Thursday, March 4, 2010

Life in the Minutiae

It was a Sunday morning in Oakland. The sun was coming up over the mountains and was blinding to the bloodshot eyes of vampires like me that work the night shift in the city. The rising sun often came as a welcome reminder that the night was over and our shift was coming to an end. A kind of new beginnings signifying the end of a rough night of weekend calls. I work from 9:30 PM until 9:30 AM. Getting off shift at that hour of the morning is challenging because the morning is a time when the call volume is very dense. In a matter of a few short hours our system quickly becomes depleted of available resources. It makes sense when you think about it. Early morning is when you have people first arising and realizing that their loved ones (or themselves) have a problem. Compound this with the large amount of people who get up and pass out in the bathroom or just get up to fast and have strokes or heart attacks and you have a busy timeframe. My partner and I have learned to anticipate that we will get a call too close to our OD (short for off-duty) time and will get held over. It’s OK if you learn to embrace the extra overtime money you will receive.

Today was such a day.

The call came in for a particularly affluent portion of the Oakland Hills called Piedmont. Piedmont is where the doctors and lawyers and anyone else who has done well in Oakland lives. Most of the houses are multi-million dollar, three-thousand square foot plus houses that are built into the mountainside with outstanding views of the San Francisco Bay and all of it’s well known landmarks. The Golden Gate, Alcatraz and the Trans-America pyramid are all clearly visible from this perch, when the famous fog gives you a break. Since the more affluent types of people rarely call unless it is a good reason, your guard is generally up a notch when you head up the hill.

We arrived at a well-kept, modern house on a very narrow canyon street that the ambulance fit down, but blocked traffic both ways. The house was built vertically so that you had to go up two flights of outdoor stone steps before you even got to the front door on the ground floor. From there the house went up another three stories. It was a code 2 call, which means that the dispatcher had determined that the patient was a “less urgent” patient and we would be responding alone without the fire department as is customary on most medical calls.

Our patient was found lying on the upstairs bathroom floor in good spirits. He was an approximately fifty year-old man in good physical condition. Apparently he had passed out earlier when going to the bathroom, but was feeling much better right now. His spouse was a MD and had fully assessed him and did not find any pertinent findings but had a gut feeling that he should go with us as a precaution. She would follow in her personal car. We were fine with that. All of his vital signs were near textbook perfect and the patient was not orthostatic, meaning that there was no drop in blood pressure with changes in position from lying down to sitting to standing. This would be a finding we would expect for a patient who passed out due to a lack of adequate blood flow to the brain. Also his blood sugar was at a perfect level. We were stumped, and our guard was down. After all, it was probably nothing and this would be an easy call. Good way to end the shift.

We assisted the patient down the several flights of stairs. He did fine and did not complain of any dizziness or pain at any time. His color was good and his coordination was normal. I was walking down backwards in front of him in anticipation of him falling. He found this odd.

“Jon, you don’t need to do that, I’m perfectly fine”.

“Steve…”not his name, but we’ll call him Steve to protect his identity “I have had people fall out on me that seem right as rain. I’m not taking any chances on these steps”.

Steve shrugged me off and continued his descent from the castle to the ambulance.

Once in the ambulance we talked about football, his job, and the neighborhood. All small talk to pass the time and make the best of an awkward situation. After all it is a bit unusual for one grown man to be poking and prodding another in the back of a van. I did all the checks I do on everyone and everything checked out. My partner Megan started the slow roll to the hospital through the windy canyon streets.

When it came time to start an IV, he was very nervous about the needle.

“I hate needles” he said.

“Nobody has ever told me they like them” I joked back at him “but most people are surprised by how quick and painless I make it. So who are you calling for the Super Bowl?” I kept him talking about things to keep his mind busy and off what I was doing.

He bore down hard when the needle broke his skin. I was a little surprised at how intolerant to pain he was. Most guys in his condition don’t even flinch. His teeth were gritting and his face was turning red. He was starting to slow his own heart rate down from the internal pressure and I wasn’t too excited about that, but a guy like him would recover fine.

“Aww come on, it’s not that bad Steve, just breath in through your nose and out through your mouth.” I coached. “Steve? STEVE?! STEVE!!!”

He was staring straight at me when the lights went out in his eyes.

I looked at the monitor and saw his heart rate drop by tens. I heard a sports announcer from the seventies in my head:

“Sixty… Fifty… Forty… Thirty… he… could… go… all… the… way! Twenty, Ten, Five, TOUCHDOWN!”

Steve was now gurgling with no cardiac activity on the monitor. His face was turning purple and the lights were out in his eyes. He began to sweat a profuse sweat we call diaphoresis. This was really bad.

“Shit!!! Megan! GO! GO! GO! GO! GO! CODE 3! GO!”

My partner Megan lit ‘em up and hit the gas. Getting back down to civilization on these windy, narrow streets, and doing so with a quickness, was going to be a trick. A trick she was up for, but none-the-less a trick.

“What do you have?” She yelled back, part morbid curiosity, part need to know, trying not to take her eyes off the road.

“No pulse, asystole, not breathing” I was really yelling now more in disbelief than anything. “Just go! PLEASE LET’S GO!”

“We are going” she said. We were going, I was whipping a horse that was already charging. It was time to stop yelling and start working. I couldn’t figure out how to communicate how quickly I wanted to be at the hospital now. Working a code blue alone was a nightmare. It’s a hassle even with a team.

“Steve! Come on man, wake up!” I gave him a brisk sternal rub that would have woken the dead. Nothing.

I don’t know what made me look out the back window. Maybe it was that feeling you get when someone is watching you. I saw his wife in the car behind us trying to keep up and straining to see what was going on with all the commotion in the back of the ambulance. I was like a tornado bouncing from cabinet to cabinet pulling out equipment thanking God I had done my rig checkout that day. There was so much to do. I pulled out my shears and cut his shirt from the neck to the belly button in one fast motion. I slapped the defibrillator pads on him and passing by his head to grab the BVM I instinctively bumped his O2 to high flow. CPR was going to start in a second and I wanted everything out that I would need. My mind was reeling, my heart was pounding in my ears, and I was a bit stunned. I was alone back there, but I could do this. I had no choice. Of course I could do it.

“What do I tell them? What do we have?” Megan broke my trance with a solid question. You don’t just fly into a hospital, you need to tell them you are coming and what kind of a mess you are about to drop in their lap so they can gather the appropriate resources.

“He just coded” I gasped, “I don’t know if this a seizure or a code or what” I felt for his carotid pulse on his neck. Nothing. No pulse. The gurgling had stopped and he was in a blank, dilated, motionless stare.

I ripped open a nasal pharangeal airway (or NPA as we call it) and lubed it up. He was going to need a secure airway and did not have one. I glanced over at the monitor and saw a ripple here and there. IVR. This was not good. This guy was healthy. We were just talking. He was a walking and talking guy with no complaints thirty seconds ago. What the hell was going on? My mind raced for answers as my body automatically ran through the well-rehearsed algorithms on autopilot.

Just as I was sliding the NPA into his nose he popped awake.

It was just like a light switch had been thrown on. His eyes suddenly became animated and his facial muscles regained the composure that makes Steve look like Steve. This is the oddest thing to see. It’s like the return of somebody’s soul to their body. Like a robot that had been switched on.

“Kaiser Oakland, go ahead” I heard the radio crackle from the front. It was time for the report.

“He’s back, we got him back!” I yelled into the cab. His heart rate did the reverse run like an end zone interception. “Zero, Ten, Twenty, Thirty”

Steve opened his eyes and took a deep yawning breath like a little kid just waking up from a nap.

“That was weird” Steve said in a dry, even tone. That was weird? This was his response from the grave? He really looked like a guy waking up from a refreshing snooze.

“Steve, you scared the hell out of me” I was reaching for his neck to check his pulse. It was back and strong. He was breathing normally. All his vitals quickly returned to normal.

“What happened? I felt like I was drifting off to sleep. Did I pass out again?” He was curious, but not concerned.

Meagan was eavesdropping on this exchange. “What do I tell them?” We were getting close to the hospital.

“Crap I don’t know, he just had two minutes of asystole with no breathing and now he’s back like nothing ever happened.” I was stabbing at the dark “I don’t know. Give me a second to get a blood pressure and take a sugar.”

His vitals were back to textbook levels again. What was going on? Did that just really happen?

“Steve, what did you see?” I asked. “Was there anything peculiar or different?”

“Not at all. I just felt sleepy.”

This gave me a huge sigh of relief. Perhaps death was not this awful thing to fear? I thought about my relatives who had recently died. Maybe it was as peaceful for them too. That would be nice.

Megan’s chaotic ring-down was an accurate description of how baffled we were I don’t fault her a bit. What do you tell someone when you don’t know what the heck is happening? The situation was radically changing even as she was talking into the mic. She ended it with a cringe anticipating the eventual laughs and jabs from everyone who heard it.

When we arrived in the ER we were quickly brought into a room with a team waiting. I had to tell and retell the story of what happened to no less than five different doctors. They all wanted to hear it straight from me because something must have been lost in translation. Healthy people don’t just die for a few minutes and come back unaware that anything had transpired. I talked with the ER doc, a cardiologist, the ICU doctor and his resident, and the patient’s family doctor who just arrived with Steve’s wife the doctor. I printed out EKG trend strips and re-enacted it over and over. They all were hunting for an obvious flaw in the assessment, but I had been diligent with this one and left no stones unturned.

Steve seemed to be doing fine in the hospital bed. A little anxious and confused about all the hub-bub but overall doing well considering a few minutes ago he was dead for all intents and purposes. I was another story. All this insanity on the tail end of a busy night had my nerves shot. I had already run a freeway accident, a “hot stroke”, and a near arrest patient on a ventilator. I was feeling the sting in my limbs and chest that you get when you go through repeated adrenalin cycles without rest in between. It feels as if your bones were replaced with metal. That’s the only way I can explain it. I was happy that Steve was alive, but still completely confused about what had just transpired. I was curious from a clinical standpoint but I was also personally invested being that this happened to a patient in my care. Was there something I could have seen or noticed to arouse my index of suspicion? More importantly, how do I make sure this doesn’t happen again?

I debriefed with my partner and retold the story about ten more times to curious hospital staff and fellow EMS workers we ran into. We were done for the day and ready for some much earned rack time. On the way back to the barn Meagan and I laughed, cranked the stereo, and talked about who was going to beat whom to bed first. We were shot. Later that day I couldn’t sleep so I called a senior medic friend who related to me a similar story. It sometimes feels good to hear a common story. He also reiterated the mantras from medic school regarding that this is exactly why we take every call seriously and perform due diligence on every patient. If I had not been careful with this patient and gathered all my information first and eggressed from the residence without the proper precautions this could have been a very different call. What if he coded and stayed dead and I had no line or no baseline vital signs? What if I had talked him into staying at home?

I know this call will change the way I look at patients, if only for a while. The hum-drum day-to-day grind will eventually again deviate my sense of normalcy, but in the meantime, I need to find that balance between paranoia and being slack. Living life in the minutiae.

Copyright 2010 Jon Kuppinger

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