Wednesday, February 17, 2010

Turkey and Pumpkin Pie

It was an unseasonably warm late afternoon for the time of year. Being just past Thanksgiving, you would expect the air to have more of a nip to it. Instead the still air had a comfortably warm heaviness to it, like an old comforter. Though it was only four o’clock, the shadows were stretched long across the Starbuck’s parking lot the way they do in early December. Perry and I were not complaining. We were having a nice slow shift that almost felt like a day off. Almost. The conversation turned to how it had been a long time since either of us had a “real call” meaning the kind of “stat” stuff you see on TV or the movies.

“Man, over the summer I was the grim reaper, but the past month has been nothing but bogus calls.” I joked.

“I know bro, you have a reputation for that. Everyone has a ‘Kup story’ about a crazy call they ran with you this year.”

The way the call deck gets shuffled is beyond approach. I stopped trying to figure it out a long time ago. Some nights you will get murdered. Critical call after critical call in a steady stream like a chain-smoker lighting one off the last. Then for the next two weeks you wont have anything above a sprained ankle or headache. There is no rhyme or reason to it. I’ve tried tracking the day, time of day, the lunar cycles, the times of year, you just can’t put a finger on it. The only thing you can count on in Oakland is that the dragon will eventually find you. It lurks and waits in the belly of the city until your guard is down and strikes with extreme prejudice.

“You know, I could go for a code.” I said, meaning working up someone who has just died. I didn’t mean at all that I wanted someone to die, just that if someone’s time was up, (and in a big city, somewhere, somehow, somebody’s number is up right now, it’s just statistics) I wanted to be there to help and to sharpen my skills as they were getting soft in this current slump.

“Dude, I totally feel you. I haven’t had a code in months.” Perry replied.

This form of small talk has a lot more behind it than seems on the surface. A couple of things are going on here. First off, we were trying to gauge our respective critical call volume as compared to the other guy’s. We always futilely try and make sense of it all, if not just for sport. Secondly, you are trying to see if your partner is “due”. This is silly superstition. Nobody is ever due, just like a blackjack table is never “hot”, but often enough it seems like it, so you still ask the questions. When you are due, you know it and walk around with the specter of death just a few steps behind you. You know it’s coming, just not when and are relieved when it comes.

The third part of this silly little verbal dance, and this is important, is we need to talk about what we do. We need to hear about each other’s calls and relay our information to them about what happened, how we responded, and lessons learned. This is part learning and part therapy. To recount a crazy and stressful situation is to revisit it using the front seat of the ambulance as a psychiatrist’s couch. When this is done to sympathetic ear that really understands the job, you get to chip away at a little piece of the burden we carry around in memories and bad dreams. That is the therapeutic component. The learning side is also important given that most patients do not fit into the neat little boxes in our protocol book or in our training session in school. You may go your whole career and only get one opportunity to see one odd presentation or unusual set of circumstances. If your partner has already hit the jackpot, you want to know about it and store it away in that little dark corner of the mind that paramedics hide all these heinous stories for retrieval later. Then when you get your chance to shine, you access that dark place and dig it out. Turn a negative into a positive.

This unseasonably warm evening in that Starbuck’s parking lot my door was opened and my feet were propped up in a position that shouldn’t have been comfortable, but somehow was. I was in deep relaxation. Shooting the breeze with one of my buddies and sipping on an iced coffee. It had been over an hour since there had been any traffic at all on the radio. It was quiet out there, but the dragon was lurking.

“Can you believe we get paid to do this?” I asked Perry.

“For real” Perry is kind of a hippie/surfer type from Santa Cruz and has the lingo and longish locks of black hair to prove it. Well, long for the public service sector anyway. His boyish looks cause many to mistake him for a student, which is the source of much razzing. All in good fun.

“So tell me about what would be your worst call right now if we got one.” I asked with my eyes lazily closed behind my sunglasses, basking in the sun like a lizard on a rock. I love to chew the fat about the job.

“I hate the kid calls” he said.

“Not me, for me it’s breathing calls. I can’t stand the anxiety and panic the patient goes through when they can’t breath. It’s as if some of their anxiety gets transferred to me”. I wasn’t kidding, I hate those calls, but I am learning to embrace them since they are a bread and butter call for us.

“I feel ya bro.”

Just then a call came in for a familiar SNF. A SNF is short for a Skilled Nursing Facility or as we call them SNIFFs. Perry was very familiar with this particular SNF and had run several calls recently on the same guy who says he is “short of breath” but really isn’t. To make matters worse, this guy weighs in at a portly three hundred plus pounds and doesn’t really help you out much so you have to carry his dead weight. Ahhh people.

As we pulled up Perry was telling me about the guy we were about to run on and I was mentally preparing how I was going to deal with it. The whole day had been a day at the beach and neither of us were going to break that vibe. We sauntered up the front door and were let in by a very anxious Filipino nurse. She was like a rabbit running around, talking too fast for us to understand and pointing us down the hall. She was standing next to an oversized and gaudily decorated Christmas Tree with various presents under. Empty cardboard boxes with festive wrap and bows on them, no doubt. It’s always weird running calls in the presence of all these icons of happy days and good spirits. That spell was broken by the familiar stench of the SNF, which is a combination of urine, feces, vomit, and rotting decubitus ulcers. How people work an eight-hour shift in these places I will never understand.

“She down there. She can’t breath. She have asthma.” The Nervous-Nelly nurse shot-gunned at us in a constant loop until we responded. Already our gears were turning. Asthma was an easy one. We deal with it all the time and can often times fix it in the field. She was awfully high-strung for an asthma call.

As we walked down the corridor decorated with cheap dollar-store Santa cut-outs, gold and red garland, and generic greetings for a joyous season, we could see some of the fire departments medical gear boxes and bags sticking out of the doorway of a room down the hall. Perry looked at me with a puzzled look.

“Dude, that’s not his room” he stated with just a hint of surprise. I just shrugged. A call is a call, I could certainly go another day without meeting our frequent caller. Besides, this was an asthma call. Easy as pie.

I was at the front of the gurney and was the first to pop my head in the room.

“Crap Perry, they’re intubating her!”

I snapped the cool breeze vibe we had been riding. It was too good to be true anyway. The reality was that firefighter was not actually intubating her, he was looking down her throat with the laryngoscope. The patient was a fifty year-old grey haired lady lying face up on the tile floor. She was pale, unconscious and struggling to breathe. The captain was busy writing down the patient’s medications and trying to get some information out of another nervous nurse The engineer was preparing an IV bag of saline.

We left the gurney in the hall and quickly entered the room, it was time to get our heads in the game.

“What do you need?” asked Perry. It was his call after all. Since we trade off every other call, I was functioning as the EMT on this dual medic bus, an assistant of sorts.

“Get me a line, she’s really tight. Not moving any air at all. I’m trying to see if I can see any blockages.” the firefighter responded. He quickly turned to setting up the BVM with an albuterol nebulizer in-line. He was going to try and force some albuterol into her lungs, maybe it would free her up a little.

Perry went straight to the patient’s head. I stayed at the feet. It was obvious the engineer was not going to get an IV. He had already tried three times with no success. I went straight for the bone drill. This patient was going to be critical, possibly a code blue. I didn’t want to waste any more time with IV needles.

“So what’s the deal?” Perry asked in an even, laid back tone. What does it take to fire this guy up? I was happy he was here.

“She’s sat-ing really low” reported the firefighter referring to her oxygen saturation in her blood. “and when I try and bag her, I don’t hear any lung sounds. It’s really weird” the firefighter was understating the gravity of the situation, which we sometimes do to cut the tension. Without oxygenation to the lungs this patient had minutes or even seconds to live depending on how long she had been down.

I had the ears near me so I put them on and listened as he tried to bag her. He was right, you couldn’t hear any of the air movement you were accustomed to hearing and I found this creepy, like nails on a chalkboard. Was she tight from her asthma or was it something more sinister? The patient was struggling to breath. Her inter-costal muscles around her ribs and collarbone were contracting around the bones outlining her rib cage. Her heaving abdomen was jerking and working overtime to try and draw in even a squeak of air. She was getting tired. She would give up soon. For now she was compensating and maintaining a pulse and cardiac rhythm, so at least we had that for the time being. We just needed a bit of time to figure this out. Just a few more seconds.

“Hang on lady, we’ll get you fixed up” I thought to myself.

Meanwhile, I got back on task and drilled her leg for IV access. It went in easily and smoothly. I could overhear Perry and the firefighter talking at the head.

“Let me take a look” he said grabbing the laryngoscope. “Hmmmmm, pass me the Magill’s” he was referring to the Magill’s forceps. An unusual set of forceps that have an angle to them that allows them to be placed deeply down a patient’s throat.

Perry retracted the forceps quickly and they were empty. Like when you play that game with the big glass enclosure and the claw that tries to pick up stuffed animals; the one nobody ever wins.

“Dammit, I almost had it”. Now we were all intrigued. We were still performing our tasks, but looking up to Perry to see what “it” was that he almost had. This was getting interesting.

“Perry, you’ve gotta hustle bro, she is brady-ing down” I said with more than a little stress in my voice.

The patient was brady-ing down, which means that her heart rate was slowly decreasing at a steady pace. It was at thirty and on it’s way down. She would be dead in moments. Her oxygenation level was also dropping and now had hit the lowest the meter will read, <50%. She was turning that color they turn just before they die. Not good.

“She’s going to code, get ready for CPR!” It was time to rally the troops. This call was about to change radically for the worse.

“I just need a sec….hold on……there!” he said and with one smooth move pulled “it” out.

We were all stunned.

“It” was an unbelievably large piece of turkey the size of a cell phone. Nobody in the room could believe it. It was coated in an orangey-brown substance that instantly grossed everyone out. Well, almost everyone. You could smell the aroma of the puree on the chunk of meat and it was decidedly pumpkin pie. They say that smell is the most potent memory recall device of all the senses. This was a festive smell that one associates with the best times of the year and childhood memories of Grandma’s house not this horrible situation we were in. Why were these two now juxtaposed images being thrust together? Better yet, why was I getting hungry in the face of this crazy call?

I broke my little mental trip to see Perry at the head holding up the piece of turkey. He was pretty damned happy with himself and experiencing a bit of disbelief in the face of this surreal situation. How did this giant piece of meat end up in this woman’s trachea? Nobody would ever eat a piece that big. What exactly was going on here?

Anyway, it was time to get back to business. As soon as that piece of turkey cleared her windpipe, the wonders of homeostasis took effect. She took a big deep breath, and then about fifty more. Her heart rate jumped back up over one hundred and her oxygen saturation crept up by twos until it was over 90%. Was this really happening? Was my little surfer buddy truly saving a life just like they do on ER?

Back to reality, there was still much work to be done. Now that she was breathing she would need a secure airway and to be transported urgently code 3 to the nearest hospital. She was not out of the woods yet. Her air had been cut off for quite a few minutes and that means her brain was not being oxygenated. Brain damage to some level was certainly possible and recovery was not guaranteed. The firefighter rode with us to support Perry and I drove as fast as possible.

Once we had turned over the patient at the hospital we popped outside and started talking about the call. We all had to metabolize what had just happened. Perry was beaming.

“Dude, that was a career call!” He kept saying over and over. “Some guys go their whole career and don’t get to do that!”

Perry was right, it was a career call and one to be proud of. One that will certainly go into heavy rotation on the story wheel when we sit around and talk about our craziest calls. I couldn’t help but start to get a little private eye on this one. There were a few odd circumstances.

For one, why was the patient fed such a large piece of meat? In reading over the patient’s file at the hospital she needed to be fed. Secondly, why were the nurses trying to sell us on asthma? Someone had to have been feeding her at the time it happened. It’s not like she swallowed a six-ounce piece of meat and coughed it up and aspirated it again. I made sure that my concerns were heard at the ER. This is always a sticky situation when you suspect a fellow health-care worker of foul play or more likely incompetence. The way I usually handle it is to present the facts in an order that allows people to see the inference without making it for them. If they feel it is worth pursuing, they will. The ER is really good about that.

So Perry and I did what most people do after a big call. We went delayed and ate a big old dinner. Food always helps. Sharing a meal with someone else is a great way to de-stress and get your energy level back to normal. Sharing it with a hero I call partner is even better.

Copyright 2010 Jon Kuppinger

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