BLEED IN BLEED OUT

When the word INBLEED pops up on our screens as a call type it inevitably means the next hour of life is gonna be either messy and stupid or boring and stupid. This is because INBLEED is the kind of call you become when you tell 911 you’re bleeding out yer butt, so the range is from “I have hemorrhoids” to lying dead in a lake of blood. That was actually a job I had a couple years ago- start as a INBLEED, turned into an UNCONSCIOUS while we were on the way and then a CARDIACARREST when we rolled up. Sure enough, the landlord met us at the door with the delightful words: “He has HIV and Hepatitis and he just vomited up all the blood in his body and died.” Sure enough, the damn room was painted, floor to ceiling with bright red blood (bright red means it’s recent, dark coffeeground blood means it’s old. For what it’s worth) and there was a dead guy lying in the middle of it all.

Anyway, you basically treat a true internally bleeding patient as if they were a trauma: they need a big IV with lots of fluid going through it and they need to get to a surgeon ASAP, no time to play. But that’s really the very rare exception that shit turns out so dramatic. Most, like 90% of em turn out as

“yeah I found a streak of blood in my stool, wanna see?”

nope.

or “I just vomited and there’s some red in it.”

What were you eating?

“Cherry ice cream with beets and ketchup.”

Hmmmm.

BUT anyway, by whatever odd logic of the EMS gods was at work last Monday, we ended with 3 inbleeds in a row, spanning the whole range of madness. The first was a chick from a shelter who’d just had a little dab a blood here and there whenever she did a number 2 for the past three weeks. Ok, doo dee doo, let’s go. Second was basically the same thing but the guy tried to fake a seizure on the way out cuz he didn’t think we were paying him enough attention. Then the last guy- he made like he was alright, even convinced himself he was I think. He’d had a near syncopal episode (almost fainted) coming back from the bathroom and while he didn’t have any active bleeding, he’d been diagnosed with a bleeding tumor and a stomach ulcer. But the dude wasn’t showing any signs of crashing or even being shocky at all, no dizziness, wasn’t pale, wasn’t weak, his blood pressure was fine, heart wasn’t racing. Did you know when your bloodpressure drops your body realizes it and makes you thirsty so you can compensate the fluid loss? That’s why so many trauma patients’ last words are “can I have some water?” and then they die.

Anyway, this dude had none of that, and he wanted to walk, so we said alright, but kept a sharp eye on him as he stood. Halfway to the door, right in the narrowest part of the hallway, he went gray, flung his arms out to either side, rolled his eyes back and collapsed. Man…

The boyfriend starts yelling about how he always does this (!?) and why he have to be so macho, then their cat starts hollering and carrying on too, and meanwhile my partner’s passing me the IV line and needles while I’m making sure dude isn’t in arrest. It’s tight in here, mind you, like one person at a time tight, and the patient’s large and in charge, but fortunately, not dead. He still needs an iv though, so I wrap the rubber cord round his big ol’ arm and start feeling round for a plump vein, but there’s NOTHING, not a damn thing. He’s waking up now, talking bout –oh I feel better now I can walk? and his man’s like –oh HELL no, boo! And I’m like, dude- where’s your veins? But like I said, he’s fat and probably bleeding out somewhere deep inside, which depresses already hiding vessels. Grrr. Then to top it off, it turns out when I do take a stab at something, his skin is alligator thick. Like, you have 2 put shoulder into it to get the needle through, which sucks for everyone. So he’s screaming and yelling, the bf’s like “man up” in a startling about face from his earlier position, and my partner’s peering over my shoulder tryingto see if my IV any good or not. I push hard, break skin but get no flashback, no love whatsoever from those escondido mothafuckas. We try twice more but with no luck.

He still wants to walk, which is generous to our backs but unfortunately, not even remotely possible. Just sittin up he gets dizzy again, so we call for a backup truck, pull out the scoop and ease him onto it. Takes some serious heave ho’ing but eventually we get him hoisted up, down the skinny ass hallway and into the ambulance and then carted safely and happily off to the hospital.

STAND UP SIT DOWN LIE DOWN DIE

The next night, after lots of ridiculous little jobs (“my elbow hurts” and “I can’t find my psych meds!”) I was workin with newguy and we walk into a fancy Spanish Harlem apartment to find a little old guy, surrounded by gawking firemen, about to die. Dude was pale as shit, gasping for air, flailing his arms around like he was drowning and couldn’t get more than a word or two out. He definitely had fluid in his lungs, you could hear that raspy gurgling from across the street- the real question was his blood pressure. If you have fluid in your lungs and your pressure’s skyhigh, which is usually the case, it’s very bad- your veins are clenched up tight, you’re heart failing miserably and you’ll eventually drown in yourself. But if you’re ful of fluid and your pressure’s low: you’re fucked. Unless someone puts some dopamine in you quick it’s all over. It’s called cardiogenic shock. That was this guy. To top it off, there was no way for us to give him the dopamine, which tightens up your vessels enough to keep your heart pumping and your pressure up, because the guy had no veins at allll. Nada. I took one look and knew it wasn’t even worth trying.

Here’s the quandary with this situation: no blood pressure means you can’t sit up- any fluid you got needs to be pooled at your upper body, vital organs, so if you sit up it’ll drop to your lower extremities and you’ll die. That’s why people in that situation, including trauma patients who’ve bled out and internal bleeders, all get transported with their feet up, lying flat on their back. On the other hand, people with fluid backing up in their lungs can’t breath, and the last thing you want to do if you can’t breath is lay back- the fluid floods right up your airway and drowns you. That’s why asthma attacks and pulmonary edema patients lean forward in what’s called tripod position.

So here we have a dude with both: no blood pressure- it was like 80 over 50, and can’t breath, and he’s anxious, freaking out, won’t tolerate even the oxygen mask that he so badly needs. So we have the scoop to lay him down in and the chair to wheel him out in but it’s a no win situation either way. He was in a sitting slouch when we got there, so I watch him sit up some and ease onto the chair. He doesn’t look much worse for it and I can tell that laying back further is increasing his agitation, and him getting more upset means his poor failing heart has to work even harder and will sooner collapse. I decide to chair it but have the fireguys walk along side with the scoop just in case he codes and we have to start doing cpr.

He’s spiraling down in the elevator, arms flailing madly like he might take off at any second, water rising higher and higher up in his lungs and everything seems to be going in slow mo, but not in the badass matrix way, only in the whytheFUCKthistakingsolong kinda way. Finally we outside, I toss partner my keys so he can set up the stretcher while I cart homeboy out. Firefighters are scurrying all around me in a frantic escort as I heave ho thru two sets of project doorways and out into the street. We do a quick 1,2,3 evaluation: dude’s still fucked, and then I jump into drivers seat and come up on the air to give the notification: 12xray (that’s our unit number) with a note to Saint Lukes.

I’m throwing into drive, restraining a hot seething curseout as the firetruck that’s blocking us in takes a few milliseconds longer than I want it to to get the f out my f’ing way.

-Go head with your notification, 12xray.

-we have a sixty three year old male, eminent cardiac arrest second to cardiogenic shock, blood pressure 80/50 heart rate 120 respirations 28 be there in 2 minutes.

In my rearview, I see my partner flittering around like a desperate little toothfairy in the back. He’s brandnew and truthbetold, I don’t think the patients gonna make it through the night, but I know the best I can do is get him to the hospital fast as humanly possible so he doesn’t have to get worked up by brandnew dude all by himself.

The *%#*&&#?!! Firetruck has pulled off now and I’m airborne through the windy upper west side streets, winding round the park, hauling ass along 110^th and screeching around onto Amsterdam. My sirens are having a temper tantrum, my lights playing rude games in red and white along the Chinese restaurants, coffee shops and saint johns cathedral and then we’re there, breathless, weary, but the dude’s still alive, if only barely.

He didn’t make it through the night tho.

KER-SPLAT

I was laughing cuz my partner was moody and not in the mood for trauma, but we had a student, and it was Sunday night in Harlem, so even without riding all over town trying to pick it up, the shit was flying our way. We’d already done a pretty low key shooting, no kinda clusterfuck just a straight forward once in the leg, dude was pretty much chilling in the doorway waiting for us and then we were sitting in Garvey Park, enjoying the firefly show when they sent us solo for a cardiac arrest on 110 and Lenox. Text said, MAN FELL OFFA BLDNG NOT BRTHNG NOT MOVING.

Now, lemme say that even when a cardiac arrest is just your regular everyday 200 year old in the nursing home type of thing, you still automatically get EMTs backing you up AND a slew of firemen and a conditions boss. This is because arrests take a lotta grunt work to deal with. It’s like any job but someone has to be doing CPR the whole damn time, and real CPR takes two people minimum to do. Then add into equation that the patients probably gonna be humongous and humongoloids as a rule only live on the top floor of buildings with no or broken elevators- it’s a production.

But even with this patient being skinny and obviously not on the top floor, another seta hands woulda really helped.

When we rolled up the fire dudes were there running around with the general melee of the building, which had emptied out for the spectacle. People were pointing and yelling- He on the awning, yo!, so we walked in the building, up a flight of stairs, down a windy hallway, through someone’s bedroom and out a window to the cement awning where we found our guy.

He had landed Wiley Coyote-style, face first, arms and legs sprawled out at impossible angles all around him. He was also about 60, skinny and frail and, most surprisingly of all, alive. Not only was he alive, he was talking, or groaning anyway. Mostly all he said was “ow” the whole time, but for an older dude who’d just eaten pavement from five stories up that’s not bad. Most guys like that we just put a sheet over.

Anyway, the bucketheads had brought their backboard up but we had a problem: the guy was facedown and had to be rolled to be placed supine on the board, but both his arms were shattered, loose like spaghetti, one of em with an open fracture, bone and everything out for all the world to see. To roll him like we usually do would’ve rolled his arm over and over underneath him like dough. Fortunately, he was slender and light, so we adjusted the arm, grabbed him all along his mangled body, supported his head and lifted him over his own arm and onto the board.

“ow.”

Then I climbed back through the window and we passed the board and dude through the window and out into the hallway. With firemen helping my partner get the guy out, i rushed ahead to the ambulance and set up our equipment. He was a trauma, so he’d need big IV lines and big bags of fluid. Because of the mechanism of injury he was likely to check out at any dang moment, so I opened up the tube kit and laid out on the little shelf next to where the patients head would be.

The door swung open and they loaded our guy in, sill moaning. He turned out to have a decent blood pressure- 130/70, and a heartrate of 70- that’s ridiculous. No one falls off a building and has perfectly normal vital signs, but who am I to complain? Either way he was still broken everywhere, and crush injuries like that can maintain and look normal right up util they don’t, and then the guy will just die.

So we lurch into motion towards Saint Lukes and find two surprisingly bulgy veins to put two bigass needles in and lots and lots of fluid and our man rolls into the hospital in the same vaguely shocked and irritated, broke ass way we found him.