First off, go read this.  This Marine says almost exactly what I am feeling.  He just beat me to the punch by a few hours. In fact, he forced me to to re-write my article into a pale version of the original in order to avoid accusations of plagarism. 

I know there is probably more than one of you wonder what kind of crazy person goes back into the Army, especially after being out for eight years!?  Its not an easy thing to decide to be sure, and there were many factors and reasons behind it. 

Back in 1998 I was discharged from the Army as an E-6.  I was 24, young for an E-6, and I was thoroughly burned out.  I was the Senior Intelligence Advisor, Collection Manager, and functioned as NCOIC of the Section, even though we had an E-8 in the section.  I had the most experience, and had written the Battalion SOPs for Intelligence Collection and Dissemination.  I saw others get AAMs, ARCOMs, and other awards for the work I did and it grated on me.  Basically, I had burned my candle at both ends and had run out of wick.  That E-8 was a friend of mine and when I left he asked me to be sure it was what I wanted because he said that people who got out at that point usually regretted it for a long time.  After several months as a civilian, I regretted the choice, but I was on a new track and headed offshore soon for a new career.

Continued...

Yes, we actually had a real honest to goodness save yesterday!  The patient recovered and was discharged from the ER sometime during the night.

The patient had overdosed on a combination of narcotic pain medications, including oxycontin and morphine, at some point during the day.  When family came home that afternoon, she was discovered.  She was in agonal, gasping, respirations at three to four a minute.  She was completely unresponsive and a shade of blue that could best be described as teal.  She was cold, and her pupils were pinpoint at 1mm and non-reactive.  In fact, if it hadn’t been for the pupils and the agonal respirations I would have figured her for dead.

The pupils were, of course, the real clue.  Pupils do not normally become pinpoint and non-reactive during a cardiac or other kind of arrest.  They become dilated and non-reactive.  We scooped her onto the stretcher, began bagging her, and moved to the unit.  During this period she went into complete respiratory arrest.  Another few minutes undiscovered and that would have been it.

Once in the unit, I intubated her and my partner began an IV.  One of the firefighters hooked up the monitor and she still had a decent blood pressure with Sinus Rhythm on the monitor.  Not surprisingly, the ST Segment was a little elevated.  Once all the equipment was hooked up, the tube secured, and the IV taped down, we headed to the ER Code 3.

The patient was fighting the Bag, which is a good sign, but only sporadically.  Given the possibility of narcotic overdose, I gave 2mg of Narcan.  A few minutes after giving the drug her pupils began to dilate.  There still wasn’t any response from a sternal rub or verbal cues, so I gave another 2mg of Narcan.  We maintained the EtCO2 between 35 and 35, which is great considering her fighting of the bag.  Shortly after the second dose of narcan her respirations picked up to about 12, but there still wasn’t much reactivity in her pupils or from noxious stimuli.

The third 2mg of Narcan went into the IV.  Now we started to perk up a little bit.  The patient had been getting good ventilation for about 10 minutes at this point, and the narcan was beginning to work.  Her head would move side to side when I bagged her against her respiration, and she began to bite the tube.  He pupils were beginning to react, albeit sluggishly.  I gave the final 2mg of Narcan and continued the BVM ventilations.

By the time we reached the ER, she would open her eyes for a moment when I spoke her name and she was breathing on her own steadily at about 12 to 14 per minute.  I continued to assist the ventilations to make sure adequate oxygen was entering her respiratory tract. We unloaded her and rolled her into the waiting ER Room.  They gave a bit more Narcan and before we left the ER she was responding to her name and looking around. Several hours later, we returned to the ER with another patient and I checked in on her.  She was awake, extubated and talking toher doctor.  He was finishing up her exam and was going to release her home shortly.  She went from a Respiratory Arrest to Discharge within a few short hours.  It felt good to know that our actions made the difference in her outcome. 

So we get paged out to a MVC the other night and race off to the location.  As usual the responders onscene have called the patient a priority 2.  She was, in reality, a priority “go home and sleep it off,” but we C-spined her and transported her to the hospital anyway.  As it turns out, she may or may not have been driving a car (her fiancee was more inebriated than her) that was following an ambulance running code to the hospital with her friend.  She was busting the reds behind the ambulance, and was smacked by a car entering the intersection.  As I have said before, people don’t watch for the big bus with all its bells and whistles, let alone the little car ignoring traffic law behind it.  Do not follow ambulances through intersections!

Also we had a case of “telegraph dysphagia” as I termed it.  The poor patient was having some kind of crisis and was terminating everything like she was dictating a telegraph:
“I am fine. Stop. I have diabetes. Stop.” “Stop.Stop.Stop. Oh I need to ride it out. Stop.”
“How much longer to the hospital? Stop.”

“You have a 60 year old male complaining of Chest Pain.  Responders have scrambled air transport, ETA 6 minutes.”

Two minutes later we pull into the driveway and maneuver around all the responder vehicles to the house.  We grab the Lifepak 12, the Jump kit, and head into the house.  We can hear the county radios “Air Transport 4 minutes.”

Our patient is an elderly male who began to complain of chest pain about an hour ago.  He is lying on the floor of the bedroom, two responders taking vitals and giving oxygen.  His family is standing next to the bed.

“Excuse me,” I say as I approach the responder on my side. He doesn’t move, but keeps sitting there.
“I need in there,” I say as he slowly puts his B/P cuff away and doesn’t move, so I move him out of the way by moving his bag to the back of the room.  I put the monitor down, power it up, and apply the B/P cuff, Oxygen Saturation probe, and the first four ECG leads while the unit does the self test.

While I am doing that, my partner moves the other responder out of his way, and explains how to “spike a bag” of fluid to the responder as he applies the tourniquet, starts questioning the patient, and getting a history.

The monitor is registering a B/P of 100/90 and an SpO2 of 97% on 15 liters of oxygen.  I attach the other leads and begin taking a 12 lead as my partner opens the drug bag and administers Aspirin and then a spray of NTG sublingual.

The 12 lead is complete and I hold up the cellphone to get a signal as I transmit it to the receiving ER.

The four minutes have past and the flight crew arrives with thier stretcher.  The first words since we arrived are spoken out loud as the patient report is given to the flight crew.  The second NTG is given as we load the flight stretcher on ours, then secure the patient in.  We load the patient out to the chopper and he heads in to the ER.  Total time was less than 8 minutes.

We return to the house to clean up and one of the family members looks to me and says “Thank you.  Great job.” We clean up, call in our report to the ER Doc ( Use of Drugs in Alabama requires contacting Medical Control afterwards, even if the patient was transferred to another unit), and head back to the station.  I nice when you have a good partner and you can run a call with hardly a word spoken between you.

Responders:
Blood Pressure is always an even number when taken manually, and a systolic BP above 110 is considered normal in most of the population.  Saying something like, “His blood pressure is low, its 117/87!” will lose you a fair amount of credibility.  Yes, this has happened at least three times aready this month.

General Populace:
• Wearing a seatbelt will, in fact, save your life.
• Failure to yield to an emergency vehicle will earn you a ticket.
• On that note: the rule is move to the right and slow, not stop dead in traffic, move to the left, turn your car perpendicular to traffic, speed up,  or pull your hair out and scream.  That too can earn you a ticket.
• If you follow the ambulance to the ER, you can not break traffic laws and follow them through lights and intersections.  People don’t watch for the unit, let alone people following behind it. Oh, it will also earn you a few tickets.
• If you ride a motorcycle, wear a helmet.
• Calling an ambulance will not get you seen quicker at the ER.  They use a system called triage, which is based on your patient care needs, not how you arrived.
• If you have had a cold for 3 weeks, it can wait till your doctor opens in the morning.  You don’t need to call 911 at 3am because you need a work excuse.

I now return you to your blogging pleasure.

Ok, so yesteray had a few things worth mentioning. :D

First, sometimes I really hate being a paramedic in Alabama.  Due to the way the state law is written, we can’t carry Morphine at our service yet.  We had a man who dislocated his hip and his pain was a 10/10.  He had dislocated it before, and asked for morphine for the pain.  I felt terrible when I had to tell him that we didn’t have it and then try to explain why.  I did contact Medical Control for some Valium, but I knew 1) it wouldn’t work, and 2) it would be denied, but I had to try something.  In the end we splinted the leg as best as we could and took him to the ER by the smoothest route we could.

There is a joke acronym in EMS - ”SFJ.” It stands for “Screamin’ fer Jeezuz.” It is often used in stories as a form of humor.  Also let me precede this by saying I am a pretty spiritual and religious fellow.  Anyway, we literally had SFJ yesterday.  The patient was riled up by her family into a panic attack.  When we arrived they were all literally “wailing and gnashing teeth,” screaming for Jesus, praying in tounges, and flailing arms about.  We loaded the patient in the back of the truck and left code 1 for the hospital.  Once everyone calmed down and realized it wasn’t the Apocalypse, all the drama died down and the ride was uneventful. Its hard to descirbe the scene, but just imagine 4-5 people running around, arms flailing, praying out loud in tounges.  Sometimes you got to love the South.

Finally, last night we were called out for an MVC. Upon arriving we found the car in a ditch and an obviously intoxicated woman running about whining, wailing, and mostly naked!  The witnesses state she was completely nake when she crashed!  She could hardly stand she was so intoxicated and was hanging off anyone in arms reach.  Firefighters, cops, and both of us had to fend her off multiple times.  She didn’t want to go to the hospital, but wanted someone to call her friend.  Since she wasn’t injured, we left her with the PD fully expecting to get a call about an hour later to take her to the ER. See, when people realize they are going to jail, they suddenly decide they are hurt and want to go to the ER thinking the cops will just drop the charges.

After that things died down and we were able to get about 4 hours of solid sleep.  I didn’t even want to crawl out of the rack at shift change this morning I was sleeping so hard.  It felt good to come home almost rested for a change.

Yesterday was our last shift out in the North end of the county.  Instead of going out with a whisper, however, the residents decided to go out with a bang.  We went in service at 7am and didn’t see the station for more than 10 minutes until about 0100 this morning.  We got no breakfast or lunch break, and as soon as we paid for dinner (all 15 minutes of it), everything started back up.  The shift ended this morning after being paged to run a BLS transfer at 0445, with a BLS crew available to do it!  In fact, we mentioned the issues (there is more than one with this particular routine transfer) to a supervisor, and when he questioned the BLS crew, they had yet to make one run after two hours in service.

My partner and I have gotten in the habit of saying something along the lines of “another life saved” after running a BS call like a drunk, cold, or something similar.  Out of all the runs we had yesterday, maybe two actually needed an ambulance, and that little bit of humor makes the day easier.  I mean, when you travel over 30 miles away emergency to pick up a patient at a nursing home and end up getting a refusal because no one told the patient and she has decided to sign a DNR, you have to laugh or go crazy.

I hate trying to get the ER to understand the following two situations:

1) The patient who’s symptoms were pretty serious on arrival, but almost completely resolve enroute to the ER either following treatment or spontaneously.  The thing is, we are there to affect changes to the patient’s condition and to stablize them prior to arrival at the ER.  If we do our jobs, then thier condition will be different than when we picked them up. 

2) The patient who decides its time to decompensate about 30 seconds before arrival.  In these cases, usually the patient is going to get worse no matter what we do anyway.  However, since they decided to go downhill so close to the ER, we rarely have time to start any interventions (other than what was strated prior to decompensation).

In both situations, you get that “whatever, you stupid ambulance driver” look from the Nurses (who have no real clue about what the situation was because they weren’t there), and you end up feeling foolish trying to explain exactly what transpired. 

That’s what I am calling what I worked today for lack of a better term.  First thing this morning we were called out into the county for a one car MVC with entrapment.  The call was located right on the edge of the two counties and in a gray area for two different services.  We ended up getting responders from the other county so we really didn’t know what we had till we arrived.

Pulling past the scene to maneuver around the responders, both of us at first thought the wreck was a car sitting on the shoulder.  As we pulled past we noticed the real wreck up the bank hidden in a thicket and wrapped around a tree, no exaggeration.  It looked as if the driver had caught the edge of the high soft shoulder at a good speed and lost control, wrapping the driver’s side of the car around the tree.  The tree was actually intruding into the driver’s compartment, and the car was completely demolished on five of six sides - no glass, ripped panels, all the bad stuff.  He was restrained and the airbag did deploy, but it didn’t seem to do any good short of keeping him alive.
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The patient initally was entrapped by a foot, but had managed to wriggle it free before we arrived.  I found him lying across the front seat with a responder holding C-spine.  The patient was conscious and alert complaining of back pain.  So while I awaited the back board and C-Spine equipment I stripped him there in the car and did an initial assessment.  He had a hematoma right between the eyes, many contusions around his chest and upper back, good pulse-motor-sensory function in all extermities, and a laceration over the knee.  We pulled him free from the car, secured him to the backboard, and loaded him in the unit.

We hooked him up to all our numerous devices and my partner started the first IV while I did the secondary exam.  He was immediately placed on 15 liters of O2. The patient was PERRL, although he had some amnesia and a questionable LOC episode.  His neck was supple, midline, without JVD.  His chest had major hematomas over the left side and along the seatbelt lines.  The area over the left chest was swollen, and there was some crepitus on palpation. The abdomen was negative for significant findings, his pelvis was stable and there was no pain, and his extermities remained unremarkable.  We headed out Code 3 as I started the second IV line.

The patient was still complaining of difficulty breathing even after Oxygen therapy.  His O2 sats were in the mid 90’s, but I had noticed a strange respiratory pattern when I asked him to take a deep breath.  When he inspired, it was painful, and his chest expanded outward, not upwards.  His sternal area did not move.  I palpated the area again and not only did I feel a little crepitus, but I noticed most of the normal landmarks were missing.  I listened over his lungs again, which is not easy in the back of a noisy ambulance running code, and he had lung sounds on each side.  I thought the left side was diminished, but he still had resonance on percussion, and his Vitals were stable.  I opened the front of the C-Collar since his head was secured and noticed a little JVD on the left side, later it appeared on the right side.

I began thinking through my rule outs - developing tension pneumothorax, hemothorax, cardiac tamponade.  The ECG was a Sinus Tachycardia, with extremely high ST Segments following the wreck.  The STs continued to rise even with good O2 sats and 15 Liters O2, probably a cardiac contusion on top of everything else.  Nothing I can do for that in the field except what I was already doing.  Cardiac Tamponade?  Probably not, although I was worried since his heart sounds seemed distant.  His B/P remained stable, and none of the other signs appeared however.  Nothing I could have done for that either that I wasn’t already doing. Hemothorax is hard to figure out in the field as it generally requires an X-ray to differentiate other than by mechanism.  Even when I percussed the lung, I was still getting resonance instead of dullness. There isn’t anything I could do for that either.  Tension Pneumothorax was the most likely candidate. Unfortunately, he did not meet the overly restrictive requirements for Needle decompression in Alabama.  Had I been in Tennessee, I would have decompressed just to be safe.  His B/P was stable, he had JVD, but no tracheal shift.  He was still conscious and alert, and he still had breath sounds on the right.

I pulled out and prepped the Chest decompression kit in case he got worse, and I closely monitored his situation. Everytime I asked he said his dyspnea was worsening, but his vitals remained stable and he remained outside the decompression protocol.  Enroute I called the ER and let them know we were enroute with the Priority One trauma.  I picked up the radio a second time and almost called the Doc for decompression orders.  If he had decompensated any further, I would have, but he remained stable from that point forward.  The strange “flail sternum” respirations became more pronouced though.

We transferred him to the ER who started thier workup.  After I had completed my paperwork, I entered the room and looked at his X-rays.  He had three obvious rib/sternum fractures on the left, and at least two - possibly three on the right.  Basically, he had broken his sternum free from his ribcage and it was “floating” on top of his chest.  He did have a hemothorax on the left, evidenced by the big white cloud where his lung should have been.  It also looked like he had fractured his pelvis in two spots, but they weren’t displaced which explained the lack of pain on pelvic examination.  The patient was in pretty serious shape.  He had struck his steering wheel, dash, and window pretty darned hard even with seat belts and airbags.  It takes a pretty big whack to fracture the sternum.

Its been awhile since I have had a “good” trauma like that.  It will definitely make you sweat, even in 40 degree weather.

It seems as though most of the calls we have been involved with over the past few shifts have all been related to Hydrocodone use in one way or another.  There was the man who took 26 of them just because he could, the teenager who combined two with a Propanolol and two beers, and the man who was “confused” after taking antibiotics.  Turns out when he got the antibiotics he also got a script for, you guessed it, Hydrocodone for pain.  He thought that it couldn’t be that causing the confusion becuase he was supposed to take it every four hours, which meant “it couldn’t be that strong.” I guess he learned.
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However, the most challenging call I have had ina while had nothing directly to do with drug use, but alchohol was involved indirectly.  The ETOH complicated the situation because the patient was intoxicated on top of his other problems.  He had been eating dinner and choked.  The choking incident had triggered and asthma attack (he had a history of emphysema and asthma).  The hypoxia caused from by the asthma had triggered a heart attack.  All in all not a good thing for the patient.

We arrived to find him on a albuterol breathing treament care of the Fire Responders.  We transferred him to the stretcher and started a second dose.  Naturally, his pulse was rapid fromt he effects of the albuterol, and he was Sinus Tach on the monitor.  Initially, there were occasional Unifocal PVCs in the rhythm, but over the next few minutes (time to start and IV and do a 12 lead), the PVCs had turned into Bigeminy, then Couplets, then Couplet Trigeminy, and finally short runs of Ventricular Tachycardia with 3-4 “funky little beats” afterwords. The patient was not doing well.  On top of the ECG, he was really hypertensive (220+/140+), and altered from the ETOH and his problems.

Naturally, he was transported Code 3.  Enroute the patient also received two NTG and .5mg of Epinephrine subcutaneously.  The trip went realtively quickly, and the PVCs subsided after the medications.  The patient’s color began to improve and he was more alert, although Lung sounds in the left lung remained non-existant.

Upon arrival, we transferred him to the ER and the Doc thought that he might have actually lodged a piece of food in the lung itself, thereby blocking airflow.  When we left they were preparing for the X-Rays and such.  Since then we haven’t heard back about the patient.  However, we are pretty darned sure that he would have gone into V-Fib and died within a few minutes had there been no prehospital interventions.  It was a difficult and challenging case, and I am glad it ended up as well as it did.