Go with your gut!

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?”

“Nope”

“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.

Assess. Decide…

Assess. Decide…

Assess. Decide…

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.

Eyes open:

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

Field Save

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?”

I nodded.

“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.

Sarah was doing compressions, the medic was still trying to get a line and I was prepping the meds and watching the monitor. The captain was questioning the man in the corner, who though he new the recently deceased, didn’t seem to know much about his medical conditions.

“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.

The monitor showed a nice tight rhythm. It was a bit slow, but still very promising.

“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.

“Hello there young lady”.

“Sir, this is the woman who was pumping on your heart” I told him.

“Oh, pretty girl like that, surprised she didn’t steal my heart.” He flirted.

“Yeah, I have my strengths” she said fluffing imaginary curls.

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.

Oopsy-Daisy!

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.

“Get up”

“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?

The Heat of the Moment

It was one of those unseasonably hot Sundays in the valley. If you live out that way you might remember the actual day a couple years back. I had picked up a valley day car that was available earlier in the week as an overtime shift. I was thinking it would be a nice break from the Oakland grind completely unaware of the impending heat wave that was coming. The thermometer on the bank’s digital sign blinked 104F, but it felt even hotter.

We were spending the bulk of the day between calls looking for shade spots to park. It’s a kind of game you have to play in the summer if you are going to be out on the street all day. A large eucalyptus tree here, an overhang there; a bridge overpass will do nicely. Anything to escape the relentless heat that was building up and fuming off the asphalt. Our inadequate air conditioner in the ambulance was doing a poor job keeping up being an older model and probably mostly out of Freon. These poor ambulances get run so hard 24/7 we are lucky to get five years out of them.

The supervisors that day were tasked with chasing all the units around with coolers full of water and Gatorade. If they found us hiding in our shady corners, we had to drink a full water in front of them on demand. Dehydration was a serious concern and given the heat, the exercise was justified. They didn’t want us becoming patients too. To make matters worse, the call volume was up from heat related illnesses so we were working even harder. Hot days like this, especially in succession tend to thin the herd a bit.

Anyway, as I was saying, it was a blistering day. We had been run pretty hard. I remember noting that I had drank close to a gallon of water without having to go to the bathroom all shift. I was sweating it all out. We stopped into 7-11 for popsicles when the call came in. It was for chest pain. I had no trouble wolfing down the frozen treat by the time we got to the call. Nice to have some ice in my belly and the windows down on the way provided some relief.

My partner this day was an exceptionally laid back guy. Nothing seemed to faze him. We’ll call him Doug.

We pulled into the parking lot of a steakhouse up by the interstate to find a single car and the fire engine over in the corner of the lot under a shade tree. The restaurant would not be open for several hours and the parking lot was deserted.

The body language of the firefighters was that of uncertainty. They were standing around a brand new, glistening model of Mercedes that I was unaware even existed. It had to be an $80,000 car at least with gull wing doors; the driver’s side was open and fully extended up. I could not see what they were looking at, all I saw was a wall of turnout coats as the firefighters were circled around what I assumed had to be the patient with the chest pain.

“Wait on the gurney Doug, I’m gonna hop out and see what we have here”. I said to my partner.

“Sure” he said in a tone that really said “whatever, I’m hourly”.

As I approached the car, I thought maybe the heat was getting to me. I could see a pair of long legs with fishnet stocking terminating in stiletto heels sticking out to the side. “What was I getting myself into?” I wondered. I could hear the firefighters talking and a faint whimpering from the direction of the as yet faceless but leggy patient.

I rounded the wall of firefighter backs to a fairly shocking find. It was a young lady in her late twenties sitting sideways in the driver’s seat with those long legs sticking outside the car. She was wearing an impossibly short black mini-skirt and low-cut halter-top combo with plenty of silver accents. It was the kind of clothing you would expect a stripper or maybe a showgirl of some sort to wear. She had a large bouquet of long stemmed roses and baby’s breath bound together with tulle and cellophane draped over one of her forearms similar to the way you would expect Miss America to hold it. I half expected to see a tiara on her head and a “Miss Livermore” sash draped over her shoulder. If this wasn’t odd enough, one of her halter straps was undone and hanging freely and the other hand was cradling one of her naked oversized, obviously surgically enhanced breasts in a move of mock modesty. She was openly weeping and having trouble choking the words out through the tears. I sensed these were not tears of pain. Something else was going on here.

“What do we have?” Doug yelled over to me from the ambulance. This was more a “What do you need” kind of question. Once he knew the nature of the call, he would know what equipment to grab.

I shrugged back at him with the international sign of “I don’t know”. I really didn’t know what to make of this. Was this an assault of some sort? Was this a psych case? “You better get over here and check this out”.

“So what is the story?” I asked the Captain. He was a burly middle-aged guy. He had a balding head, walrus mustache, and the kind of belly that takes years of firehouse eating to develop. He was a little on the grumpy side today, probably the heat.

“I guess her breast hurts?” he said in a questioning tone. They must have arrived just before us and I don’t think they had gotten anywhere with her yet. I could tell this call was making him uncomfortable being that she was such an attractive young lady and looked like something out of a Calvin Klein ad. I took their uncertainty as a cue to jump in. I squatted down next to her and put on my best concerned look of authority.

“Ma’am, what seems to be the problem?” I asked trying not to choke on the fumes from her sickeningly sweet and quite liberally applied perfume.

“My breast is killing me” she said looking down at her breast. The body glitter on her chest was catching the sun and was distracting me. Making me squint.

“OK, do you have any chest pain or shortness of breath?” I asked. Had to stick with priorities even if I am talking to a human Barbie doll.

“No” she blurted and got back to sobbing.

“Any other medical conditions I need to know about?”

“No” again.

“Did you hurt it somehow?” I asked. “Did someone hurt you?” adding the next question with more emphasis before she could answer the first.

“No, nothing like that.” She said as she regained her composure for a moment. “I think it popped” she looked up at me with mascara streaking down her cheeks. This girl was wearing a lot of make up. Her hair and nails spoke of hours of expensive treatments. Her sculpted body told me she was concerned with appearance, this was hard for her to have a problem with a part of her body that she obviously held so dearly both figuratively and now literally.

“What popped?” I asked.

“My implant, I think it popped” she stated flatly.

That’s when the call took a turn to the bizarre.

“Look, see how different they are?”

She dropped her hands down and let both sides of the halter top drop exposing both of her enormous breasts. The Captain let out a strange noise that was half snort and half cough. I looked over at him and thought his head was going to explode.

“Jesus Christ!” he said, took two steps backwards, turned away and said to me, “this one is all you Jon”. He made a bee-line back to his rig. Something in him said “get out of here” and he was listening. I tried not to chuckle. A big, tough, grown man paralyzed by breasts was a sight to see.

I looked back at Doug and he was just standing there transfixed as were the other firefighters. Mouths slightly open. Everyone was just soaking it in and not sure how to proceed. This was definitely not in the training manual.

I had to do something. I was a bit uncomfortable with this scene. Five grown men, servants of the public no less, in a parking lot standing around an attractive young lady dressed, or should I say undressed, to the nines. This sideshow had run it's course, time to get back to business.

“OK, dear, let me help you” I pulled her straps back up and walked her over to the ambulance signaling to my partner with my eyes to head over that way. I had Doug help her step up into the back of the ambulance, which was no easy feat with those spikes she was walking on. He got started gathering info and taking vital signs for me freeing me up for a moment.

I walked over to the fire crew. They were all red-faced and quietly chatting with smug looks of humor in their eyes. This was a strange call for a bunch of young men to go on. Not in any way emergent and quite surprising. The heat was not making it better.

“You OK Cap?” I teased.

“What the hell was that?” he asked through his bushy firefighter mustache with his hands on his hips. He almost looked exhausted “I thought I was going to have a heart attack when she pulled those things out!” he said.

“I thought you were too” I joked. “You guys can clear, we got it from here”

“OK” he said and walked back over to the back of the ambulance with me. The shock was wearing off and he was getting back to his jovial self. The back of the ambulance was still open. The Captain popped his head in to say his goodbyes and wish her good luck as good Captains do to wrap up their portion of the contact.

Unfortunately he walked in on the wrong part of the conversation. Again she had bared her chest and was demonstrating to my partner the differences in how they moved, bounced, felt, etc… My partner did not seem to mind the demonstration.

“Will you stop that!” the Captain said to her gruffly and walked back to his rig shaking his head. “I am too old for this crap!” I couldn’t hold back the laughter anymore. I walked around the side of the rig. The whole fire crew was laughing now. Luckily the patient was out of earshot in the back of the ambulance with the A/C blasting.

In the end it was a non-emergent call and all went routine from there on out. We transported the patient to the emergency room at her request even though in our opinion she really did not need this level of care or transport. I am glad we did as it turned out that she had a good amount of alcohol and cocaine on board though we did not smell or detect anything. Perhaps our minds were distracted enough to dull our normal “Spidey-Senses” for things like alcohol. If we had let her go on her way, she could have really caused a horrible accident and injured herself or someone else. That would have been tragic.

The emergency room doctor concurred that she probably did have a rupture of an implant and prescribed her some mild pain-killers to hold her over until she could see her regular physician. She put on her little asymmetry demonstration for whomever at the hospital was willing to sit through it. Being mostly female nurses, there were not many takers.

After the call, my partner and I spent a good amount of time over popsicles speculating who she was and what her back-story was. This young lady was something of a mystery and it was fun to try and make something more out of her than she probably was.

Was she a beauty queen on her way home from a contest?

Was she a high-priced call girl on her way to service a celebrity?

Was she some kind of secret agent on a mission undercover as a stripper?

Was she just some superficial gal who had landed a rich sugar daddy?

We will never know, but that call will go down in my memory as one of the more unusual and entertaining calls I have ever been on, and probably ever will.

He works in mysterious ways

It was a nice sunny afternoon in Oakland when the call came in for “man down”. I love that description, seems so sinister, yet rarely is. We pulled up at the same time as the fire department to a boxy, two story apartment complex that had the look of a converted cheap hotel. This one was badly in need of a new roof and paint. The external stairways and walkways were framed with rusty wrought iron railings and a decent amount of trash to navigate through. There were several older large black women dressed as if coming straight from church waving to us from the top step. Wool dresses, matching hats, purses and pumps. Color coordinated to the max.

We made our way up the rickety steps. They were center supported concrete slabs with spidery cracks veining the cement. The corners of most of them were chipped off, one was only two-thirds of a step. The center steel beam that held up the steps from below creaked and groaned under the stress of three firefighters, my partner and I plus all of our equipment trudging up the steps. I tried not to think about it. Much the way you don’t look at the cheap cotter pins that hold together a Farris wheel when you are stopped at the top.

At the door on the second floor, the church women met us. They were excited, sweaty and all talking at once.

“We just got home and she aint right” one said.

“I don’t know what happened, she was fine this morning” said another.

“Oh Lord don’t take her like this!” pleaded another one at the sky above.

We were calmly led to the back bedroom by the woman who seemed to have the most control over her emotions. On the bed we found an obese younger woman, approximately forty years old dressed in an old fashioned pale pink dress lying face up on the bed. Next to her was an empty bottle of opiate-based pain-killers. Another empty one was sitting on the nightstand. Just clues. Gotta keep your eyes and ears open and let the scene talk to you.

The woman was breathing maybe four times a minute and shallow. She did not respond to our shouts or when we shook her. I could tell she was not getting enough oxygen without testing her pulse oximetry.

“Let’s bag her” I said to the firefighter. “one every five seconds” I added.

As the firefighter repositioned her airway and began to assist her with her respirations, I continued with my assessment. Her radial pulses were weak and she was sweaty. Her pupils were pinpoint and she had some frothy sputum around her mouth. I noted it and moved on.

The engineer was just finishing getting the blood pressure.

“It’s really low and hard to hear…maybe sixty over palp?” he more asked than stated.

I could hear my partner asking questions in the background of the family.

“What medicines does she take? Does she have any medical problems? Any allergies to medications? Does she drink or take any illegal drugs? When did you last see her normal? Has she been sick lately?” All the right questions. Nothing obvious was sticking out. I kept thinking about the empty pill bottles, our only clue thus far.

“Let’s get a line going. Can you spike me a bag?” I asked the engineer.

“Sure” he said and got to it.

“Can you put her feet up please?” I asked the Captain who was standing at her feet.

“Copy” He got right on it.

“I’ll check her sugar.”

When you anticipate a patient needing medications or fluids and it seems as if they are going to be a stat patient, we will often start an IV on scene to get it going before we move. In the case of this patient, she was not only hypotensive, but I was suspecting an overdose. We would not be playing around too much here, it would be a stat transport as she was not doing well.

“I’m going to try some Narcan” I told the captain. I spun around and grabbed the box of Naloxone, better known as Narcan. Narcan is a wonderful drug that is a competitive opiate receptor inhibitor. It will bind to the opiate receptors and prevent the opiates, such as heroin, morphine, or methadone from having the effect of slowing down the breathing and ultimately killing the patient. The drawbacks are that it will not remove the opiates in the system, just block them so when the Narcan wears off, they will OD all over again if enough opiates are still in their system. Narcan also will take away the high instantly sending an addicted patient into acute withdrawal syndrome which could including seizure, profuse sweating, explosive diarrhea, abdominal pain and vomiting, heart attack to name a few, so we are careful with it. Only enough to get the respirations normal.

Just as I was preparing the Narcan, in walks a mousy woman in all black wearing a matching black hat with black roses and a short veil pinned up. She had thick glasses from the 80s that magnified her eyes. She was holding an old leather bible. It was clear by the way the rest of the family was acting that this was someone to be respected. Possibly an elder of the family or a holy person.

“Excuse me” she said in a meek voice. “Do you mind if I say a prayer?”

“Well ma’am we are working real hard here to save this young lady, pray if you need to it certainly can’t hurt”. The Captain reassured.

“Thank you” she said quietly and jockeyed for a good position at the patient’s feet.

I don’t understand what happened in the next few seconds, but this meek and mild old woman suddenly became aflame with the holy spirit. She turned into the shouting preacher complete with throwing her hands up in the air and punctuating the pertinent syllables in her sentences like she belonged in a travelling revival tent in the turn of the century south.

“Lord!” she started with a dramatic pause letting all the air leave her before springing back up “It is not time to take this humble servant!” she said impossibly loud with an elongated “ssssssss” on the “this”. “She has so much more of your work to do! Do not take her today, I beg of you. Give us more time. Do not take her. Not like this. Not like this! Not like this!” The repeated part got louder and more dramatic with each pass. The other women were starting to grunt and nod in agreement getting more involved in this impromptu prayer meeting.

She was throwing her body onto the legs of our patient and wailing. She was throwing elbows to keep us back. The prayer was much more than we had expected. Her arms ran from the tops of the patient’s thighs down her legs and she chanted and pleaded with her maker to reconsider what surely must be a mistake.

It got to the point where we were not able to get to the patient to do our job anymore. The little prayer had turned into a full-on sermon complete with theatrics, call and answer, and singing. It was time to shut this down, or at the very least get some room to work.

“Ma’am please, I understand you need to pray, but we need to work here” the captain reasoned. “If you don’t let us help your friend here, she will die. And soon.”

“You can’t save her, only the Holy Spirit can make that decision” she retorted sternly in the captains face “Do you hear me boy?” she redirected her eyes up “You can save her! Only you!” she shouted at the cracked ceiling with the old fashioned fixture on it before swinging her hips to block the path of the captain the way a defensive guard does underneath the basket. We gave her another ten seconds of sermon time before we shut it down. This was getting ridiculous.

“Let’s go” the Capt said nicely as he forcibly removed her, pinning her arms to her sides.

“I’m not done! I’m not done! Hear me Lord!” she yelled over her shoulder as she was lifted out of the work zone.

“Well you can finish from over there” the now-miffed Captain stated gruffly.

With the would-be prophet out of the way, we got back to work. I quickly started a line and pushed 2 mg of Narcan and stood back to witness the chemical miracle that Narcan is, from a distance. Sometimes people come out of this violently or start projectile vomiting. I didn’t need that.

Nothing.

I looked over at my partner. “Get the stair chair, we need to roll”.

By the time the chair was there, I pushed an additional 2 mg and had delivered a 500 ml bolus of normal saline. Still nothing.

We all looked at each other, this wasn’t right. “Come on!” I thought. “Everything is pointing to overdose, accidental or otherwise. What the hell is going on here?” I thought silently in my head. Protocols were flashing before my eyes, but no answers.

“Suggestions? Ideas? Anything?” I asked my fellow rescuers. They were as dumbfounded as I. We all at once decided to get her out of here. At least do something we know how to do that will benefit the patient.

We managed to get her lifeless, slumped over body strapped onto the stair chair and get her down from the second floor and into the ambulance. It took all five of us and we were pretty shot by the time we got her down.

I grabbed the fire medic to ride with me and we took off code three to the hospital. It was just a short hop, maybe three minutes total transport time. I was grateful for that. This would soon be over and she would have a higher level of care available to her.

Once at the hospital, we told the doctor the whole deal and how we suspected narcotic overdose but the Narcan wasn’t working. Of course he ordered up another 2 mg of Narcan, guess he thought I must have done it wrong. I wasn’t offended, he needed to see it for himself. It didn’t work any better than the previous two doses. I left the patient with the team who was now aggressively searching for a cause. Younger people don’t usually just present like this. There has to be something.

About five hours later I returned to the hospital and they told me she had passed. I was a bit confused. The doctor filled me in. She had had a major vessel in her brain spontaneously rupture. This caused enough brain herniation to pinpoint her pupils and reduce her respirations which ultimately killed her. He told me there was nothing we could have done differently.

The lesson I walked away from on this call was two fold. The first is obviously to keep an open mind and think outside the box. Everything is not always as it seems. The second is that there is no end to people’s arrogance to think that if they just say one more prayer or shout louder, their God will hear them and reverse a medical situation. Prayer is a powerful tool and provides comfort for many in times of need, but when it gets in the way of saving someone’s life, it is another thing all together.

I am reminded of a joke I once heard in a sermon. Here it is modified to fit the scene.

A woman’s friend is dying in a bed and she calls 911. She yells out to God to save the friend. The paramedic tries to save the friend but she jumps in and says “No, God will save her.” Then the fire captain picks up the gear and tries, and she likewise beats him back citing God will save her. Finally an EMT jumps in and tries but is again beaten back similar to the other two. The friend dies right in front of them despite her pleas to God and she is distraught.

Many years later when the woman dies she goes to heaven and meets God and asks “Why didn’t you save my friend when I pleaded for your help? Have I not always been your humble servant?” God took a deep breath and said “What more did you want, I sent you a Paramedic, a fire Captain and an EMT!!”