AFTER

A lot of my posts end with some variation of this: "And then we zipped off into the night..."

Right. That's because that tends to be the moment when our active part of the story ends. But what happens after all that frenzy? On the way, we're keeping things in order, check and rechecking things. Often we're climbing over each other, grabbing whatever hand holds we can while the bus screeches around a corner. Sometimes there's a cop back there, looking puzzled. We're taking blood pressures, making sure EKG leads are still on, squinting at monitors, maybe getting another IV. Jobs can be so dynamic: you can start with one kinda mess and wind up with a whole other one in a matter of seconds, and the body has so many ways of reacting to trauma. Sometimes a seizure is a seizure, sometimes it's a sad grasp for attention, sometimes it's the first moment of cardiac arrest. People turn so many different colors for so many different reasons.

Then we finally pull up to the bay, the beep beep back up and the bump against the tire holders. There's a final scramble to get everything disconnected and loaded onto the stretcher and then we flood inside, sometimes one riding the stretcher, pumping up and down on the guy's chest as two others guide it through the linoleum hallways into the waiting arms of trauma surgeons, interns and anesthesiologists. There's the hectic, fragile inbetween time, as the care for the patient goes passes from us to them, and their machines and protocols whirr into effect and we tit for tat back and forth, summarizing the past wild half-hour in a 30 sec soundbite (not unlike the elevator pitch, now that i think about it...)

Some doctors make a point of not giving a fuck. They talk over you, look away as you give the report, roll their eyes, ask you the same question five times. Even with EMS being what it is, still seems a hard concept for some doctors to grasp that, if we do our job right, a patient who was critical ten minutes ago is chilling by the time they show up at the ER. So sometimes we have to explain ourselves very explicitly, sometimes we do our best and then walk away shrugging. Other docs are extra EMS-happy, all up in our process, how'd it go, what was the apartment like, what did witnesses say, all that, which is great of course, more for the patient than anyone else, because some of those details can make the difference between life and death.

We step back while the hospital takes over.
You get curious - put so much work into getting someone there in one piece, you wanna know what happens. But I've learned sometimes it's better to step away. I've felt that rush of frustration when you know they're not putting their all in and things go sour. Watched situations spiral out of control, and there's nothing we can do from our end. So you step away. You watch, you learn, and then you step back, smile or shake your head, finish the paperwork and go get dinner.

This Week In Other People's Disasters

There's an ebb and a flow.
months and months will pass and you'll only bring in chronic neck pain, chest colds, the occasional migraine and the same five drunks again and again. A minor MVA will seem exciting. These are the months i want to quit and never see an ambulance again in my life. Then, just when you're starting to drop your guard and accept that you're really just a glorified taxi for the inept and accident proned and chronically vaguely unwell, some real ass shit goes down.
And while you're still marveling that anything worthwhile happened at all, it happens again. And then you're pivoting and splicing your way through a whole barrage of megacodes, epic disasters, medical mysteries and whatever other series of other people's misfortunes the world has to offer. Fun!

These past two weeks were in that vain. First a perfectly healthy looking fifty-year old just up and died for no apparent reason in the West 4th Street train station in the middle of the mid-afternoon rush home. So death became a spectator sport because let's be honest, who wouldn't stop and stare at such a sight: A team of firemen, EMTs and medics pumping up and down on the guy's chest, yelling commands, disagreements, possibilities, drug administration numbers, semi-coded curseouts, intubating, sticking in IVs, glancing at monitors...All that. The gapers irritate me, but the truth is i'd watch too.

He came back. And well he should've, young fellow like that, plus he dropped in public, which means everything happened fast and speed is everything in those situations. Still, you never presume someone will come through. Well, I don't. But yes, there was that bounding pulse at his neck and then we heaved him up four flights to ground level and loaded him onto the bus and lo behold, the pulse was gone. Crap. Did some shit, got things ready to move and enroute he came back, good strong pound pound and a solid blood pressure to boot and last time I checked he was still at it.

Then some dude who'd been coughing for like six weeks called from around the corner from the hospital because he was "coughing a lot."

Ok.

Then was the 40 year old that nearly passed out in a swank uptown bistro. She'd had a sudden bout of unfathomably intense abdominal pain ( did she say "unfathomably?" maybe not. But her face did. ) and when she went to the ladies room everything got bleary. She slid down the wall and we found her sobbing, holding her tummy and with no blood pressure at all. No blood pressure, unless there's a good healthy reason for it like you're an athlete or extraordinarily chill or a yoga master, is a very very bad thing. It usually means you're about to die. Your heart should be zooming at that point, to compensate, pumping as much blood as it can and if it's not you're really really about to die. So, her heart wasn't going that fast, another bad thing.
Why do people have no blood pressure? Either their blood vessels have suddenly opened up wide to fight off a perceived threat, like with an infection or a allergic reaction, or the heart isn't pumping right, usually this would be a massive heart attack or someone with a cardiac problem already in the works, or you're losing blood or massively dehydrated. Since she's not febrile or breaking out in hives it's not the vessels, and she's not having chest pain or a cardiac patient so it's almost definitely not cardiogenic shock, so we're left with the fluid. She's not visibly bleeding out, she hasn't been shot, so the bleed is internal. Usually, these are in the GI tract and they eventually find their way out in the form of blackish tarlike poop. No fun. Sometimes it comes out all fresh and bri...you get the point.
Anyway, ok, that's a good possibility here, but there's another piece of the puzzle to consider. The patient's last menstrual period was two months ago -- she could be pregnant. Anytime you have a hypotensive, almost passing-out woman with sudden onset lower abdominal pain and any possibility at all of being pregnant you pretty much have to assume she's having an ectopic pregnancy. This is when the egg fertilizes in the fallopian tube and then ruptures, causing massive internal bleeding. Which is exactly what happened with our lady.
There's not much we can do for that prehospital. We put a huge IV in to replace as much fluid as we can as fast as we can. We throw an oxygen mask on her, we lean her back and move fast, plowing rudely through the shocked diners and whispering waiters. We haul ass to the bus and then haul ass to the hospital and let 'em know what we comin' with so they have fluids and surgeons standing by.

Then some lady called for her grandad, he was having "chest pain", even though he hasn't spoken or moved any of his extremities since 1998, still, he was having chest pain. And difficulty breathing. And he had to go to the hospital. Right.

Then a slew of drunks. All familiar.

Then an old guy laid out in his own piss, squirming, moaning, writhing. Home Health Aid epically unhelpful, but still, he's a diabetic so we just go head and check his sugar figuring that'll be that. And it's low! So low the monitor just says "LO" which is great for him, because sugar is a thing we can fix up, so we do. Except then he's still not with it. And his blood pressure's insanely high, 240/130 or somesuch disasterness. This is all very bad. It means he's having a stroke and there's absolutely nothing we can do except move fast, and even in the ER they'll be pretty helpless because with stroke treatment, timing is everything and since we can't get a straight story from the HHA, who's probably high and definitely...not bright, we don't know the onset time. So, grandpa is basically on his own as far as healing. We package him up, drop a most difficult and delicate IV in one of the meandering little slipstream veins hiding along his forearm and go go go, knowing all the while the deal is basically done.

Dead Guy In An Elevator

maybe I should start having more chipper names for these posts... Maybe that'd be deceitful though. I dont want people coming here thinking it's gonna be all care bears and unicorns and then getting traumatized when people keep dying. Yeah, okay. *keeps title*

ANYWAY: job comes in as "MAN ACTING WEIRD, DIZZY IN ELEVATOR" and the address is an old people home on East 128th Street. Apparently by "acting weird" they meant "dead" because when we get there there's a crowd of geris staring at an open elevator door and inside there's a guy lying there on his back, dead. Well, damn near dead, I should say, because just as we roll up he takes one, final gurgly breath (gurgley? Gurgle-y? ...whatever) and then he's really dead. 

Oy. 

We gently, respectfully and very quickly drag him out because when you're working up a cardiac arrest the last place you want to be is in a cramped little elevator. We park him right in front of the door and start a round of compressions.

Now normally, i think i've probably said this before a bunch of times here but there it is, normally when you have a cardiac arrest they send two units so the EMTs can pump away at CPR while we get our advanced life support on, intubation and IV meds and electricity, but here since the job came in as "acting weird" they just sent us. So, there's a lot going on. I can't even tell you the exact order of things happening, because there's a few moments in there where your hands just move in automatic pilot, compressing the chest and tearing open packages and setting up IV lines and tubes and compressing the chest more and getting the oxygen tank and tube in order. At some point the elevator door opened again and a gaggle of elders was traumatized and then the elevator door closed and we pulled the guy a little further into the lobby.

We called for backup but they were still a few minutes out. The only other person around with less than a century of living was the security guard and he was about 12 with the wispy beginnings of a 'stache just starting to make an appearance at the edges of his mouth. 

I ask him if he knows CPR.

"No," he squeaks. 

"Well, time for a free lesson, c'mere."

I gotta give the kid credit: he jumped in even though he was clearly boggleyed at the whole situation. 

Push right here, I said, pointing to the sternum. Just like on TV.

He did some kinda timid, halfassed finger dips and I told him he had to put some back into it, which he did. The ugly truth about CPR is that usually if you're doing it right it means you're breaking some ribs, a dull crunching with a little extra give that you actually get used to pretty quickly, but probably less so when you're bar mitzvah age and have never done it before. 

Cardiac arrests always feel like you're fourteen steps behind, because every second that something isn't done yet is another second that the guy is dead and not getting the oxygen or circulation he needs. Still, it's not stressful in the way paperwork or organizing concerts or meeting deadlines is. You know you can only move so fast with precision, and you move just that fast. Yes you feel behind but once you've done em for a while you also know you're never nearly as far behind as you feel. It always starts with a flurry of movement: There're so many things that needs to happen right off the bat and then as shit falls into place I always take a second to step back and say out loud what's going on. 

75 year old male -- i mumble -- cardiac arrest, asystole on the monitor IV in place with cold fluids running and epi, vasopressin and dextrose on board intubated with CPR in progress for 10 minutes no change on monitor unknown history allergies meds...hmmm...

By this time the EMTs have arrived and relieved the anxious security guard just when he was getting the hang of things. I'm thinking we might have to call this one. There's no point in transporting a dead body to the hospital just so they can pronounce him there and he hasn't had any changes in his rhythm since we started. Plus he's old, and the older you are the smaller you're chances of popping back around after you code. I tell them to hold compressions and check a pulse. One of the EMTs is getting into it with the cluster of ancient onlookers, ("Keep it moving people, nothing to see here" riiiiiight...whether from Alzheimers, non-English speaking or just not giving a fuck, they all just stand there, mouths hanging open). She gives up and puts her fingers on the guy's neck and says "Oh! Pulse!"

We recheck and indeed, the man has his very own pulse and, it turns out, a halfway decent blood pressure to boot. Then things happen fast. They have to, because people don't necessarily stay back when they come back and we've already emptied half the med kit into this guy. We do a cursory wipedown/cleanup, load the guy onto the stretcher, careful not to pull out any IVs or disrupt the tube and take off in a blaze of screeches and lights. 

MEGACODE

Spoiler Alert: The patient in this post does not make it. I want to get that out of the way because there's some ups and downs in how it plays out and I don't want to put y'all through the emotional manipulation of wondering if she'll get through or not.

We show up on a DIFF BREATHER call and find a 70 year old woman flat on her back with no pulse. She's a dialysis patient and has pink frothy sputum lining her mouth so it's a safe guess she went into fluid overload from kidney failure and her lungs filled up, effectively drowning her. A FDNY chief has decided by chance to show up on the job with us and she has one of the Medical Control doctors along with her, so we have a physician on scene along with the Fire Fighters helping out with CPR.
This turns out to be cool and works in our favor because the Doc is actually very laid back and not trying to run shit - we're able to circumvent the annoying process of calling Online MedCon to get permission for certain medications. Sometimes, when too many authority figures and egos get on scene together there's an inevitable clusterfuck to be managed, but fortunately that wasn't the case here.

So we put our monitor on the patient to see what rhythm her heart's in. What we see looks like a regular old heart rhythm, a little slow perhaps but basically could be a perfectly healthy person. Except she has no pulse. This is called Pulseless Electrical Activity and happens because sometimes the heart has a little life left in it, just enough for the electrical impulses to keep flickering away but they're not getting capture with the actual musculature of the heart, so there's no beat, no movement to speak of, just a parade of ghost complexes marching past the monitor screen.
So we start CPR, i set up the intubation kit while my partner prepares the IV and the Chief gets the woman's basic information from her son. I'm trying a new technique with intubation, just a simple adjustment on how I grip the handle of the tool we use to open up a patient's airway but it works like a charm: I can see straight down her throat and the two diagonal white lines of her vocal chords open up in front of my eyes, a perfect view. I slide the tube in, we confirm it's in place by listening to her lung sounds and my partner gets the IV as the Chief comes back in to inform us the woman is a leukemia patient, besides the kidney failure.
We stop compressions, check a pulse and low behold, there it is, thumping away a little weakly but still: there. So we start setting up to transport her and are trying to check the blood pressure when she loses pulses again, we jump back into CPR, start pushing medications. When we stop the next time she's in Ventricular Fibrillation. Commonly known as v-fib, this is when the ventricles are just jiggling away uselessly, not pumping blood, not doing much at all but sending crazy wavy lines on the monitor. I charge up the paddles, an alarming wail climbing in pitch till it's a squeal, make sure everyone's clear and then shock - the patient's lifeless body jolts once and we start CPR again.
It happens again- four more times in fact, till we're all looking back and forth at each other like "Really?!" because v-fib is not a rhythm that tends to stick around. When you shock your effectively jolting the heart with the intention of restarting and usually it'll either come back as some living rhythm or just flatline out and that's that.
We've already pushed four different medications into her, meds to stimulate her heart, meds to preserve her tissues, meds to balance her electrolytes, meds to keep her sugar levels up, and now we push another that reduces the irritability of her cardiac cells to keep them from fibrillating. When we check again it's in an extremely rare form of v-fib called Torsades de Pointes (here's another Torsades case i had with a happier ending) which is actually quite beautiful, a spiraling double helix kind of pattern on the monitor and gets a whole other medication to try to tame it back to something healthier.
Nothing works.
After we shock her five times the squiggle steadies out into flat with only occasional, large messy blips. This is called idioventricular and it's the end. It means the ventricles have all but given up and are just sending a last, useless series of impulses out. We keep pumping the chest, keep squeezing oxygen into her, keep giving meds but finally the last squiggles pass by and the line is fully flat. At this point, the patient has been down over 45 minutes and we've given her every medication and treatment possible to keep her alive. It's a moment when a medic has to understand that the time has come, our resources are exhausted, we pronounce the patient and begin the careful process of undoing the past hour of messy interventions, pulling out IVs and unsticking the shock pads, finally lifting her lifeless body onto the couch and making her look as peaceful and presentable as possible for the family.

A HUGE DUDE LOSES HIS CHIN AND HIS SHIT

Apparently, this cat was talking on his cell phone and then, for no clear reason, ate pavement. According to the witness, he just dropped. When we found him, his mouth was around someone front step and there was a pool of blood and some teeth nearby. Securing his spine, we rolled him over, back boarded him, got him on the bus, took a better look. He'd somehow managed to slice his chin almost off -- it looked like the butt of a french roll of bread but it was still attached slightly so when we put the c-collar on the chin got flipped upwards and was resting on his mouth.
He was still completely knocked out when PD asked if we needed them and we said no thank you and pulled off and THEN homeboy decided to wake up. I was driving, but apparently his eyes popped open and he went right for the collar around his neck, Frankenstein style. Then, and this I heard along with probably half of the East Village, he said "WHAT THE FUCK!?!"
I pulled over the ambulance.
The dude I was working with is solid enough but we had a student that day, more or less the intern from 30 Rock, and the patient was easily 300 lbs and pissed. He had already unstrapped his upper body and was sitting up straight, swiping at the student and yelling "REALLY? YOU GONNA DO ME LIKE THAT? THIS IS HOW YOU GONNA DO ME? REALLY?" While the student just made little cooing noises and said "no, no, that's not how we did you sir! We didn't do you like that!"
The cops had been following us and when they saw me pull over they jumped out and we all rushed the back compartment. The guy had a big broken tooth grin on and he was looking back and forth at us with wide, uncomprehending eyes and giggling and repeating one of the above phrases like a damn Elmo doll on crack.
"Just lie down, buddy," one of the cops said.
"REALLY THOUGH? WHAT THE-"
'Lie down!"
You can't reason with folks when they're off the deep end like that. His chin was still flapping back and forth on his face and he was covered in blood and still grinning like an asshole.
Fuck it, my partner said, unimpressed. Just roll carefully.
And he was right. You're not gonna win coming at the dude, he wont' be talked into normalcy, and it'd take more than the two cops and three of us to wrastle him into any kind of submission. I rolled carefully and when we got to the ER and reeled him out he was still on that same shit, except now he was reaching into his mouth and trying to pull out shards of his own teeth.
With some struggle, we got him into the ER and thru to the trauma room, where the assembled doctors asked us: What happened to this dude?
I let him answer that question himself.

ON BALANCE & COMPASSION

We were held up in the ER for a while the other day, crossed the sacred 40 minute threshold that sends little alarms up and down the system computers, pissing off captains who send angry messages to lieutenants who in turn send angry and/or passive aggressive messages to us. But since we're in the ER, we don't get the messages, which come in on our onboard computer, so then heated lieutenants continue to get messages and fly over in their SUVs, full of wrath and indignation. This particular lieutenant came up on me all a-foaming and frothing as I was walking back to the unit to give an update.
WHY, he demanded, HAVE YOU BEEN IN THE ER FOR SO LONG!?
clearly he didn't want an answer, because no one who asks a question in all caps really expects anything but a blank stare. I presume. Because if you really wanted to know something, surely you'd ask it in a mature-type way, using your inside voice and whatnot. Surely.
WHAT EXACTLY IS SO IMPORTANT THAT YOU HAVE TO BE IN THE ER FOR FORTY MINUTES?!
As it happened, we'd found the patient unconscious and ODing with no blood pressure in an apartment full of men that claimed to know her but didn't have any information on her and told multiple glaring lies about how she ended up that way before disappearing completely and then locking us out as soon as we removed her to the ambulance, so we ended up spending a good chunk of time trying to explain the situation to some skeptical young doctors that didn't seem interested in such complications, and my partner was only now wrapping up the paperwork.
But that wasn't an answer that would get me very far, because what does any of that matter in comparison to the almighty power of numbers? The brass in EMS, in a sickly trickle down sort of way described above, is obsessed with numbers. Numbers make the EMS wheel turn. Period. You find occasional lieutenants here and there that still hang on to some interest in what's going on with the patient or whether or not one of us is traumatized or burnt out, but when someone with a light blue shirt is getting worked up, it's usually got something to do with blipping alerts on computer screens downtown and the corresponding tirade of messages from superiors.

ARE YOU GOING TO ANSWER MY QUESTION?! OR SHOULD I JUST GO AHEAD AND WRITE YOU UP RIGHT NOW!?
and honestly I was so surprised by how upset he was I really had nothing to say for a second. But then I just told him No, I didn't like his attitude or how he was addressing me and so I wouldn't be answering his questions. As he got all red and puffy another lieutenant swept in, one of the ones that seems to give a damn about a thing or two, and dismissed the first one sayin "I got this" and then the whole situation pretty much fizzled out: my partner finished his paperwork, I put us back in the system, life went on.

I said it on twitter and it stands true still, on a job with so many reasons to get worked up, I have no interest in giving time or energy to a person that can't control his temper over numbers. None at all. We who deal with actual people have to work every day to land in that delicate balance between caring too much and not caring at all. We all slide back and forth along that spectrum throughout our lives and careers and the best medics I know aren't the ones that cry for every patient (they burn out quick) or the ones that smirk and roll their eyes at every patient (they're already burnt). They're the ones that know how to measure out their compassion evenly, quietly, justly, sometimes with crass humor or a kind word, and without going overboard so they can do what they have to do and walk away at the end of each shift leaving the job and all its pettiness, hilarity and tragedy behind them when they go.