I see dead people

This post arose from a discussion I had with a colleague.  I was being singled out, and essentially berated, for terminating resuscitation efforts on an 87 year old man who died while his wife was in church.  His wife agreed, as did the physician on the phone.  I was at the hospital after obtaining the physician's order signature to terminate resuscitation. 

My colleague stated "people aren't dead until they are in a hospital, and a doctor says they are dead."

My colleague is an idiot, and thankfully, does not wear the same patch as I do, and does not serve in a primary caregiver role. 

He is of the thinking that there is "something that they can do" that we can't.  Like open cardiac massage on a 60-something year old patient?  Hardly.  This job is nothing like television makes it out to be.  (Did anyone ever get pooped on during an episode of E.R.?)

Death is the most unavoidable part of life.  From the moment we are born, or from the moment we are conceived, depending on your political leanings, we are destined to die. 

The CDC reported 2,436,652 deaths in 2008.  Only 170,314 of those were attributed to "Accidents (unintentional injuries) Intentional self-harm (suicide) and Assault (Homicide).  We are ten times more likely to die from heart disease or cancer.  Interestingly enough, Blacks have a much higher infant mortality rate, more than twice that of whites. 

EMS responds every day to people not breathing, and without a pulse.  Out-of-hospital cardiac arrest has, for lack of a better term, a terrible prognosis.  On the high end of the prognosis, 8% of patients in prehospital cardiac arrest survive to discharge, while the low end cites a percentage of 2.  The prognosis for in-hospital cardiac arrests are much higher, but still gravely low.  One could argue for the importance of early defibrillation, and the access to healthcare providers in the hospital.  (Even the janitors at my local hospital have CPR certification.)

Patients presenting in the prehospital system with either ventricular fibrillation or pulseless ventricular tachycardia have a 10-15 times greater chance of survival. 

These are statistics from one source, the CDC.  I doubt you would find a prehospital provider that would argue with these statistics, however.  Personally, in my years of experience, I have seen a total of 2 patients who presented initially in ventricular fibrillation survive to hospital discharge, 2 patients who presented in pulseless ventricular tachycardia, and 0 who presented in a pulseless electrical activity (PEA, EMD, Ventricular escape, whatever...) survive past the emergency room.  I could not tell you how many cardiac arrest calls I have run, but I would venture to say it is well over 200, which would be in line with the (admittedly doubtful) Wikipedia article.

Transporting patients without perfusing rhythms is fruitless.  It does nothing but provide false hope for family members, increase the risks of accident enroute to the hospital, and increase the opportunity for injury to a provider in the back of the ambulance. 

As mentioned by a person much smarter than I, "asystole is not a workable rhythm, it is a confirmation of death."

Granted, there are times to perform CPR and transport these patients to a hospital.  The elderly person who collapses at the Sunday buffet is a good example.  It simply wouldn't be prudent to leave a dead body covered by a sheet in front of the salad line.

There are also times in which transport is not warranted.  The person in cardiac arrest, with a patent airway and intravenous access, with no signs of life, and no response to pharmacological intervention should, with family concurrence, have efforts terminated on scene.

Medical directors who insist their medics continue to transport dead people emergency to the closest hospital do nothing to advance this field.  Medics who are not ready to challenge those medical directors are doing nothing for the field either. 

We, as a whole, should stop transporting dead people to the hospital, only for a physician to confirm what we already know.

My colleague is still an idiot.

A what plan?

20 something female, pregnant, having contractions.  These are usually lame calls. 

I mean, you've known for how many weeks you would need a ride to the hospital?  One would think you could save enough money for cab fare in 40 weeks.  But ambulances are free.

This is a nice neighborhood, where kids go to private schools.  This call is getting lamer.

Met by a nice, well dressed gentleman who directs us upstairs, to his wife, who is allegedly having contractions.  I say allegedly, because I'm not sure if she is having contractions, or simply auditioning for a dying walrus. 

She hands my partner a 2 inch, pink binder. 

"This is my birthing plan.  I want to make sure it gets to the hospital with me."

"Excuse me, what?  A what plan?"

"My birthing plan.  I want to make sure everything goes the way I want it."

"Was going to the hospital by ambulance part of your birthing plan?"  (Hey, I'm just curious.)

"Well, no.  That part wasn't in the plan."

The binder doesn't make it with us.  We forgot it.  Honestly.

Damned Germans

Took an old guy home the other day.  Well, not "home" as in his private residence, but "home" as in his very expensive, clean-smelling senior living facility.  This is the kind of place in an affluent neighborhood, that costs $10,000 a month just for a room.  Well, a suite, really. 

These are fun calls for me.  They take me out of the 911 system, and I can relax for a few minutes.

He is somewhat hard of hearing, but really nothing is wrong with him.  He certainly doesn't meet Medicare guidelines for non-emergent ambulance transportation.  That's not my problem though.

He and I talk.  He was married for 63 years, until his wife died recently.  He still considers himself married, and still wears his wedding band.  He has 4 children, 11 grandchildren, 27 great-grandchildren and 2 great-great-grandchildren.  He knows each and every one of their names, where they live, and what they do for a living.  He also knows which ones come and visit him, and which ones don't.  He says I remind him of one of his grandchildren, and that he likes me.

I tell my partner to drive slower and take the long way. 

We talk some more.  He tells me his secret to staying married for so long was to smile at his wife and say "I'm sorry" alot.  He says he married his best friend, and that they never spent a single night apart.  He doesn't tear up, but he is visibly saddened that his bride isn't with him any more.  He smiles when he talks about her. 

We get to his senior-living facility, and wheel him inside.  He is obviously very popular with the staff and residents.  Every single person says hello to him.  His suite is very nice.  He has lots of pictures of his family, and they all are attractive people, with big smiles on their faces. 

Slimm and I lower the stretcher, and I help him to his chair.  He asks me for a favor; to go to his bar and make him a scotch and water.  I like this guy even more now. 

I bring him his drink and notice a shadow box on the wall.  In this shadow box I notice some military insignia, medals, ribbons and such.  I notice a Silver Star, Bronze Star, 2 Purple Hearts, and various other medals and ribbons.  I count 18 ribbons in the shadow box.  I don't recognize the first one.  It's blue, with thin red stripes on the ends, with a smaller white strip between the red and blue.  I put that image in the back of my head for Wikipedia later. 

I notice his Colonel insignia, and I feel mildly ashamed that I called him "Mister" instead of "Colonel."  I prefer to call veterans by their rank.  I may not have been born in this country, but I certainly feel admiration and respect for veterans. 

"What did you get all this ribbons and medals for?"

"Killing all of those damned Germans."

Damned Germans, indeed, Colonel.

Slimm and I both shake his hand, and he gives a manly, respectful handshake, and makes eye contact, and says "thank you" while he does.  We bid him goodbye, and make it back to the ambulance to go in service for the next call. 

I pull out my iPhone and look up the ribbon online.  It's the Distinguished Service Cross.  It is the second-highest decoration, only behind the Medal of Honor.  I feel honored to have spent time with a true American hero.

Damned Germans, indeed.

ProQA Fail

Partner of the day and I had just finished working an incredibly impossible arrest. 17 defibrillations, and almost a complete drug box used. 17 minutes were spent in the house prior to moving the patient, mainly because the personnel on scene were all waiting for a rhythm change, be it positive or negative. We never got one though. That's a different story.

Seriously, who stays in v-fib for 40 minutes?

So, anyway, we get a non-emergent run dropped on us. These are pretty rare, since I have responded emergency to runny noses, and eye pain. This was for a man who was dizzy, which was also interesting. Usually, if a caller even mentions that someone in the house, or the near vicinity, might even be close to remotely being dizzy, or if they know of someone who has ever been dizzy, then a full response is warranted. A full response being a BLS Engine, an ALS Rescue, and an ALS ambulance. Again, I digress.

Suffice it to say that the call taker must have really thought this call was stupid to call it non-emergency.

So, POD and I drive in to this very nice neighborhood, which isn't rare in this part of the county. The houses probably start in the high 400s, and the house we find is probably nearer to the top of the market in this neighborhood.

We've got a waver!

I love wavers. If we didn't have people jumping up and down screaming at us (as if we can hear them from 800 yards through the rolled-up windows, over the diesel engine, the radio traffic, and our general conversation) I have no idea how we would ever find 123 Main Street.

Except for the numbers on the mailbox.

This is a nice looking gentleman, probably not our patient, since our dispatch information is suggesting a 60ish year old. This guy is probably early 30s.

POD and I decide to take in the monitor and the stretcher. Hey, it's the least we could do, right. This call sounds like utter horseshit, but we might as well grab some equipment. And the computer for a refusal. These people usually just want their blood pressure checked.

The waver walks up to us and begins to talk.

“My father and I got home from the gym about 30 minutes ago, and he's been really dizzy since then.”

Okay, maybe not an utter horseshit call, but it still sounds kinda stupid. Waver has an accent that, coupled with his thick, dark hair and complexion, lead me to believe he is middle eastern. That's about as specific as I can get.  I can hear a Yankee from across a parking lot, however.

It's 68 degrees in the well-appointed home. I know this because I immediately felt cold when we walked in the door, and happened to walk past the thermostat, where I saw the 68. Just into the living room was a man, lying on the floor. He didn't look good.

Okay, maybe it's a genuine call. This guy looks sick. You know how white people turn kinda blue? This guy looked kinda like a blue middle-eastern guy. And he was wet.

Like, just got out of the pool wet. Obviously, I have a real patient.

He seems to be awake, but to compound his sickness, his son tells me that he only speaks Farsi. I most vertainly do not speak Farsi. I ask all the normal questions for a guy who looks like this.

30 minutes onset after coming home from the gym. No chest pain. No difficulty breathing. No nausea. No vomiting. No syncope. Had a stent placed in Iran 7 years ago. No meds. No allergies. Yada, yada, yada.

All this is going on while I do my best to dry off this incredibly diaphoretic, hirsute man, and get the electrodes to stick to him. Times like this I wish I carried tincture of benzoin in the monitor bag. B/P cycles 72/43.

Well, no wonder I couldn't feel a radial pulse.

The monitor is on, and prints it's initial rhythm strip:

Oh, snap! I would be dizzy too if my heart rate was in the 40s. And if it was junctional.

“Can you tell your father I need to shave some of the hair on his skin, and put more stickers on his chest? Mmmkay, thanks.”

The monitor keeps saying something about “Noisy data.” Forget that, print a damned 12-lead.

Okay, time to go. I reach for the combo pads, just in case this goes south, and also because of a lesson taught to me a long time ago by a coworker.

My Farsi-speaking patient now has eyes the size of dinner plates. His eyes look like he knows I am about to "light him up" or something.  He looks at his son and says something incomprehensible to me, and his son in turn looks at me.

“Can you tell me what is going on with my father?”

“He's having a heart attack.”

Surprisingly calm. “Okay. Can we go to Secular Hospital (with no PCI, and notorious for screwing stuff up).

“No, but we can go to Saint Catholic, right down the street.” (World-renowned, PCI-capable, and will actually listen to a paramedic and activate the cath lab on our word.) Thankfully, son agrees.  As if he had a choice.  I am NOT going back in to CQI to explain myself.

POD gives me a nice, smooth ride, which takes about 15 minutes. I get a 16 in an AC somehow, and give him a good, hefty fluid bolus. 324 of aspirin is in. Blood pressure comes up a few points, to 90 systolic. Hey, it's better, but nothing to be too excited about. Thankfully, my service transmits 12-leads, and Saint Catholic felt like answering the phone.

Not only that, they actually hand the phone to not just a physician, but the interventional cardiologist who is awaiting my arrival. I literally transmitted this 12-lead 5 minutes ago, and there is a PCI doc waiting on me?

Cool.

The rest of the story is pretty boring. He went to the cath lab, he got stented, spent the night, then went back home to his son's house. I'd like to check on him, but I probably won't. There's lots of patient's I would like to check on, but I never do.

Sometimes, I start an IV and not much else.

Good call, even with the interesting mistake between 911 call and the actual dispatch.  I'm not a dispatcher, but I wonder how something like that happens. 

Have you seen this cat?

Missing: Approximately 12 year old, 11 pound, Siamese male cat.  Answers to "Buttercup" or "Lorenzo"

Buttercup's owner is currently admitted to local hospital, and cat may be lost and in need of assistance.

Use caution when approaching the cat, as he is known to be very neurotic at times, especially when separated from his neurotic owner for extended periods of time.  When communicating with Buttercup, it is best to use an inside, high pitched, baby-talk voice.  It is very important that you explain every single movement to Buttercup, lest he suffer a feline psychotic break.

Buttercup may be in need of medical attention, and has been known to crave antifreeze when left home alone without his owner.

If found, Buttercup is easily soothed by large numbers of QVC boxes, bolts of fabric, and Peter Popoff marathons.

He might just need a normal owner.

Healthcare is broken

Of course it is.  It has been for years.  And it will only get worse.  Ask Canadians why they come to America to pay cash for their operations instead of sitting on a waiting list. 

Today, I transported a man, who called 911 because he was having "burning while urinating."  Now, one might opine that perhaps this was a man who had no access to health care, or couldn't afford it, or blah, blah blah.  None of that is the case.

This guy lives in an active adult living complex which costs somewhere in the neighborhood of $1,000 per month.  His apartment was well-furnished, and I noticed a degree from a 4-year university.  His keys had a (what appeared to be fairly new) remote keyless entry for a Buick.  He used his iPhone to call his daughter to tell her he would need a ride home from the hospital.  He had prescription medications from a private physician.  He was well-dressed, in brand-name clothing.  Along with his prescription medications, he handed Slimm a Medicare card.

This patient phoned his private physician who informed him that he was unable to make an appointment for today, and suggested the patient seek care in an emergency room.  The patient decided that it would be more convenient to call 911, then to get in his own car and drive himself there.  He mentioned he wanted to "be seen quicker."

Several thoughts:

This man's problem (likely) could have been treated with a $60 visit to his primary care physician, and with $10 generic antibiotics.  Instead, he tied up a valuable resource for 45 minutes, costing Medicare roughly $800 for the ambulance ride, and probably somewhere near $1,500 for the ER visit. 

Means testing has been suggested for Social Security.  Perhaps it is time to means test Medicare, along with Medicaid.  I'm not suggesting that we throw our senior citizens to the wolves.  We certainly owe them a debt.  But $2,300 for a urinary tract infection?

While healthcare is certainly broken, and in need of fixing, President Obama's suggestion of a single-payor system will never fix the problem, but will only add to the fraud and rampant fiscal irresponsibility.  I would propose my idea for a healthcare solution, but that is a topic for another post.  I will go so far as to say that a single-payor system will only lead to rationing and a decrease in the quality of care.  (See my earlier comment on Canada.)

Shame on the private physician for suggesting the the patient increase the burden on an already over-burdened ER instead of either a) squeezing the patient into the schedule, even if it meant staying late, or b) calling a prescription in to a local pharmacy for an antibiotic, and making an appointment for tomorrow.

Shame on the patient for being so incredibly selfish as to demand a crew of two people, capable of performing meaningful interventions, be taken away from the citizens in their zone to provide him a courtesy ride to the local hospital. 

Shame on me for contributing to the fleecing of America.

I would apologize, but if I didn't transport this man to the hospital, then I wouldn't have a job.  And my family likes to eat. 

(sorry, America)

Impressive

From a patient's H&P: (edited somewhat, of course...)

History significant for :

• Non-insulin-dependent diabetes controlled with diet.
• Hypertension
• Asthma
• Obstructive sleep apnea, requiring CPAP at 18cmH2O  (WOW!)
• Chronic renal failure, requiring hemodialysis
• Cardiomyopathy with ejection fraction of 40%
• Peripheral vascular disease
• Hypercholesterolemia
• Neuropathy
• Acute respiratory failure requiring tracheostomy and mechanical ventilation
• Morbid obesity with a BMI > 60
• Depression (ya think?)
• 15 pack-year smoker, with frequent marijuana abuse

This patient was 26.

Hey! Didn't I see this house on TV?

I don't care for abdominal pain. They are generally the most lame calls ever. If your tummy hurts so bad that you need to call the ambulance, you had better be close to death if you want any sympathy.

We can't get in this house. Hoarder-style. Smell it from the street. It smells like rotting death covered in trash and human waste. From 40 yards away.

Seriously, I don't know how this house hasn't exploded from the sheer amount of crap stuffed inside of it.
Literally, this guy should be on TV. If you've ever seen Hoarders on A&E, then you have a good frame of reference for just how full of crap this house is.

If you have ever worked on an ambulance, you have a good frame of reference for just how full of crap this guy is.

This guy has abdominal pain (allegedly) that is so bad, he absolutely has to go to the hospital, but, oh, let him get some shoes first, and find a book to take with him. Mom, you can ride up front. I'm impressed with your lack of ability to find clothes that match with all that crap you have in your house. Hey, at least the clothes are clean, and I don't have to turn on the exhaust fan in the back of the ambulance.

Slimm advises me discreetly that Tummyacher just got back from the doctor's office 3 hours ago with pain med prescriptions.

Now he is known as Faketummyacherseeker.

Interestingly enough, I catch him peeking over his shoulder at me. I am, of course, sitting in the Captain chair, from which I frequently write my blog posts. Unless you are my boss, then I write them after I get home, on my own time.

Each time he looks at me (I am generally ignoring him, of course, because, frankly, I think he's full of shit), his whines and whimpers get just a little bit louder.

"What does the pain feel like?"

"Oh, it's awful. I can't really describe it. It hurts really bad."

"How bad on a scale of 1-10?"

"Twelve."

Obviously not a mathematician.  "Does anything make it worse?"

"Moving makes it worse. It's just terrible."

"Does anything make it better?"

"Usually Dilaudid makes the pain go away. OOOOhhhhhhh, ithurtsbad!"

Of course it does, Mr. Faketummyacherseeker, of course it does.

Non-emergency?

Earlier, I discussed the disproportionate use of lights and sirens in our responses.  Sure enough, someone just has to prove me wrong.

We are responding to a doc-in-the-box that calls our service at least once a day.  This clinic doesn't have a stellar reputation, nor does it have a terrible reputation.  Just another urgent care facility. 

Apparently, they called my dispatch center directly and requested an ambulance.  Somewhere during that conversation, an employee at said urgent care facility mentioned that the patient was complaining of chest pain.  And difficulty breathing.  And has a history of PE.  And an abnormal EKG. 

...And wants us to come non emergency.

This patient was genuinely sick.  She was in sinus tach at 130, and in obvious distress.  Her room air O2 saturations were very easy to take, as the clinic staff hadn't bothered to administer any, much less check her SpO2.  It was 88.  The staff did, however, start a 24 gauge INT for me.  Sweet.

Her 12-lead, physical exam and history all scream PE.  And this doctor either:

A. Didn't know it.  (Which makes me wonder why not)
B. Wasn't that concerned about it.  (Which makes me want to ask him why) ...or...
C. Knew that I personally would be the one to respond and take care of the patient.  (Which makes me want to shake his hand.)

Maybe I'm just complaining too much.

Not a happy Hanukkah

It was Christmas season, only a few days before. Actually, it was in the middle of Hanukkah, which is pertinent, given the Star of David around his neck.

It was late evening, when most normal people are winding down, in bed, perhaps with a snack, or watching some late news. The address was for a fairly nice neighborhood, full of upper-middle class homes, and successful people. For a man "not feeling well."

Cupcake and I arrived only a few minutes behind the first-in Engine and Rescue units. We took our stretcher and first-in bag with us into the well-appointed home, and were directed through a
kitchen, full of pictures of children and what appeared to be a new grandchild.

As I rounded the corner, Elrod and I made eye contact, and I saw the distinct look of fear in his eyes. The look that says "this guy is sick something bad." Elrod is a career paramedic, with 20 years under his belt.  He has seen some sick people before.  His eyes tell me enough.  Elrod is starting a line while Tim is hooking up the monitor and Kevin puts a nonrebreather on him. I look at the wife. "What's going on?"

"He hasn't felt good for a few days. He just took the trash out, and came in and said he couldn't breathe."

"No, he doesn't take any medications."

I get a glimpse of the patient in the dim light, with the glow of Fox News in the background. He looks terrible. Like, as my father would say, "death eatin' a cracker." His skin is grey. An amalgamation of pale, cyanotic, diaphoretic and dusky.

"Forget the line, Elrod. Let's get him on the stretcher."

Cupcake and I are out of the house with the patient within 4 minutes of walking in. She asks if I want a rider to the hospital, which is 10 minutes away. 6 minutes with her heavy foot.

"I want to leave. If there is a rider in the back with me when you get up front, so be it. Otherwise, lets get the hell out of here."

No rider.

O2 saturation is 88% with 15 liters going. I get a blood pressure that is terrible. 82/50. His carotid is incredibly fast and weak. The monitor is counting out 140. A minute later I have two 16 gauge lines going. I don't know how I found those veins, but I did.  His skin still looks terrible.

I'm throwing the 12-lead on as fast as I possibly can.

"I can't breathe."

"I know, buddy. I can breathe for you if you would like, so you can try and relax."

"Okay."

I drop an NPA in and start bagging him. "Data quality prohibits interpretation" says the monitor. Shit. I don't need a crappy algorithm to tell me this guy had a massive MI over the past few days. B/P cycles again: 73/49.

Cupcake tells me we are 2 minutes away from the hospital. That's two minutes too long. He should have been there 2 days ago.

We unload him from the truck. "I'm about to die."

Cupcake says "no you aren't, there are really good doctors in here, and they are going to take great care of you."

We walk with incredible alacrity into the ER, and the receiving doc sees my NPA, and shows us to a room close by. "Let's get RSI."

"I'm going to put you to sleep and put a tube in your throat so we can breathe for you."

"Okay."

The drugs are in, and the tube follows quickly. As does the noises from the monitor. V-tach. "He have a pulse?"  "No."  "Start CPR."

Normally, I am out of the room at this point, so the more educated people can do their jobs. Usually, I am just in the way. Not this time. I'm right there. I haven't had time to leave yet, and the crash cart is blocking my exit.  I start compressions, pushing hard and fast on this man that was talking to me just moments ago.

Epi is in. Charge. Shock. Asystole.

More compressions. Something catches my eye at the door to the room. It's Cupcake, and she has turned her head. I hear a vaguely familiar, polite voice: "Is he doing better?..." as I see his wife come around the curtain.

We make eye contact and she sees me doing chest compressions on her husband of 30 years.

What followed was the most terrible, shrill, eardrum piercing sound I have ever heard. The sound that all of my fellow EMSers have heard, and dread hearing again. It's the sound that still, to this day, awakens me occasionally from a still sleep.

The next few minutes were a blur. More drugs are pushed, more joules are administered, all with no effect. The wife has since come into the room, and is sitting on a chair next to her husband, talking to him, as I continue to compress his heart, and respiratory continues to inflate his lungs.

"You can't go now, you need to come back. You can't leave me."

"It's okay if you need to go, honey. I understand. You are a wonderful husband."

I can't believe I am seeing these stages of grief happen in front of me. She looks at the doctor.

"I think he's gone. He's not coming back."

Doctor and I make eye contact, and he gives me an almost imperceptible nod. I stop, and walk out the room, then I hear the wife again.

"Wait."

I turn around, and she looks through my eyes, hers full of tears, and mine full of failure.

"You did a great job. I know you took good care of Danny, and you did everything you could. Make sure you go home and hug your wife real good, and kiss that sweet boy of yours."

How on earth did she know I was married, with a young child? Oh, damn, his 3 month picture is on my nametag.

She hugged me hard. For what seemed like an eternity, and I returned to my ambulance with her tears soaking my shirt, and a few of mine on my cheeks.

3 days later I read his obituary.  He was a lawyer.  His office was only blocks from mine.  He was an avid tennis player, and a father of 3, with a baby granddaughter. 

I wish he would have called earlier.

Pleasant Vomiting

Respond emergency for a female who feels sick, and with a racing heart.

Sounds cool enough. (I like giving adenosine.)

We are met by the fire crew. "Leave your stretcher in the ambulance. She will be sitting on a john boat in the driveway."

Interesting.  (What's that bout a john boat?...)

"I vomited violently about an hour ago, and I want to go to the hospital. I laid down, and my heart started racing."

Sinus tach at 113.

"Violent vomiting" was mentioned no fewer than 15 times on the way to the hospital.

Straight to triage.