one day Bart Simpson brings a guitar on the bus. Otto dazzles the kids playing “Freebird” and “Stairway to Heaven” until he realizes he’s late to school. He drives really fast, gets in an accident, and loses his license. The principal, Mr. Skinner, has to be the new bus driver. He has the kids all sing in unison, “Hail to the bus driver, bus driver, bus driver. Hail to the bus driver, bus driver man.” The problem is, Mr. Skinner has a hard time pulling out into traffic and the kids are always very late to school. In the end, a reformed Otto gets his license back and pulls into traffic with ease. Everything else that has gone awry is settled. Mr. Skinner, looking out and seeing the school bus arrive on time, says heroically of Otto, “Hail to the bus driver, bus driver man.” I want someday for people to say of me, “Hail to the paramedic, paramedic man.”
We are sent for a man down at the corner of Madison and Broad—ETOH country, an area where we pick up many drunks and ETOHs, abusers of ethyl alcohol. We spot him sitting on the curb in front of the liquor store. When we go to lift him, he takes a swing at us. He stands with poor balance and has liquor on his breath. “Leave me alone,” he says. “I’m not bothering anybody.”
We let go of his arms to see if he can stand on his own, and he starts to walk right into traffic. We grab him and pull him back to the sidewalk. “You’re going to the hospital,” I say.
Most drunks are transported on the bench seat rather than on the stretcher, but I lay him down so I can take a set of vital signs. It is a hot day and his skin is cool and clammy. His pressure is a little low, and his pulse a little on the high side. I decide to put in an IV line. At the least he needs to be rehydrated. While I am drawing up my blood tubes, I have my partner check his blood sugar by putting a drop of blood from the needle onto a Chemstrip, which gives a ballpark reading within two minutes.
“Blood sugar forty,” my partner says. “Good pickup.”
“Are you a diabetic?” I ask the man.
“Leave me alone,” he says.
I give him twenty-five grams of dextrose through the IV line. Within moments he is alert and his speech is improved. He admits to drinking three beers but says he hasn’t eaten all day. “How’d you know I was a diabetic?” he asks.
I am feeling pretty good about myself on this one. “I didn’t. I just was being thorough. Your skin was cool and clammy. You needed to get hydrated, so I checked your blood sugar. Just part of a thorough assessment.”
“You mean you didn’t see this?” He holds up his wrist, from which dangles a silver medical bracelet that has a red cross on it and says “Diabetic.”
“Ahh, no,” I say, suddenly deflated, thinking that looking for a medical bracelet is one of the first things they teach in first responder and EMT classes. It is an essential part of your patient assessment. It is something I rarely even think about.
“They never do,” he says, and tells me how he got beaten up for taking a swin
g at a cop just the week before.
I shake my head. I think about suggesting that he wear a T-shirt that says, “I am a diabetic,” though probably even then neither the cop nor I would have noticed it.
At the hospital as I give the report to the triage nurse, another triage nurse comes by, looks at the patient, makes a face, and says, why do they have a line in him, he’s just a regular drunk.
“Blood sugar of forty,” the triage nurse says in our defense.
The other nurse says, “Oh,” standing corrected.
The call comes in for a person unconscious, but when we come through the door, we see a thirty-year-old man sitting stiffly in a chair, getting oxygen from a policeman. He took some of these, the cop says, handing me a bottle of Haldol. The man can follow my movements, and he squeezes my hands when I ask him to. I ask him what happened and he says he doesn’t know. His pulse is 100. His pressure is good. His pupils are dilated but reactive. He answers my questions in a slow voice, almost like he is mentally disabled. The muscles in his face are stiff. He wears no medical bracelets of any kind.
The father, a bald, nervous man, tells me he wants him to go to John Dempsey Hospital, where they know all about him.
“Has this happened before?” I ask.
“Just take him to the hospital. They have his records there.”
“I need to know some background here before I can give him any care.”
“You don’t need to do anything but take him to the hospital.”
“This has happened before?”
The wife says yes, once last year.
“What kind of condition does he have?”
“They know at the hospital,” the father says.
“What is his condition?”
“They don’t tell us. Just take him to the hospital.”
The cop catches my eye as if to say he has some information to tell me out of the father’s range.
We put the man on the stretcher and get him into the ambulance. The cop tells me he thinks drugs are involved, which is why the father is being so difficult.
I nod.
The father comes over, and I tell him we’re going to go without lights and sirens. That I am going to start an IV and put his son on the heart monitor.
“You don’t need to do that. Just take him to the hospital. You’re wasting time.”
I do the IV en route. The man denied he did any drugs. He says he drank only one beer. I am boggled by what is going on. He is stable, so I am not worried about him, but this is something I haven’t encountered before. It appears to be a reaction to a drug, but there are no hives, no difficulty breathing, no itchiness, only joint stiffness.
We wheel him into the hospital, and the nurse recognizes him. I start relating the story as best I can, and she stops me. “It is a dystonic reaction,” she says.
“What?”
“A dystonic reaction.”
“Okay.” I have never heard of it before, though that night I will read all about it—a reaction to Haldol that can be relieved within minutes with fifty milligrams of Benadryl, a drug I carry.
The father shows up and somewhat sheepishly thanks me and shakes my hand. I guess he is apologizing for being an asshole, and now that his son is in the hospital and I didn’t kill him, all is well.
There is nothing in my protocol book about dystonic reactions. I look through my old textbook, Brady’s Paramedic Emergency Care, and find a small paragraph about it on page 814:
Adverse reactions have a striking presentation as various muscle groups become dystonic. A patient may report the following signs: eye deviation, head deviation, difficulty speaking due to a “thick” tongue, involuntary arm or leg twitching/jerking. Fortunately, these reactions may be alleviated with the administration of diphenhydramine (Benadryl). An IV should be established, and twenty-five to fifty milligrams of diphenhydramine may be given IV push. Diphenhydramine normally reverses the extrapyramidal effects quickly with great relief to the patient.
I don’t remember discussing it in class. Unless I was taking a leak when we did it. There is so much I still don’t know.
I think how next time I get a call like this I will recognize it. If the father is treating me like shit, I will put in a line right there in the living room, call medical control on my radio, ask for orders for Benadryl. Take a small vial out of my magic kit. Draw it up in a one cubic centimeter syringe. Push it in. Within minutes, the stiffness will disappear. The son will stand and proclaim, “I can walk! I can walk!” The mother will sit down at the home organ and start playing the Hallelujah Chorus, and I will blow kisses and bow deeply.
But this time, I get back in the ambulance, feeling a little depressed, and wondering how many more calls lie ahead that I will not know the answers to.
The Chain of Survival
Glenn and I are in 451 outside Saint Francis. He is sleeping in the driver’s seat with his head on a pair of towel rolls against the window. I’m stretched out on the bench in back. The radio crackles numbers. “Four-five-one.”
Glenn picks it up. I sit up and put the pillow back on the stretcher.
“Four-five-one,” Glenn says.
“Four-five-one. Signal seventeen in Bloomfield. Blue Hills Avenue for the cardiac arrest.”
I am stepping into the front seat. After Glenn repeats the address, he says to me, “This is the big one, boss.”
We turn right onto Woodland, which takes us across Homestead to Albany Avenue, where we turn left, and then a few streets later, right onto Blue Hills, which runs past Mount Sinai Hospital into Bloomfield. We reconfirm the address on the radio.
“It should be on the left once you cross Cottage Grove. It’s in the parking lot.”
As we pull into the drive, we spot the whirling blue lights of police cars. A cop waves us over. Someone is holding an umbrella over a body, which other people kneel over. They are doing CPR.
I jump out and grab the heart monitor and oxygen bag from the side door. I recognize Kerry Bedick, a volunteer with Bloomfield Ambulance. “This is a witnessed arrest,” he says. “She got CPR right away.”
It is an older woman in her sixties. She doesn’t yet have the dead look that most people in arrest have. The pavement is wet. “Let’s get her on a board and into the back of the ambulance,” I say. Normally, you work a nontraumatic cardiac arrest where they fall, but if I have to shock her, I need dry ground.
We turn her on her side, slide the board under her, and lift her onto the stretcher. I jump into the ambulance through the side door and set up at the head. I put the monitor on the bench to the right. I lay out my airway kit. I get out the ambu-bag and attach it to the in-house oxygen supply.
The stretcher is lifted into the ambulance and the woman is slid in. I apply the monitor. She is in ventricular fibrillation, a rhythm of uncoordinated movements. I set the charge for 200 joules.
“Everybody clear.”
I hit the shock buttons. Her body jolts. I look at the monitor.
Flat line.
“Asystole,” I say. “Glenn, get the line.”
I assist ventilations, then turn them over to Marissa Mancchio, an EMT who has arrived in a second ambulance to assist us. I get out my laryngoscope and attempt the intubation. Her throat is full of secretions. I can’t see the cords. I pull out and Marissa resumes bagging. The other EMT is spiking a bag of saline for Glenn. I go back in but still can’t see the cords. I pull out. Marissa bags, while I get the suction ready. I stick the suction in the woman’s mouth and suck out the secretions.
“You’ve got the line?” I ask Glenn.
“All set,” he says.
I take an epi out of the drug box and hand it to him. He pushes it through the line. I recheck the monitor. She’s in v-tach.
“Clear.” I charge at 200J and shock again.
She goes into a supraventricular tachycardia (SVT). I feel her throat. Boom. Boom. Boom. Against my fingers. A pulse. “My God,” I say. “We have pulses.” I look at her. She is out, but
she seems to be coming alive like a person trying to awake from a paralyzing sleep.
I hand Glenn a one hundred milligram vial of lidocaine. He pushes it.
I try again for the tube, but now she is gagging on the laryngoscope. We go back to bagging her with the ambu-bag.
We are now en route to the hospital.
I look at the monitor. She is going at 170 on the monitor. The rhythm seems to be flying by. I can’t tell if she’s in a PSVT or v-tach. She is on the borderline of life, coming back from the other side. I think, don’t blow it, you might have a save here. I am frightened to shock her, it may kill her, it may put her back down, but she needs it.
I wait five seconds, ten seconds, fifteen. I shock her again. The rhythm is clearly PSVT now. Her pulses are still there.
At Mount Sinai, we roll right into their cardiac room. Dr. Dansky looks at the monitor. “Is that v-tach or PSVT?” he asks.
“She’s been real close,” I say.
“Shock her again,” he says.
We blast her once more. The rhythm again looks more like a PSVT.
“How are the pulses?”
“Good pulses,” a nurse says.
We move her onto the bed.
We stand back and watch as the doctor calls out orders for a lidocaine drip and magnesium. He intubates her. She has a pressure and good pulses.
“Her eyes are open,” a nurse says. “Hello.”
It has all happened too quickly to grasp fully. I realize now I am soaked with sweat.
“Good job,” Dr. Dansky says to us.
Glenn and I turn to each other and shake hands. He pats me on the back. “Your first save. Good going.”
“You, too. You got the line in. The epi did the job. That was the turning point.”
We shake again and stand around amazed, like sudden contest winners.
Paramedic Page 16