Tuesday, November 22, 2011
The final knot in the knurled up ball of muck that morning commute had become came fast and furiously in the form of hail. Ice fell from the sky in various sizes from those rivaling golf balls down to minute pebbles. The roadway was coated and in California, nobody adjusts driving speed for anything, least of all weather; an accident was imminent.
The call was for a part of the freeway where one freeway splits up into two others. The lanes peel off to the left and right with signage to direct. There are several choices and often times people make either last minute decisions to change lanes, or more likely realize they are on the wrong path and abruptly adjust. The latter was the suspected cause of the call we were going on.
“Five-oh-Six, Five-oh-Six copy code three.” The dispatcher said in a calm voice devoid of emotion.
“Five-oh-Six, I have a code three for you. It’s for the MVA, unknown injuries, bus involved, possible MCI, I’ll start an advisory. Please advise additional units upon arrival.” And we were given the location.
“Five-oh-Six, we copy the call. Ten-Eight.”
We were rolling code three down the shoulder of the freeway. The crunching of the tires against the new-fallen ice cubes made for a unique experience. It was loud enough in the cab that it was difficult to talk over when added to the siren. We were only about a half-mile from the reported location of the call and traffic was already backed up in a disjointed, slow-moving queue. All of the motorists jockeying for position made the lines of traffic bob and weave like rows of snakes in the throws of death. The shoulder was our only refuge, but we had to take it slow given the severity of the ice storm we were in and the suspicion that a driver would get frustrated and pull into our path on the wide-open shoulder. It was a gamble, but our only option.
The hail suddenly stopped as if a water faucet had been turned off and the sun again came out, keeping the daily promise of California sunshine alive. The sun was riding very low on the horizon and was illuminating all of the ice, now covering the freeway, sending blinding glares in all directions.
“Oh man, this is going to cause some serious accidents.” My partner said to me.
“Town biz for sure. Good thing traffic is pretty much stopped. Hard to get into an accident at five miles an hour.”
“Oh, they can figure out a way.” My partner joked.
We got up to the accident at the head of the line of cars and it was a simple fender bender already moving over to the side with CHP on scene. There was no bus in site. I rolled down my window and my partner crept the ambulance up to the officer directing traffic and moving along the rubber-neckers.
“What do you got?” I asked the CHP officer, yelling over the traffic crunching the ice balls on the freeway.
“Non-injury. Should be cleaned up in five.”
“Where’s the bus?”
His eyebrows raised a bit and a smile crept across his face. “Oh, you are on that call.” He said with a knowing nod as he chewed his gum. I remember his teeth looking a brilliant white illuminated by the argent glare of the sun off of the hail. I could see myself squinting in the reflection of his mirrored aviator sunglasses. He pointed down the freeway and against the extreme glare of the sun on all the ice I could see a dark blue bus on the side of the road with a few other cars haphazardly positioned on the freeway. I could hear the fire engine about five hundred yards behind us laying on the horn to get the commuters to just give them an inch so they can get by. There were a couple CHP cruisers on scene and they were running around a bit. This would be some action. “Enjoy!” he said slamming his clipboard shut and turning back to his task.
I was worried. Traffic was picking up from zero to sixty just past the minor accident once everyone got an eyeful of nothing. They were accelerating like horses out of a race gate without knowledge of what they were driving into.
As I got closer I realized that the accident was spread out, maybe even more than one accident. There was a pair of cars against the center K-rail that looked like maybe just a minor fender-bender. The occupants had self-extricated and made their way over to the shoulder on foot and appeared to be exchanging documents. Traffic was zipping by and cars were obviously having trouble navigating the slick road as they fishtailed around. There were two other cars and a dark blue bus on the far right shoulder. Five lanes total so there was plenty of room for cars to zip through and CHP had not been able to control traffic. This would be a confusing call to triage.
It didn’t look like there was anyone in the cars so I went over to the bus. As I approached it, I noted the bars on the windows. This was a prison transport bus! I popped my head in and saw there were several officers inside taking inventory on the prisoners and triaging their complaints. Of course everyone had a complaint but a couple were legitimate. The officer approached me.
“We have two head bleeds, a broken hand, a skinned knee and a broken forearm. Everyone else is neck and back pain.” He said mocking fake neck pain.
I thought this seemed like a lot of injuries for a crash like this with minimum mechanism until I noticed they were all handcuffed. They had no way to break their fall into the seats and railings in front of them. “How horrible would that be?” I thought. It was time to report what we had and call for more resources. I ran back to the ambulance to get my partner.
“Call an MCI and get a sup here. Tell them we need at least three more ambulances and when you are done get in there with some BLS supplies. Mostly minor traumas. They are all prisoners so we’ll need restraints.”
Just as I turned around the fire engine was pulling up. I gave report to the captain and he directed his guys what to do to help out with triage and bandaging everyone up and preparing for transport.
I looked down the freeway to the other smaller accident and noticed it was cleared. The CHP officer had opened the lanes and it looked like the start of a drag race. Everyone was accelerating towards us. The freeway surface was still covered with millions of little ice cubes and the sun was still refracting the light in every which way possible. This was going to be a disaster. The first few cars zipped by hardly even noticing we were there. Then the rubber-necking started. Car after car of drivers craning their necks towards us to see what we were doing on the shoulder only looking forward again at the last second and narrowly avoiding the unsuspected stalled cars in the number one lane.
As luck would have it eventually somebody plowed hard into one of the cars. The sound of the locked up tires grinding the ice on the cement was unnerving. The point of impact was parallel to where the fire captain and I were standing so we had front row seats to a show we did not want to be at. The small, silver sedan hit the stalled cars so hard her rear wheels lifted off the ground. I could feel the vibration through the pavement and the crash itself was deafening. There was an immediate stress reaction that made my heart sink and took my breath away. Very similar to the feeling when you get dumped by a girlfriend or get some equally bad news.
“Holy shit!” said the captain.
I instinctively turned to avoid the debris from the crash. Some did come our way, but nothing that was too threatening and nobody got hurt.
“Call for another unit” I said to the captain and he did immediately. “And more CHP, we need this mess shut down before someone gets killed.”
My partner returned from the bus to give me a count and progress report on what the firefighters were doing. The three of us were staring at the car that had just stacked up behind the already stalled car. We could tell there was a small person in the driver’s seat. Probably a woman judging from the small size. It was very hard to see with all the glare. She was franticly moving around in the front seat. We were pretty sure she was going to get out of the car. The last thing we wanted her to do. We were yelling to her and waving our arms around to get her attention but she seemed very focused and not interested in our input one bit.
Her door opened on the opposite side of us as we were looking at her across five lanes of aggressively moving traffic. We saw her feet below the car silhouetted against the glaring background and her head appear above the car. She was going to make a run for it. This could not end well. Now some of the cops had joined in yelling to her to stay in the car, but she either could not understand us or was not listening. She moved to the back door and opened it up.
“What is she doing?” asked the captain, more to himself than any of us.
“Maybe she needs to get her phone or her briefcase or something” my partner suggested.
“What can be so important?” I asked.
“Maybe she got her bell rung and she is altered?” my partner added. This was certainly possible.
We speculated only for a moment later, for the answer came and it was not the one we were looking for.
Two little toddler feet were added to the adult feet already seen under the car. I felt like someone had just punched me in the gut. “NO!” I said instinctively. I thought I was going to pass out for a second. She was going to put a little kid into this traffic and we were going to witness a horrible, traumatic death of a child just feet in front of us.
The chorus of emergency workers trying to make her reconsider her suicide run was growing louder. She lifted the child up, or at least the feet disappeared and she came around the back of the car. We now had our first look at her. She was a small Asian woman. Perhaps five feet tall, maybe ninety pounds if she was lucky. She was in professional dress and her eyes were ablaze with fear and determination. She was clutching the small child to her chest under some kind of blanket. We could not see the child’s face or head, but the little legs were sticking out below the blanket. Without checking the traffic she just hunkered down and ran full speed across five lanes towards us like a macabre live action version of “Frogger” but without any judgment or timing. I had played that game enough times as a child to know that if you play it like that, the frog always dies.
I couldn’t look, but I had to. Our eyes were riveted to see how this would play out.
The scene was reminiscent of Vietnam era movies when you see the mother tucking and running with a child at her bosom against a backdrop of napalm exploding. She ran into the traffic and somehow managed to thread the deadly needle ending up on the shoulder next to us in fetal position. She would not let go of the child and was sobbing uncontrollably. There was no way to assess her for injuries as she not only did not speak English, but was not allowing us to touch or assess her in any way. We decided to give her a moment to calm down.
I left a firefighter with her and headed back to the bus. The other ambulances and cops were now arriving and we had all the help we needed. The freeway was shut down and tow trucks came to move the wreckage to the shoulder. The rest of the call went like clockwork, but was a challenge because we were spent from adrenalin overload. My EMT and the firefighters were able to quickly triage and bandage up all the prisoners and transport everyone who wanted to be seen. The woman eventually was able to calm down enough to let go of the child and let us assess them both. No injuries, just shaken up. We still transported them to the hospital since the mechanism of the crash was so brutal.
This call took a long time to get out of my head. There were so many things that could have gone wrong and they all ran through my mind and haunted me regardless of the fact that they did not materialize. There were a dozen scenarios, all of them much worse than the actual outcome that could have easily come to pass on that brilliant morning in Oakland. Sometimes, at the psychological level, the suggestion of what could happen is worse than reality.
copywright 2011 Jon Kuppinger
Tuesday, August 16, 2011
I was picking up an overtime weekend shift to try and compensate for some lost time I had due to an injury in my rotator cuff and my lower back. Minor setbacks like that can really cripple you financially. I was working with a new guy. We had been talking about how he had never had anything really bad yet like a shooting or stabbing, which is not a great idea. In general, I’m not superstitious, but everybody knows not to talk about something unless you want it to happen. One of the first rules. You never mention that it is “slow” or “quiet” either, unless you are looking to get run. Of course, on this day, we were stupid enough to talk about my partner’s lack of “good” calls.
We heard a number of calls drop in succession on a hot corner notorious for gang activity. There were a total of four all within a block of each other. We were assigned as first unit in on a GSW (gun shot wound) with a non-secure scene. My partner hit the lights, the siren and the gas and we cut through the town.
As we were approaching the scene, we were trying to be cognizant of the fact that there were no fewer than four calls all on the same block. All kinds of fire trucks, police cars and ambulances were all triangulating in on this one block at a high rate of speed. That can be very dangerous to all the responders, so we took it on alert. The pouring rain cut down on visibility further complicating the response.
Two of the calls on this block were for GSWs, most likely related to each other being that close in proximity. One was for a MVA (motor vehicle accident). The fourth seemed to be a medical that was unrelated. Certainly possible given the level of poverty and lack of even basic health care this area is famous for. Some people will go a lifetime without any preventative care with astronomical hypertension and untreated cardiac conditions. Walking, ticking, time bombs just waiting for their fifties to creep up on them. A few blocks out we heard a second unit attached to our call and dispatched to our location. So now we had five ambulances, four fire engines, countless cops and who knows what other resources coming. Add to that a couple dozen looky-lous and you have a recipe for disaster.
Since we were first to arrive (besides the police of course) the bystanders were easily as confused as we were as to where we were supposed to be at. We saw a BLS rig from another transporting agency a block from us with several police cars. It looked like they were on the ground working someone up. As we passed the first scene the bystanders were obviously very agitated we were not stopping for their patient. The jumped up and down and yelled waving their hands over their head. Some of them held up their iPhones to film us. A cop jumped out into the street pointing back to the first clump of people on the sidewalk indicating that was going to be our call. Apparently he and the BLS crew had his corner of the block handled and we were needed back a couple houses.
I called in again to dispatch asking if the scene was secure. The answer came in an OPD officer shining a flashlight at us and directing us through the crowd to a small run down house with way too many people in front if it pointing down their driveway.
“I guess the scene is secure and this is our guy.” I said to my partner.
“Five fifty-nine we are on scene, waved in by PD.” My partner said into the radio.
“Well, ask and you shall receive, here’s your shooting you were looking for.” I said to my partner.
I was putting my gloves on waiting for the ambulance to come to a stop. I wanted to be ready to jump out and get to work immediately. These kinds of scenes can be very sketchy and the quicker you get the victim packaged up and out of there the better. There were police and firefighters swarming all over the place with about fifty concerned citizens mucking up the progress. Everyone wanted to tell somebody their version of what they saw or more likely didn’t see.
Once the rig stopped I said to my partner, “I’ll get the board and C-spine, you get the gurney ready and get it as close as you can.”
I ran around to the back of the ambulance and the fire engine was just pulling up. The Lieutenant stepped out talking into his mike on his shoulder and the medic approached me.
“Know anything yet?” he asked me.
“The cops said he’s out back.” I said handing him some of the gear.
I particularly liked this fire medic. He has always been competent, supportive and an all-around nice guy on previous calls. I was happy it was him.
We walked down the crowded driveway into the back yard. There was a pit bull on a chain that could almost, but no quite reach us. He was testing the strength of the chain and barking like he would certainly eat us given the chance. I didn’t want to find out.
“Hey puppy!” The medic said, acting as if he were going to approach the dog and then backing off saying “just kidding”.
There was a bald, plain-clothes cop in the alleyway in dark sunglasses with a badge on a chain dangling over his hastily donned bulletproof vest. He was holding an assault rifle at the ready and his attention was darting around ready for any combat that came his way. He had a handgun in a holster attached to his belt on his jeans. He was waving to us to move along and make it snappy. There were at least three iPhones tracking us from the windows and porches as we walked back along the narrow driveway to the one car garage behind the little shack of a house.
Everyone films everything in the hood.
Our patient was around the side of the small, detached garage lying on his side cradling his ribs with his arms and rocking back and forth in pain. There was a rusted and slightly physically compromised chain-link fence on two sides of him defining the property line. He had tight cornrows in his hair, looked to be about forty years old with a number of scars on his face. He was wearing a thick, light brown leather jacket over a nice dress shirt that might have been silk. He wore expensive designer jeans, and classic Air Jordans, laced up so he could run. This is the uniform of the older gangsters in the hood. All the kids now wear long white T-shirt, saggy pants, and unlaced hi-tops that make them walk in a funny waddle. Their pants sag well below their crotch so they wear brightly colored or patterned boxer shorts to contrast the simple colors they wear on the outside. In the summer, lose the shirt. In the winter, add a bulky black bubble jacket that may or may not be hiding a sawed-off shotgun or a strap in their waistband. It is for them to know and you to ponder. They sport long extension braids with an oversized, precariously perched baseball cap that has perversely converted the colors of the local sports team’s logo to fit the colors of their gang, car or otherwise and wear gold or platinum removable “grills” in their mouth. The OGs have their own “classier” uniforms and wear their hair cropped much closer and wear gold, not platinum or silver. The OGs have real gold teeth, not these fake “grills” the posers wear. My guy was an OG.
We stood over him for a second trying to figure out what the problem was. There was no blood. He appeared to have either ran in this backyard and found himself trapped or jumped over the fence from the yard behind him and ran out of steam. Either way, it wasn’t clear exactly what was wrong with him.
“What happened man?” I asked him.
“I got shot” he said through clinched teeth.
“Where?” I asked him.
“In the chest” he gasped.
“OK, we are going to have to take all your clothes off” I started to tug on his jacket and he reacted violently pulling away.
“Man, what you trying to do? That hurts!” he barked at us. He had anger in his eyes.
I could smell the combination of leather and the unique tangy odor of adrenalin driven sweat that cut through the musty smell of garbage cans and wet weeds he was lying in.
“I can either take your jacket off or cut it off. Your choice, but it’s coming off.” I told him with authority.
We were running out of time. A critical trauma like this hast to be packaged up and on the road to the hospital in less than ten minutes from arrival. I usually shoot for six. It’s the patient’s best fighting chance of survival to keep it brief on scene.
He quickly sat up and held his arms out like a kid does when it is time to take a jacket off and they want mom or dad’s help. So much for keeping him immobilized in the position found. We pulled the jacket off and there was the blood. The whole upper left side of his dress shirt and wife-beater T-shirt were soaked in bright red blood. I quickly cut the shirt off with my shears and asked him to hold his arms up so I could see under his arms.
There were a total of five holes in his chest. Two were under the armpit area. One was exactly over where you would point if I asked you where your heart was. He was breathing in short breaths so my concern was up that a lung might be punctured. I couldn’t believe he was alive much less talking to us.
I could hear sirens all around us. This wasn’t over yet.
“OK, I’m gonna need you to lay down on this board.” I told him. He did.
As soon as we got him on the board I took his shoes and pants off to look for more holes. He didn’t have any more.
Then the heavens opened up. The rain came fast and furious in sheets. It was time to hustle and get the patient out of the back yard and into the cover of the ambulance. I was wearing rain slicker pants so my bottom half was OK, but from the waist up was getting soaked. I thought it must be worse for the patient who is now naked and on a board getting pelted with rain.
Once in the ambulance we got to work quickly. I got a baseline set of vital signs which were amazingly normal. He said it was getting hard to breathe and was starting to really complain of pain in the chest. I listened to his lungs. They were equal, with good tidal volume and air movement, but he still winced in every inspiration. The holes in his chest were oozing, but not aggressively bleeding and there was no obvious signs of a sucking chest wound. I covered the wounds with occlusive dressings, and prepared the decompression kit just in case the situation worsened.
On the way, I tried to make conversation with the patient just to keep him conscious. He was not very forthcoming and knew he was potentially in a lot of trouble so the less he says the better. I don’t make a habit of asking about the details of crimes or even wanting to know as it affects my ability to provide unbiased care. I was able to get out of him that he had no pre-existing medical conditions, took no medications and had no allergies to medications that he knew of.
We came into the hospital hot. His vitals were still holding well and his bleeding was well under control, but still, this was a guy who took several rounds to the chest in the area of his heart. If things were good right now, chances are they wouldn’t stay that way too long.
After I turned over to the trauma team and the students and residents swarmed him like yellow jackets on a spilled soda, I asked one of the nurses if the other guy came it yet.
“What other guy?” she asked.
“There was another gunshot patient on scene” I said.
Another crew came in fast and furious. They were performing CPR on the go as they hustled in to the ER leaving a trail of watered down blood behind them as it was still torrentially raining out. They were bagging the patient and someone was holding pressure just below the armpit on what I assumed was a wound.
“Is this the guy from the car?” I asked.
“Yeah. One shot axillary. Witnesses say your guy was the driver”
Through talking with the other crew, I was able to put it all together. Suddenly it all made sense. My guy was driving, the shooter was in a passing car that pulled up to the driver’s side and opened up on them striking my guy four or five times and hitting the passenger once. This caused the car to crash into another car, creating further injuries to the other vehicle’s occupants and rendering the OG’s car inoperable. The OG bailed out of the car and jumped a few fences between backyards until he either ran out of steam or felt he was a safe enough distance to call out for help.
I talked with the ER doctor later and got the rundown on the injuries. The OG would be going home later that day. The other guy would be going to the morgue. The cops said there were no outstanding warrants and my guy was not on parole so given that he is not talking, he will be free to walk.
But the inequality of the equation, and what kind of freaked me out is the following. My guy had several holes in his chest. They were all at the perfect trajectory, speed and caliber that they were able to bounce off of ribs. On first inspection, clearly any could have killed him. The other guy only had a lone hole but it was in just the right exact position to slip between two ribs and hit a major vessel (the aorta most likely but any major vessel would do) an cause him to bleed out internally in seconds. Just dumb luck. But the trauma game is a matter of millimeters and a lot of dumb luck.
On my next run to the hospital I stopped into OG’s room. He was all smiles and had a friend visiting him. A youngster in a long white T-shirt, braids, sideways red hat, baggy jeans and unlaced hi-tops. Associate is probably a better word. There was a large bandage over his whole upper left chest, but other than that he looked to be in very good health.
“Well there’s the luckiest guy in the world” I said as I walked in startling him and his guest.
“Hey!” he said “This is Jon, the paramedic that picked me out there when they shot me” he introduced me to his friend. His friend gave me the nod, no words.
“I hear you are getting out of here soon” I said.
“That’s what the doc says. Nothing major hit, just flesh wounds.”
“Hmmmm, that’s great.” I said. “So here is what you have to do.”
“Yeah?” I had his attention.
“As soon as you get out of here, you need to go straight to the minimart at the bottom of the hill.”
“Why?” he asked.
“Because you need to buy a lottery ticket tonight, you are the luckiest son of a bitch in the world.”
“Awww man, you know it. I think I used up all my luck though. Aint no thing. I’ve been shot before.”
“ I still think you should get yourself a ticket.” I persisted.
“Alright then, I’ll do that.”
“Oh, and buddy, if you win, I get half!”
We both laughed and I headed back out to prepare for the next call.
Monday, January 10, 2011
You can ask anyone in the emergency business, this time of year our calls take on a different light. I don’t know if there is any documentation to back this up or if it is just superstition because we are more sensitive around Christmas. Perhaps it is just how shocking it is to see some of the scenes we walk in on against the familiar backdrop of red and green holiday decorations that for the first half of our lives invoked cheer, magic, and wonderment.
For our patients, and really everyone in general, there are indeed more stresses this time of year. There are many unwanted family interactions ending in violence and sometimes even death. Depression is common even among people who do not normally exhibit psychological problems throughout the year; and for those who are normally clinically depressed, it can be more profound in the face of the expectation they must be happy. People also tend to eat much more than they normally would; gorging ones self can compound any of the pre-existing medical complications they already have. Anyone who has ever tried to be on a diet during this time of year knows the pressures to make poor food choices are crushing at best.
There is one other seasonal factor that is responsible for bringing Party Boy, the subject of this story, into my life. Typically around the holidays, people tend to overindulge in the intoxicant of their choice, be it alcohol, narcotics, or whatever else they can get their hands on.
The call came in for a residence that was on one of those strange little streets that keep starting and stopping depending on which block you were on. You would hit the dead end, but then go around a block and pick it up again. Of course the map book does not reflect these little idiosyncracies. This made us a little later to the call than we like to be, but still well within our allotted time.
The house was a multi-unit, single story house and the address we were looking for was in the back of the building. The door was open and we were met by one of the firefighters walking out.
“You guys might want to bring some extra sheets and towels, he’s all covered in vomit and blood” she said punctuating with a look of exaggerated disgust.
“What’s the deal?” I asked. We still didn’t know. The call was for “unknown medical” which could be anything from a hangnail to dead.
“We don’t know yet, he’s spitting up blood and has vomit all over him.” She said.
“Great”. I said not meaning it at all.
“I’ll get the blankets and tarp” my partner said, “you can go ahead and see what we have”. She was telling me not to worry about the equipment, she would get it for us. Partners who are helpful in this way are like gold.
I walked down the walk with the firefighter and she and I made small talk. She had been in the house and knew what she was about to walk back into. I didn’t but had a pretty good idea. We wanted the next twenty feet to at least be somewhat pleasant.
I stepped up the steps and knocked as I usually do on the doorframe even though the door was open to announce my entrance.
The apartment was shockingly neat and tidy on the inside betraying the shabby exterior. Recently refinished hardwood floors. Modern colored paint on the walls with white crown molding. The kitchen looked like it had been updated recently. Not at all what I expected from the outside. There was a thirty-something young lady sitting on the couch in an oversized white T-shirt pulled over her black legging covered legs. Her knees were drawn up to her chest under the shirt and she looked as if she had been crying. She had long dyed black hair and acne and piercings on her face. Her look screamed “I just woke up!” She just pointed to the bedroom off to the side.
As I entered the bedroom, I couldn’t see exactly what was going on but could hear guttural and inhuman noises coming out of the room as if someone had captured some prehistoric animal. The firefighters were shifting their weight back and forth like they were trying to trap the animal.
It was then I first saw Party Boy.
Party Boy was about thirty years old, Caucasian, short black hair, dark eyes, and shaved hairless. Everywhere. He was completely naked, very thin, covered in random tattoos, vomit, and had blood streaked all down the front of his chest from his obviously broken nose and busted lip. He had a wild, wide-eyed stare that matched the bizarre noises coming out of his mouth. His head twitched back and forth over-reacting to every noise, but with a thousand yard stare that seemingly looked through walls. He was fully sexually aroused and was attempting to manually pleasure himself while using his free hand to ward off the would be captors. His mouth was hanging open except when he closed it to gather bloody saliva which he spit at the firefighters. They did their best to dodge the flying blood globules. I felt like they were doing a great job, nothing I needed to get involved in, so I backed out of the room and approached the young lady.
“Who is he to you?” I asked her.
“She’s the girlfriend” the clipboard wielding lieutenant responded for her. “But she doesn’t seem to know much about him at all.”
“EX-girlfriend!” she corrected with emphasis on the “ex”. “As of right now, phhssssssstt” she said drawing her hand across her throat in the universal symbol for cutting. I felt like I was in the movie Scarface.
“Oh excuse me” the lieutenant said feigning respect “The EX-girlfriend says our guy in there has an addiction to GHB and took too much of it.” He said with mock emphasis on the “ex” and an additional eye roll.
GHB is a powerful illegal drug that works as an intoxicant as well as an amnesiac. It’s used mostly as either in small doses as a performance enhancement drug for athletes or in larger doses as a date rape drug. Some more adventurous types take it themselves to get ultra-high.
“Do you know anything else about him?” I asked the freshly available ex-girlfriend over the crashing of what sounded like a lamp hitting the floor in the bedroom.
“You know what?” she said springing to action and jumping off the couch with a sudden burst of happy energy. “I have the number to the perfect person to ask about him” she ran to the kitchen where she rummaged around in a drawer before producing a small telephone number book. She thumbed through the book, mumbling names to herself as she passed through them alphabetically before exclaiming in success “Here it is!” She held out the book and pointed to a name and number “She will tell you all you need to know about him” she said with a smile, proud of herself for setting up this little piece of drama.
“Is this a family member?” I asked.
“Nope, this is the bitch who was his girlfriend before me. She would looooove a call from you guys. She can have him back, I’m done with him. Her problem now I guess” She said with finality and a smirk that seemed to indicate that her role in this was over.
“So this is the number to the EX-EX-girlfriend?” the lieutenant teased pointing to the number.
“Yeah, something like that” she said with an icy look.
The mood in the room was broken by the arrival of my partner.
“So what do we have?” she asked me.
“Probably OD, they have their hands full in there.” I motioned over to the room with all the commotion in it. “He’s naked and filthy.”
“Who’s this?” my partner thumbed to the ex-girlfriend.
“The girlfriend, but she’s not helping much.” I said loud enough so she could hear.
“EX-girlfriend!” she corrected. This was getting comical.
Now that everyone had arrived, it was time to corral Party Boy and get him out of the ex-girlfriend’s house.
“How do you want to do this?” I asked the lieutenant.
“I guess we just grab him and go.”
“I’ll get the straps and the gurney ready” my partner said and stepped out.
One of the firefighters went high, the other went low and quickly he was off his feet and struggling. The rest of us jumped in, everyone got a limb. We were walking in short little steps since Party Boy was doing everything possible to free himself by writhing around and flailing his restrained arms and legs. I was walking down the steps backwards when stepped in something squishy. Immediately everyone smelled it.
“Who stepped in the dog crap?” one of the firefighters asked wrinkling his nose as we negotiated the corner on the landing.
I knew it was me. Great, this was all I needed to make this call better. A naked guy, his pain in the butt ex-girlfriend, blood, vomit, and now dog poo on my boots. Just great.
“I don’t think it’s our guy” one of the firefighters said looking for feces and not seeing any.
“No, that would be me.” I said. “I stepped in it on the steps.” I would have to clean that up later. Right now, it was time to take care of Party Boy before he hurts himself worse.
As soon as he hit the gurney we wrapped him up and tied him down. He had a wild look in his eye like he wanted to communicate, but his brain was way too blotto to allow for words to be formed. Instead, he was left with grunts and snorts to work with.
We wheeled him into the ambulance and I was for the first time able to really assess him. He had a broken nose, from what I am not sure. He kept opening his mouth so I could see there was no other oral trauma other than his split lip and the nose. I think the blood was from his nosebleed dripping down the back of his throat. I had to sit on him to get a blood pressure and pulse since he was thrashing around careful to avoid his erection standing at full mast under the blanket. Then it came to me, all the while he was pleasuring himself as we were trying to corral him, that was what he wanted to do. I freed one of his hands and he immediately went to work on his penis under the blankets. It significantly cut down on his manic behavior, but the way he was staring right through my partner with this hypersexual behavior was giving me and her the creeps. His grunts and snorts switched to noises that sounded happier, so I guess we were meeting the need of reducing his suffering. This distraction bought me time to get an IV and get some Benadryl on board to calm him down which significantly reduced his manic behavior.
We brought him into the hospital, masturbating vigorously the entire time through the ER and onto the hospital bed. I gave my report and left, happy to be rid of Party Boy. Besides, I had to hose the doggy doo off the bottom of my boot.
About three hours later we were back at the same hospital wrapping things up with a different patient and we saw Party Boy in one of the observation rooms. He was awake, sitting up in bed and looking bewildered. His hair was messed up and he was now clothed. He had a look in his eye that told me he was much more oriented. It’s funny how when the lights are on inside someone they look like a different person, almost unrecognizable as the wild man we had met earlier. I decided to pop in and ask him some questions since I was missing a lot of info from my report and I wanted to be sure we could bill him for this one.
“Hey dude, how are you feeling?” I asked.
“Like crap. He said.”
“I need to get some info from you” I asked getting what I needed out of the way. I got his name, address, phone number, SSN, and insurance info.
“You don’t remember me do you.” I said.
“Nope. I don’t remember anything.” He said genuinely.
“You OD’d on GHB. I brought you in.” I said.
“What? What the heck is GHB?” he said. He was a skilled liar.
“It’s a drug. Some people call it a date rape drug. It’s an anesthetic used recreationally as a hypnotic.”
“Never heard of it. I don’t do any drugs. That can’t be. I’m totally clean.” He said flatly.
“That’s funny, your girlfriend, uh I mean EX-girlfriend says you are addicted to it.”
“I don’t know anything about that.” He said knowing that I knew very well that he was lying. “Can I go home now?” he said.
“Not my call, bud. That’s up to the doctor. Feel better.” I said and left the room.
He was yelling after me tugging on his wrist restraints as I left and that was the last I saw of him. Fitting given the hell he gave us back at the house.
I stopped back in about an hour after that and asked the nurse about him.
“So where’s Party Boy?” he knew exactly who I was talking about.
“We took the restraints off and he took off leaving the hospital in his gown only. He didn’t have shoes, a wallet, phone, nothing. “
“Did he ever cop to the GHB?” I asked.
“Nah, he just kept on denying. Deny, deny, deny.”
“How did his tox screen come back” I asked.
“Pretty much positive for everything. He was tanked up on everything including alcohol. I’m gonna say that was one hell of a party going on in his head.”
“Yeah, something tells me we will be seeing him again.” I said.
“For sure.” The nurse said before turning and getting back to his other duties.
I turned and walked back out of the sliding double doors feeling the cold blast of damp air hit my face. It was still pouring rain out there. Another call was out there waiting for me. Another adventure just over the horizon.
Monday, November 29, 2010
It was the first call of the day on the week of Thanksgiving. It was cool and blustery outside, raining on and off. The leaves, which had made their final curtain call, were ablaze in yellow, orange, and red; contrasting the dull, gray, overcast skies that threatened us ominously. Many of the leaves had already made the leap to the ground creating colorful, yet slimy masses waiting for an ambulance to try and take a corner too quickly.
My partner and I were wearing our rain gear, which is too hot for sitting in an ambulance, but too difficult to deal with taking on and off each time we get in and out. Besides, our seats were already wet from our clothing, so we would have to deal with it.
The call was in a more upscale part of Oakland. This particular part is walking distance from a quaint section of downtown that has a Main Street feel to it. The patient had already been walked down to the portico and was sitting on the front steps, protected from the rain. He was wearing a T-shirt, jeans, and sneakers and was not looking like today was his best day.
Using and umbrella in the 911 system is not an option. Not only does it limit where you go, it also takes away a valuable hand that you need to do the job correctly. We put up our hoods and made the dash from the ambulance to the doorway without the gurney. It was raining hard enough that taking the gurney out would be a bad idea unless it is absolutely necessary.
“So what do we have?” I asked the Lieutenant.
“Looks like abdominal pain” he responded.
“Might be cardiac” the medic said and raised up the sublingual nitroglycerin spray pump to the patient’s mouth.
“Hold on…” I tried to stop him from delivering the spray. It was no use. He was on it.
When nitroglycerin is delivered for a suspected cardiac event, most notably indicated by chest pain, it causes vaso-dilation of the coronary arteries and often relieves the pain. This is good. The problem is, it often can hide the indicators of a heart attack from the EKG until the medicine wears off. Time we don’t have to waste.
“OK, let’s just get him in the ambulance.” I said wanting to get things moving along.
We loaded the patient up and I got to work assessing him.
“Any chest pain sir?”
“Nope. Where is my newspaper?” he asked. Really odd question given his situation. Where were his priorities? I thought.
“Any shortness of breath?”
“Nope” he was however breathing faster than normal and appeared anxious. I put him on oxygen anyway.
His behavior had me a bit confused. Where was this call going? He was sweaty and it was cold out, but it was possible he could have been in the rain this morning or could still be damp from a shower. I asked and both of these answers came back negative.
“Where exactly does it hurt?”
It’s like heartburn, right here” he said pointing to his upper stomach, right where you would expect acid reflux or a hiatal hernia to hurt. “My wallet is in my back left pocket in case I die.” He added nonchalantly.
I started to wonder about this talk we were having.
“Any medical history?”
“Allergies, medications, eat anything unusual? Acid reflux? Nausea, vomiting, diarrhea, blood in stools or urine? Any cardiac history? Diabetes? Ulcers?”
The answers were “no” to all of those questions.
While I was asking these questions I was taking vital signs and hooking him up to the monitor for a 12 lead electro-cardiogram. I shot the EKG and it came back negative for clear signs of a heart attack, but did show some depression in the ST segment; this was a possible harbinger of impending doom.
My partner was standing in the rain at the end of the bench by the open doors typing the info into the computer as I spit it out to her.
“So, what do you think?” she asked quietly. I leaned into her to talk, out of earshot of the patient.
“I’m not sure. My gut is saying cardiac, but I have nothing showing. Maybe it’s just anxiety or psych?” I half-asked, half-stated.
“Is that dynamite?” The patient loudly asked pointing to our road flares with an anxious look on his face.
“Yeah, we carry dynamite on all emergency rigs in this county. You never know when you are going to need to blow something up” I replied sarcastically.
He took the answer at face value and didn’t question it.
I looked at my partner with a look that said “See what I mean?”
“Let’s just roll to Summit” she said. “They are a cardiac center anyway, best place for him either way."
We were literally blocks from the hospital so I had my partner go ahead and go code 2, but alert them that we are suspecting a cardiac patient, but we don’t have the proof.
In route I took another couple of EKGs. They were all still negative, but it was progressing.
“I can’t get this guy to shoot an MI, but he totally looks like one” I yelled up to my partner.
“Maybe try a right sided EKG?” she suggested. It’s nice to have a smart partner.
“Good idea.” I tried it, but still no indication clearly pointing to the heart attack I new this guy was heading for.
This is when the fear and doubt sets in for paramedics. We are alone out there and have to follow three simple steps: Assess, Decide, and Act. Assessing is easy. So is acting. It’s the deciding to act that is the problem in these borderline cases. Do I act conservatively and go full cardiac? What if this guy is just a psych case and has us fooled? What if he is just an odd-ball with an ulcer starting? What if his references to his own death are his sense of impending doom that sets in prior to cardiac arrest? Do I want to give four aspirin to a guy with a stomach acid problem? Why is he sweating? Am I so sure that I am willing to risk the trust and reputation I have built with the Emergency Room staff on a gamble? All of these thoughts and many others immediately swirled in my head.
I kept stalling out.
I closed my eyes for a second and blanked my mind. I decided to open them and go with the kind of patient I saw when I opened them.
CARDIAC. It was clear as a bell.
This entire evolution in my mind took about 15 seconds but felt like an hour.
I quickly fell into the routine of treating a cardiac patient. All doubt was gone. My sense of calm had returned and I was working through a familiar protocol in my mind. Oxygen, Nitro, Aspirin, IV, vital signs, backup EKGs, blood sugar. The next two blocks we drove were like clockwork.
I could hear the familiar beeping of the ambulance backing up into the bay. I thought to myself, what musical note is that? Enough of that nonsense, we were here and it was time to switch everything over.
I was met by the triage nurse in the doorway. He was a bit confused as to what we were bringing in.
“So what is this now?” he asked.
“ABD pain, epigastric, feels like heartburn. It looks cardiac to me. Can’t get the EKG to back me up though. Good depression in the ST segment.” I said with confidence.
“Put him in X” the nurse said indicating the room for the stat patients.
I gave my turn over and got to work on my paperwork. The nurse walked out of the room telling me that they were getting a “positive” for an MI. A heart attack. The Nitro had finally worn off and the heart attack was showing through on the diagnostic equipment. It got really busy in there. Chest X-rays, preparations were made for the cath-lab and the patient was whisked away.
An hour later we were back at the hospital and I was told that the patient had suffered a massive heart attack. His lateral anterior descending coronary artery was 100% occluded; it needed to be cleaned out and stented in order to restore adequate blood flow to the muscle of the heart before the tissue dies. I looked at my partner and she at I. We were right. Dangerously close to not being right. If we had brought him to another hospital that say was not suited for cardiac care there would have been valuable time wasted in transferring him to a cardiac center. This delay could potentially result in unrecoverable cardiac muscle tissue that would significantly reduce output.
The cardiologist and nurses all echoed my sentiments that this particular patient was a peculiar one. He was very anxious, kept asking odd questions, and needed to be given ativan to control his anxiety. The odd things is that his anxiety was not directed at the fact that he was suffering a heart attack, or at least he didn’t point to that. He was more worried about his clothing, the time, his newspaper and other seemingly insignificant worries.
In my younger days, (without dating myself too much) REO Speedwagon, a Canadian rock band had a hit called “Should I Follow my head or follow my heart” that while they applied it to relationship choices, still rings true. Your mind can talk your “gut” out of making decisions that at a base level you know are correct, perhaps you just can’t articulate why in a manner suitable to satisfy your intellect. I thought about this and decided from here on out, I am going to follow my gut more. I’ll see how it goes.
copyright 2010 Jon Kuppinger
copyright 2010 Jon Kuppinger
Thursday, October 7, 2010
It was an unusually warm Monday for being before noon. Normally in downtown Oakland, the sun doesn’t burn off the fog until around noon or so. On this day, the grey blanket that serves as our own built in air conditioner had made an early departure. The temperature was already up over eighty degrees at eight AM.
My “black cloud” was in full effect. In the last few shifts I had run several code three returns, meaning that the patient was in such poor condition that they required lights and sirens on the return to the hospital. This kind of thing runs in cycles and when it is on, we call it the black cloud. A sort of tribute to the cloud that followed the Pink Panther around. When things are light we call it the white cloud. Silly superstitions, but they can get in your head and mess you up if you let them in.
My partner this day, Sarah, was an entertaining one. She and I shared a similar taste in music and we were jamming out to Frank Zappa’s “Joe’s Garage” in the parking lot of Summit Medical Center when the call came in.
“Five One Two, Five Twelve, can you clear the hospital for a code three?” The dispatcher asked.
My partner raised an eyebrow at me with the inquisitive look that asked “what do you want me to say?”
“Sure, what do you have?” my partner Sara responded over the radio.
“Sixty-four year old male, shortness of breath.” And they followed with the address.
“Ten-eight.” She said, meaning we were on the way.
We pulled into to the well-worn neighborhood to find the fire engine parked in front of an old, small Victorian house with a huge staircase leading up to the front door. The fire engineer was leaning up against the engine fiddling with some gadget and waved to us as we pulled up. He looked very relaxed so our guard went down a notch.
“Hey guys” he said over the chugging of the idling diesels. “Looks like an SOB” (meaning shortness of breath.) “What do you think of this weather?” he added with his face up to the sun and arms stretched out as if to measure the air.
“Friggin’ beautiful!” I responded. “Finally summer arrives in Oakland”. Now we were in casual mode and it was all smiles and jokes. How bad could it be if our sunglass bespectacled member of Oakland’s Bravest was so relaxed?
The house was a typical Victorian in that it was narrow and built straight up with fantastic, yet neglected appointments and detail giving it more of a haunted house vibe than the intended charming San Francisco row house look. I estimated this house was probably over one hundred years old and nobody had cared for it in the last thirty to forty years. The Pepto Bismol colored pink paint, which is not unusual for these older Victorians, was missing and in areas exposing rotted boards. This Victorian was sitting on top of it’s garage, as so many of them do, making the front door a good fifteen feet off the ground.
I walked up the red painted steps leading up to the front door. The thick red paint was chipped showing the century old cement underneath. The steps were littered with old dead potted plants, old kitchen appliances and beer cans. Trip hazards galore. The handrail was wooden and worn. Sections of it were missing, others were replaced with what looked like broomstick handles.
The door had so much rot and pet damage that I was surprised it could actually even keep the wind out let alone unwanted strangers and stray animals.
The front door was already open and in the darkness of the house in contrast to the direct sunlight of outside, all I could see was the “OAKLAND FIRE” emblazoned on the firefighters’ backs in stark white block lettering. It almost looked like the letters were floating and bobbing on their own in the darkness. The smell of dirt and old tobacco was there to greet me as I approached the door.
I popped my head into the front room.
When my eyes adjusted to the darkness I realized this place was filthy, and not the kind you could fix. Everything inside was so covered with dirt, smoke damage and dust that it all had settled into a dark brown grayish color. There were already way too many people in this dingy room. There was the patient, myself, three very large firefighters and another older black man sitting so quietly in the corner it startled me when he moved. His dingy clothing and unkempt skin and hair made him blend in with everything else in there that was dark brown and grey. I wondered how many years he had sat in that exact chair watching the world go by, day by day in the darkness.
“What do we have?” I asked the fire medic trying to get a look at the patient. I could tell someone was sitting there, but all I could make out was the glare off his glasses and the huffing and puffing of someone in respiratory distress.
“Shortness of breath, might want to grab a stair chair, he’s not gonna walk for us” the fire medic responded.
I walked back out to the porch and yelled down to Sarah to grab the stair chair. She was just setting up the gurney at the bottom of the stairs anticipating the patient coming out.
“Got it” she yelled back as she headed to the back of the ambulance to fetch the dreaded stair chair.
The stair chair is a device that looks like it was invented in the dark ages and probably is more responsible for paramedic workmen’s compensation claims than any other device we have. It is a collapsible aluminum framed wheelchair of sorts with extendable handles and straps. The idea is that the patient can sit in the chair and you get on either side and carry the chair similar to how Egyptian slaves carried their queen. You can opt to roll it on the ground (as it was designed to be used) and guide it along stooped over if you desire a debilitating back injury, but most go for carrying, that way you can use your arms and legs for most of the heavy lifting, not your back. This thing is a paramedic killer.
I stuck my head back in the house and got my first real look at the patient through the wall of well-muscled firefighters, who seemed to be watching the patient. Our patient was indeed clearly struggling to catch his breath and “tripoding” with both hands on his knees. He was breathing at least fifty times a minute. He was too dark black and the room was too dark to see the quality of his skin tone, but I could see what little light there was reflecting off the sweat on his face and neck. His oversized glasses were fogging up from his exhalations escaping through the top of his mask. I could see frothy foam coming out of his mouth around the oxygen mask indicating to me that he may be drowning in his own fluids.
I glanced over at the cardiac monitor and it made me jump a bit.
“Guys, he’s in SVT at 220 bpm!” I said.
“Oh boy… somebody spike me a line” the medic said shifting his attention to me. “I was planning on taking this on the road as soon as you guys arrived” he said in an apologetic tone.
“Got it” the extra firefighter who was previously just standing there said and got to work on getting an IV line flooded.
“I’ll get the drugs” I said. “meanwhile, this guy is going to need CPAP”
“You think so?” he asked.
“Yeah, I think so.” I said.
The patient suddenly slumped and the monitor went completely unorganized.
“He coded” the medic said. The guy in the corner didn’t react.
Just then Sara stepped in and saw us lowering him to the floor.
“I’ve got CPR” she said and jockeyed for position at the old man’s now bare chest. She began chest compressions immediately. I went over to the gear and grabbed a BVM and tossed it to the fire medic.
“Get him on the pads, we need to shock him now” I said tossing the pads to the lieutenant who was staring intently at his clipboard. “Can’t we get anymore light in here?”
“There’s a light over there.” The silent grey man from the corner spoke up in a gravely drawl that gave me the creeps. “You can cut it on over by the door.” How much do you have to drink and smoke to get that voice?
“Do we have that line yet?” I asked the medic? I was feeling like I was clearly in charge now and everyone was willing to just take orders.
“I can’t get it” he said. There were a number of needles in the guy, none of them flowing.
“Don’t worry about it, clear the patient, charging” The defibrillator began it’s rising siren that signifies the capacitors are charging up. Then the tone changed to one that sounded like the European cop cars. It was time to shock.
“Clear! Shocking now!” I yelled.
The patient jerked, and everyone jumped back into action.
“Yall’ve been here before, same kinda thing I think” he said in his rotten zombie voice to the lieutenant.
“Hold CPR, I’m going to check the rhythm” I said.
“Check for a pulse” I asked the medic.
“Yup, he’s got one. Weak, but it’s there.”
“Breathing on his own?” I asked.
“I need suction” Sarah said.
The lieutenant handed her the suction device and she sucked about 50cc of water and who knows what else out of his mouth and throat before resuming assisting with ventilations.
“LT, we need to get this show on the road” I said to the lieutenant.
He stepped out to the steps and whistled to his engineer who popped his head around the corner of the fire engine.
“Get the backboard up here, we’re heading out.”
The engineer was at the door quickly with the board and in a matter of seconds we had the patient strapped to it and ready to go.
“I’ll run ahead and prep the gurney” Sara said as she squeezed by everyone and headed down the stairs.
We lifted the man, four of us, two at each end and began to walk with him out the front door.
“Coming out feet first!” the captain yelled.
We descended the steps and strapped the patient to the gurney, all the while continuing to assist with respirations. I could see his chest rising and falling. This was a good sign.
We had developed a group of neighborhood people on the sidewalk watching. Ghetto paparazzi, as I call them, were recording the whole event on their cell phones. This was status quo these days in Oakland. All police and fire actions were recorded by the citizens just hoping that we did something wrong or illegal. The news channels pay well for that kind of footage if something is done wrong. Sometimes they will even provoke and critique us to try and get a reaction they can film.
Once in the ambulance we headed off to the hospital code 3. The fire medic was in the seat just over the head of the patient helping him breath. I was down at the body. I established IV access and was just hanging the line when the patient regained consciousness.
It was slow at first, but he came around pretty quickly.
“Good morning sunshine!” The fire medic said looking down into the patient’s face from the top.
“What happened?” he asked very confused as to where he was.
“You died sir, but now you are back. “ the fire medic said.
“Oh, not again.” He said.
“Again?” the fire medic asked?
“Yeah, I died and you guys shocked me back about a year ago.” He said nonchalantly. He wasn’t thanking us, just stating the facts.
“Well, happy we could be here for you” I said as I checked his lung and heart sounds. His heart sounded fine, but his lungs were junky, like someone crumpling up cellophane.
“Let’s get him on CPAP” I suggested to the fire medic who was taking care of the respirations side of things.
“Is he filling up again?” he asked.
“He’s almost full.”
The CPAP creates positive pressure in the lungs to force the water back across the alveolar barrier and into the blood stream. This creates great relief for the patient, but is not without it’s drawbacks. Most patients hate it because it feels like they are being force-fed oxygen (which is pretty much what is going on) and they end up feeling claustrophobic.
After we arrived at the hospital and I gave my turn over to the ER doctor, I got to writing my report. This would be a long one. A lot happened in that short ten minutes we were with the patient. After my report was done, I stopped by to see the patient and he was sitting up in bed and talking.
“Hey, Mr. Paramedic!” he said, still a bit rough sounding, but amazingly alert and spry for having just died less than an hour ago. In the good light I could now clearly see the man I had been working so hard to save. He was about seventy years old with a shock of receded grey hair. His skin was leathery from too much sun exposure and he had a barrel chest with spindly arms and legs. Tell tale signs of a chronic COPD patient. He was breathing comfortably now and all his vital signs had normalized.
“How are you doing sir?” I asked.
“Oh you know, I’ve seen better days.” He said in a southern drawl. “Probably gonna see a few more thanks to you guys.”
“Ah, don’t worry about it. Just doing our job.” I said. “Although it is nice to meet you now that you are alive.” I joked.
“Sit down here, let’s visit a while.” He said.
We sat and talked for about a half an hour, periodically interrupted by nurses and interns. Everyone wanted to see the guy who coded and was now right as rain. I learned that he was from Mississippi and he learned that I was from New York. He worked forty years at the Port of Oakland off-loading ships and I was in the Navy. He had been married for fifty years before she died a few years back. I showed him pictures of my wife and kids. We talked.
Eventually, Sarah poked her head into the room “Hey, they need us to clear for the next call” she said. “Oh hi!” She just realized how well he was doing.
He even signed my paperwork for the transport. That is a first. I have never done CPR on someone and then had them sign for themselves at the end of the call. Usually a crying family member or the receiving RN signs the paperwork. Usually the patient has passed at that point.
We cleared the hospital and headed out for the next call without knowing what it was going to be. Trucking down the pothole-ridden roads of Oakland, sirens blaring, lights flashing, with Frank Zappa back on the stereo we closed the chapter on this one and rode off into the unknown.
Tuesday, July 6, 2010
It was well past midnight on a slow night on the west side of Oakland. Sometimes the city sleeps, but not for long. More like cat-naps. My partner and I were enjoying the fact that there was not much to do. We were killing the time by watching some nursing school lecture videos. I think it was one on blood chemistry. Really fascinating stuff, until the peace of the night was interrupted by a call.
The call was for a fall, with back pain. We showed up to the fourth floor of an apartment complex on the west side. This was the kind of place where all the hallways were exterior to the building. There was nothing but a wrought iron railing keeping you on the ledge. The light blue paint was chipping off the stucco in dinner plate sized flakes, which were scattered around the foundation. No one had bothered to pick them up.
This particular call was a “code 2” call, meaning the 911 dispatcher had determined that the fire department was not needed. This could be because of either the nature, severity, or priority of the call did not in their opinion warrant immediate attention, but still required a paramedic to check the patient out and possibly transport. In this instance, they made the right call. It was not a significant emergency.
“Hello? Paramedics!” I announced as I opened the door after knocking several times with no response.
“Don’t let the cat out!” a voice yelled back in a neurotic tone. I guess you have to have your priorities and for this guy, it is the cat.
I opened the door to find an apartment with all kinds of take-out food boxes everywhere. Chinese boxes. Pizza boxes. Fast food wrappers and bags. The urge to kick the two liter soda bottles as I waded through them was a little overwhelming, but I managed. I think this guy just went out, got food and brought it back and the boxes, bags, and bottles fell where they may once they had outlived their function.
We found our patient sitting in the cool blue light of his old 30-inch tube television. He was on an old shaggy couch in the middle of his apartment. He was a fuzzy headed nerd of a guy wearing dark rimmed glasses and an old Star Trek T-shirt. He was watching the TV and sitting stiff-legged in a very awkward position with a look of feigned distress on his face. He was easily 350 lbs if he was an ounce.
“Sir? Did you call 911?” I asked.
“Yes, I can’t move my legs”. His gaze was fixed on the television. Apparently not wanting to miss the next segment of Babylon 5.
“Hmmm…..Can you normally move them?” I asked further.
“Yes” not exactly a fountain of information.
“OK then, did you hurt your legs or fall down?” I asked even further.
“I fell down the stairs today and hurt my back."
“Those stairs out there?” I asked and he nodded in reply.
Oh great. I walked around behind him and held C-spine. This is when you hold a patient’s head steady so they don’t move it for fear of possibly severing their spine with a broken piece of vertebrae following a fall or trauma.
“Megan, let’s get some vitals” I asked my partner. “And turn the TV off and the lights on please”
“Sure”. She got to it.
“Awwww man, did you have to turn off the TV?” he whined.
“Sir, where does it hurt?” I asked ignoring the question about the TV.
“Everywhere”. He replied not making any eye contact with me. His tone was smug and almost teasing. Perhaps this was not his first rodeo.
“I can’t clear this guy, we are going to have to put him on a board” I told my partner. “He can’t decide what hurts, what doesn’t; can and can’t move limbs; his story is all messed up and he had a fall on the cement steps.”
“I’ll go get the equipment” she said.
This can be a tricky situation. Often times, someone technically fits into a protocol and has to be treated a certain way even though every bone in your body is telling you it is stupid to do so.
In the mean time I called dispatch and had the fire department sent out. They would be sleeping and I would be waking them up for this. I was pretty embarrassed to call them. I know this is BS. They will know it is BS. We will all know it is BS, but we will all have to follow guidelines and put him on a board and carry him down. For that, I needed more manpower.
My partner came back up with the equipment. I wasn’t sure how I was going to be able to do this by the book. He was very large and probably not too compliant. I could tell he was kind of excited about the idea of being strapped to a board, but had to keep up the charade of paralysis which meant we were not going to get any help.
I decided the best bet was to shove the board down from behind him on the couch. He was holding his legs straight out so if I could get his butt up, I might just be able to get him on the board elegantly without too much jarring. Megan had to straddle him and grab his belt to get his hips to move forward. With the collar on the board did indeed slide behind his stiff body and then I just pulled the couch out from under him. It was not easy and I definitely broke a sweat, but we got him to the floor flat on his back and that was the goal.
Just then I heard the familiar yelp of the fire engine’s air breaks out front. Megan finished up with the straps and the head bed and I went outside to meet the fire crew. They knew this guy and his games and were in no hurry to get up the stairs.
I met them just outside the door.
“Guys, I am so sorry, we had to C-spine him” I explained. “I did not want to wake you up, but I just can’t take the chance with him giving us all these inconsistent answers”.
“It’s cool Jon” the medic said. “We’ve been there before”. I had run several hairy calls with this particular crew. We trusted each other.
The fire medic walked in the room and began to question the patient to try and clear his C-spine. He didn’t get anywhere but frustrated and looked back to his Captain.
“Let’s get in here and get him downstairs” he said to his crew.
“See what I mean?” I asked him, looking to bolster my case.
“Yeah, let’s just get this over with. Four point work for you?” he asked the group.
We all made affirmative gestures and/or grunts and got into position.
“Where is the elevator in this building?” the Captain asked the patient.
“What elevator?” the patient asked.
“You have got to be kidding me” the Captain replied under his breath. A dark feeling was sinking in to all of us that we may have to carry this guy down four flights of stairs. Not cool. The Captain made a sweeping motion with is hand and the most junior firefighter jogged out of the room and down the hall. He came back confirming the bad news. There was no elevator.
So we picked the guy up. This would have to be done the old fashioned way.
The complication posed to us with this guy was he could not, or should I say, would not follow simple directions. A backboard can be uncomfortable. I have been strapped to a board many times in training and it is confining, hard on the back, and can make you feel out of control. But it does package you well for carrying and ultimately protects your spine from unnecessary twisting or movement, which is the purpose of the board. It gets more complicated when you are obese and your jiggling waves of fat over-exaggerate every movement made by your weight bearers. A slight tip to the left becomes a full-on list control issue with an extra hundred pounds of undulating adipose cycling behind it.
So given that little twist, we had decided to lift the patient using the four point method. Similar to the way pall-bearers carry a coffin. Two at each end with a person on each side helping to control list. This worked fine going down the hallway. It was tight, but with a little shuffling and sucking in of guts, we were able to make it to the stairwell.
This is where we took a pause and looked at the daunting task ahead.
The stairwell was wide enough for two people to walk comfortably next to each other, I would say three feet at the most. The puzzle was, how were we going to carry a six-foot four man down this series of square spirals down four flights given we could not utilize the inner parts of the stairwell for turns due to the support poles. The only answer was to take the corners wide.
This was not a good idea, but it was an idea.
In order to execute this move, it would require the patient is lifted to chest height and for periods of time suspended over open space until the corner was turned. This was not so bad on the side facing the apartments, but on the outside it literally meant nothing under him but our arms.
I looked over the edge to assess what was below and saw there was a jagged old wooden fence, a cement alley and trash cans. So if this guy falls, being strapped to a board, he pretty much dies. I reported my concerns back to the captain, who thought about it for a second and decided we needed to get him down so we would first try the tipping method. Anyone who had moved a couch through a doorway and had to execute a turn knows this one. As we tipped the patient up he began to flail his arms around yelling that he couldn’t breath. OK, this wouldn’t work. Back to plan A.
We planned it out pretty well. My partner ran ahead to prep the gurney for our arrival and to clear all the trash out of the stairwell. Feet first is the safest and easiest way. We put one guy in front to assist with step counts and catch any stumbling firefighters. We stuck with the four-point approach with one person on the side to try and stabilize him and provide emotional support. It was only four flights, that’s sixteen turns. Piece of cake. I had a lot of muscle with me. I wasn’t worried. I got on the front by the feet being one of the bigger guys and we began our descent.
So far so good. The patient was whining a bit, but no real problems. It was very challenging to keep the patient at chest height. My concentration was fixed on using good lifting form and not slipping on the stairs.
One flight down.
“Anyone need to rest?” The captain asked. Great question, looking out for his guys.
“Nope” we all said through gritted teeth. Sometimes it is just better to do it all at once.
Everything was going fine until we rounded the outer edge of the third floor. The feet had just gone over the edge and we were swinging the head around to make the turn when our patient began panicking. He was grabbing our arms, grabbing the wall, grabbing anything he could and was swinging his body around. This was not good, there was nowhere for us to go with him.
“Hey buddy, you need to relax for us, we’re almost there, we got you” the captain said in the most soothing tone he could muster.
“I’m gonna fall!” the patient yelled and began to lunge.
“Ahhhh” yelled one the firefighter on the head side. He let go and was grabbing his lower back. Something had twisted and suddenly we had three points of contact.
The patient sensed our momentary loss of control and completely panicked swinging his arms around and screaming. We were losing control fast and everyone was yelling. The patient was over open space and then the weirdest thing happened.
All at once, he just flipped upside down. I don’t understand from a physics standpoint exactly what happened, but here we were, clearly not in control of a patient, suspended three floors above certain death and we were grasping at anything to try and control the gyroscopic effect of him flipping over. I was hanging on the wall suspended by my stomach, feet off the ground holding my end with the other guy who was also leaning way over holding the back of the board. The lone guy at the head was doing everything he could to not let go. The captain had jumped in at the waist level and was using his feet to brace himself against the half-wall. Without him, it would have been over.
“OK, everyone on three…one, two, THREE!” the captain said.
And the patient came up and over the wall landing down on the stairs face down. Not hard enough to hurt him, but clearly enough to freak him out. Hell, we were all a little freaked out.
The captain went over to the guy who had hurt his back and me and the engine medic flipped the patient back onto his back. He had the true look of terror in his eyes. And then he suddenly calmed said the weirdest thing.
“I dropped my wallet”.
What the hell, we almost killed this guy and he was worried about his wallet? We sent the trainee down to find it amongst the garbage cans and the fence that surely would have split our portly patient into two good-sized chunks.
“This is crazy” the engine medic said to me and approached the patient with a “I’m going to fix this problem now” intensity to him.
“When did you fall?” he asked the patient with his authority voice on. It would be clear to anyone that he meant business and his questions were to be answered directly. It worked.
“At two o’clock.” Our plus-sized near-death survivor responded.
“A.M. or P.M.?” he asked further.
“P.M.” It had been over twelve hours, it was now three A.M.
“Then what happened?” he urged on.
“Then I went to get something to eat and came back home and watched TV until I called 911”. He stated.
“Can you move your hands and feet? Can you feel this? Any pain in your neck or back?” he was now getting very confrontational and hostile to the patient.
All the answers came back indicating there was no injury and the story supported someone who clearly had walked around for hours without any major problems. The medic ripped all the straps off.
“I can’t, I fell today, I hurt my back”
“Get the hell up, I am not going to ask you again” he was now standing over the patient in a threatening pose.
Get up he did, with a quickness. He showed no signs of any deficits or disability and was able to walk down the rest of the stairs under his own power pain free. Once at the bottom, the engine medic told me that he had been on many calls with this guy and he often would fake injuries or play games with them.
“That would have been nice to know at the beginning of the call” I thought to myself.
From the bottom of the stairs on, it was easy to load him into the ambulance and the ride into the ER was uneventful. The whole way he kept muttering that he was sorry and expressed that he did not want me to be mad at him. He was not actually hurt, he just needed an adjustment to his psych meds at the most.
The firefighter who hurt his back ended up being OK, though he again added another injury to an already weak back. He got a couple weeks off to recuperate and some physical therapy. I would be upset if he had a possible career-ending injury given the situation.
It took me a little time to decompress from this one.
While nothing really happened and the patient was safely delivered to the hospital in one piece, if we had dropped him, it would have pretty much been the end of my career.
What was the number to that truck driving school?