Saturday, March 27, 2010

The Bleeder

It was the first night without my regular partner in a while. She had transferred over to critical care transport on the day shift leaving me with what we affectionately call “mystery meat”. Mystery meat is when you don’t know who your partner is going to be. It is a bit of a gamble really. If you roll a seven you get a great partner who knows their job and can hold a conversation. If you roll snake eyes you get a lazy partner or maybe a dead fish that doesn’t speak for the entire twelve hours of the shift. This night I was lucky and rolled a seven.

Nadine was a tall, well-mannered young lady who obviously was a bit classier than the typical EMS worker. Her soft-spoken confidence spoke to someone who knew her job, but wouldn’t tell you so. We were having a good night of conversation between calls with the new Sade album playing softly in the background when a call came in for the west side. It was a shunt bleed.

When a patient’s kidneys fail, they are often offered dialysis as a way to prolong their lives. Three times a week they go a dialysis facility and a machine is hooked up to a port, usually on their arm. Their blood is cycled out of their body and through a machine that cleans their blood and removes excess toxins and volume. The machine serves as a form of artificial kidney for the patient. The port is called a “shunt” and is the direct line into their major veins and arteries. If this port breaks open, they will bleed out in a short time. It is a true life-threatening emergency.

“Have you ever had one of these?” I asked.

“Yeah, a couple, they can get real messy” she replied as we sped through the abandoned and darkened streets of downtown.

“I had one a couple months back and she almost bled out. The room was like a murder scene, blood everywhere”. I ran through my bleeding control protocol in my head quickly. There would not be any time for fooling around, we would have to go as soon as we arrived.

We pulled up in front of the run-down apartment complex at the same time as the fire department was arriving. There was a thirty-something woman standing in her pajamas waving to us frantically.

“Please hurry! Please hurry!” she pleaded. “We can’t stop the bleeding”.

“I’ll grab the trauma dressings and wrap” I yelled to the fire captain, ”You guys check it out”.

The captain nodded to me and they headed in with the frantic woman. I often worry about taking control like that, after all, technically it is the fire captain’s scene but it was clear the fire crew had just woke up and were in no mood to be leaders.

“Nadine, not sure what we are going to need, jus bring the gurney to the bottom of the stairs please, get some extra sheets, I’m going to run ahead with the trauma dressings”. She gave me a look that told me she understood. We were all in work mode now.

I walked into the apartment and was surprised at how many people were there. There were at least six adult women in this house not counting myself or the fire department. One was sound asleep on the couch. Sleeping through all this commotion. Interesting. I made a note.

As I poked my head into the back bedroom that everyone was pointing to, I saw our patient lying on the bed. The contrast of the bright red blood against the white sheets was startling. There was a steady stream flowing from her upper right arm and her middle-aged daughter was trying to hold pressure with a towel. I ripped open all the dressing packages and asked the firefighter to cut off her nightgown sleeve. It was completely blood-soaked anyway and was ruined. I asked the daughter to carefully pull away the towel and when I did a pulsing stream of fresh blood shot through the deep-red coagulated jelly that had collected around the site of the shunt due to the towel being on her arm. I quickly pressed a trauma dressing on her arm and began wrapping it as tightly as possible.

Around and around and around we wrapped the dressings until her now-oversized upper arm looked like that of a bodybuilder. Blood was still streaming out of the end of the dressing at her elbow.

“Squeeze here, and here, and lift it up” I directed the firefighter. “And get comfortable, you can’t let go until we get to the hospital”.

“Are you kidding me?” He asked. He was just a kid.

“Congrats buddy, you just got the worst job in EMS. Holding a bleed” I smiled at him. His captain winked at me, he thought it was funny. They love to see the new guys squirm.

The patient’s daughter was pacing around the room. She was worried and needed a job to do.

“Can you grab me a robe, some slippers, and her medical card” I asked. Having a task is very helpful for people who feel helpless. She disappeared into the other room, the tears stopped temporarily replaced by determination.

“Gurneys at the steps, need a stair chair?” my partner Nadine shouted from the front room.

“Awww crap” I thought to myself. Of course we would need one, I had forgotten we were on the third floor and there was no elevator.

“Yeah, good idea” I said a bit embarrassed I didn’t think of it myself.

“Good thing I brought one up” she teased. I love partners like this that think proactively.

We loaded the patient into the chair and buckled her in for safety. I got on the bottom and one of the firefighters took the top. The patient only weighed about one-fifty. We could easily handle that. We decided to just carry her down instead of going step by step. I find it easier on the back with lighter patients than the up and down of dropping on each step. That way you only have to bend over once, not at each step.

Once in the ambulance I threw another dressing around the existing one and began the bizarre dance of working on the back of an ambulance around a fully necessary firefighter who was stopping the bleeding, but now serving as a roadblock to the front half of the ambulance. The patient was getting pale now and her eyes were starting to swim the way they do before you pass out.

Right out of the blue she vomited. And I don’t mean just a little vomit, more like the projectile kind you see little kids do.

“Don’t let go!” I coached the firefighter really holding back a giggle, after all this was a serious call. But it was funny to see this kid getting assaulted from every side. He was getting covered. His arms were already soaked up to the elbows in blood and now his chest and hair had vomit in them. Good thing he had a long sleeve pull-over on. That thing was going in the garbage when the call was over.

“What do you need?” It was Nadine. She had slipped in the side door and was going to help from the other side of the firefighter.

“Suction. She just puked all over.”

“OK, got it” she said as she turned on the electronic suction and began clearing the patient’s airway. Aspiration can be very serious and lead to life-threatening pneumonia. Nadine would try and clear as much as she could from her mouth.

As soon as her airway was clear and it looked like she wasn’t going to vomit anymore, we all knew it was time to go.

Our patient’s daughter who had waved us in was now standing at the back of the ambulance watching us work and coaching her mother to “Keep on living” and to “fight”. She was fighting tears and trying her best to bury her own fears and give all her strength to her mother.

“Where are you taking her?” she asked.

“The closest, it’s just around the corner.” I said.

“No don’t take here there, she’ll wait forever!” She pleaded. The hospital in question was a busy one and you could wait there for hours as it is often overrun with patients.

“Don’t worry, they won’t make her wait this time” I promised. The back doors closed. Bleeds don’t wait.

“Code three, shunt bleed, hypovolemia, approx 500-1000 mls.” I shouted up to the cab.

“B/P is 90/P, tachy at 128 bpm, pale and cool, starting IV now, GCS 14” I added.

“Copy” Nadine yelled back, signaling she understood.

The sirens came on and we bounced along down the pothole-ridden streets. Being that the firefighter couldn’t free up a hand to reach for anything on his end of the ambulance or risk spraying more blood on the walls and floor of the ambulance than there already was I had to get creative and contort myself around him. It was becoming like a disgusting game of Twister.

I got my vital signs, started and IV flowing wide open and put the patient on oxygen just in time to pull in. It was only a mile or so, felt longer.

We wheeled in fast with the firefighter in tow. His forearms had to be burning by now. Blood was streaming off his elbows and leaving a trail from the back of the ambulance, through the triage plenum, past registration and into the trauma room. We wouldn’t be hard to find.

For some reason, the resident doctor doing his rotations at the hospital kept hearing “shot” instead of “shunt”. Perhaps it was because he has seen so many gunshot victims. In any event, it provided a moment of levity as we did this round of Abbott and Costello.

“Where was she shot?”

“Shunt not shot”

“What? Yeah, shot”


“I know, WHERE was she shot?” he emphasized.

Funny stuff. But this was serious, we just bowled through him to the room where they take all the stat patients.

The code team at the hospital was ready for us. We quickly transferred her to the bed, the firefighter was still holding her arm through this exercise. Most of the team had gloves, gown, and face shields on now.

“OK you can let go now.” The doc said. He was ready to resume control.

“You sure, it’s gonna blow if I do” the firefighter said. He knew, he was holding it.

“Let go, we need to see what we have”

My partner, myself and anyone else in the room who had seen this kind of thing before faded back. I actually left the room to the other side of the glass. The new doc leaned in.

As soon as the firefighter let go and the bandage was off, the doc got covered with blood. So did the bed, the equipment, the floor, pretty much anything within three feet.

I laughed to myself. So did an number of the senior nurses. They saw it coming.

“Clamp it down clamp it down! “ the new doc shouted.

A quick thinking nurse put a B/P cuff above the shunt and pumped it up. It stopped. Half the people left the room. This emergency was over.

Over the next few hours this patient would receive as much fluid and blood products as she could take to replace the volume she had lost. The emergency was over and she would live to see another day.

I cleaned myself up, finished my report and went out to the ambulance bay. Nadine was out there scrubbing the back of the ambulance.

“We better go delayed” I said, meaning that dispatch would be told we were out of service for a while to clean up.

“Already on it” she said with a smile. Again, a step ahead of me. When the little details are taken care of, it really takes a lot of stress off a paramedic, especially on stat calls.

“You hungry?”

“Starved, let’s go eat.”

1 comment:

TOTWTYTR said...

A good situation for a tourniquet.