In 2 Ze Bone!

Been on a little blog vacation- ok a bigass 1 actually- while i concentrate on some fiction but it's a slow ass night 2night and may actually have a second to knock 1 out.

I can't remember if I've been over the criteria for True Death on here yet, but anyway it bares repeating cuz it's morbidly fascinating and that is the theme of this blog.
If you die, the job gets entered into the system as a CARDIAC ARREST, which just means your heart stopped. Doens't matter if it happened today, yesterday or 12 years ago, you still have to get evaluated and pronounced and/or worked up by EMS. The other day we had a dude that died in a shelter, got pronounced by EMS cuz he was QUITE dead but never got picked up by the morgue so 3 hrs later they put the job back in the system hoping to get the ME guys 2 show up and take the body but got us instead. The bunk room was cleared out, all the guy's roomates standin irritably off to the side waiting to get back to bed, and lo and behold the dude was still dead- it was a guy I've had several times as a patient actually, a real ornery cat that always refused 2 go to the hospital no matter how messed up he was. There was nothing to do, because we don't take bodies to the morgue (usedto though) so we got back in the truck and went our way, much to everyone's disappointment.

Anyway, what is the criteria for being SO completely dead that we don't even go through the motions of trying to bring you back? There's 5:
Rigor Mortis, which is when the body becomes rigid, usually several hours after death.
Dependent Lividity, which is the pooling of the blood at the lowest point of your body and basically looks like a huge grimy stain.
Decomposition, which is....gross. And you can usually smell from a block away.
Obvious Death, which covers everything from splattered across the pavement to decapitation.
And having a Do Not Resuscitate Order, which doesn't happen nearly enough, in this medics opinion.

If you don't meet any of those criteria, we're gonna be intubting you, putting an IV in with load of medications and possibly shocking you and dragging you to a hospital while some grumpy fireman pumps on your chest. This lady we had the other day didn't fit any of the criteria BUT she was quite large and didn't have any available IV access. When you have a cardiac arrest with no kinda veins to put your meds in2 there is now one other option: the bone.

Right below the knee cap there is a flat plateau along the humerus. I place my fingers along it, pushing through layers of fat and muscle until I'm sure I have the spot. Lather it up with an alcohol swab and place the tip of a largeass needle against it, my hand gripping the blue plastic handle. Around me, the typical cardiac arrest chaos is swirling- partner intubating, EMTs sweating as they bounce up and down on that chest, nursing home attendants blabbering about how they just saw the patient a few minutes ago and everything was fine, lieutenant gazing at the lovely trees outside the window... I push the needle into the flesh, twisting in a screwdriver motion as I go. It slides in without much resistance till i reach the bone, then i have to push harder, put some back in2 it before the satisfying (yes I said satisfying) POP! comes and I know I'm in. The needle has entered the marrow. I pull out the needle, leaving the catheter in place and attach up the IV line, adjusting the flush to gush full blast, which will push fluid through to the bloodstream and give us the access we need to get medications on board.

We push our meds and when there's no response from the patient make a phonecall to our medical control doctors to get a Time of Death. We're wheeling the empty stretcher out towards the elevators when the lieutenant looks up from her window gazing: "You guys think that tree out there is fake? It's so pretty!"

DANCING W/ DEATH

I'm a little tipsy right now, which seems like the best time 2 write a blog about death.
Imma also tryn write this as quickly as humanly possible with minimal thinking involved cuz i suspect that if I even slightly overthink it, the shit'll come out all crapademic and corny.

Death isn't the tragedy, from where we stand, its the perpetual slow state of constantly dying that really sucks. I'll tryn explain:
I usedta work Transports- that's as opposed to 911. Transports means ur bussing the same sick and dying folks back and forth day in and day out btwn nursing homes, dialysis centers, crappy little apartments, ICU units...watching limbs rot off one by one, mental statuses decrease into total vegetation. THAT shit, is depressing.
It's also the polar opposite of 'Emergency,' which is why most of us got in2 the field, to deal w/ emergencies, right? Right.
We're good w/ the acute: u about having a heartattack? we got nitro to spread those veins open and keep the blood flowing. Not breathing? Here's a tube and some oxygen to keep things moving.
In 911, things move fast. Within a 45 min job, a patient can go from about to die to dead to back alive and kicking to dead again. Or vice versa. And that's when we are most alive, jumping in and out of protocols, stepping back to assess and reassess, checking in w/ each other, staying light on our feet, planning thinking moving working...
What it comes down 2 is this: Trauma lives in the body. They say it again and again in all the books and lectures, but what does that really mean? It means that when your body is all up in that trauma, when you are literally entwined with the heart and lungs of the patient, connecting IVs to veins and plotting exit strategies and busting ass to hospitals, the experience of someone else's effed up situation is completely different than when u are walking by, helplessly witnessing it.

This is why we sleep at night. Because whether the patient makes it thru ok, ends up a vegetable for life or dies completely, we have played our part, added our small piece to the puzzle of their survival, with the knowledge that we do what we do and the rest is in God's hands.

THE WANDERER

She’s 42, passed out on the floor in her own vomit and barely breathing.
Damn seems like all my blogs start this way…I have one about to happen about dealing w/ trauma and death on the job but interesting shit keeps happening, so that’ll be next weeks…
Annnnyway: she’s 42, etc etc etc has no medical problems and no signs of trauma. According to her husband, she just took a pain medication from the Dominican Republic- some ish I never heard of- felt itchy, groggy, puked, passed out. The itchiness speaks to an allergic reaction and the pain meds speak to a possible overdose; both could cause vomiting, syncope and respiratory arrest, but neither is a sure shot answer. First of all she’s not covered in hives, in fact there’s none at all to be seen. It doesn’t sound like she took enough to OD though, unless she had something else on board, which the husband swears up and down that she doesn’t. So, the EMTs are giving her ventilations, my partner sets up his tube and I get the IV ready. On our EKG monitor she’s a normal rhythm at a healthy 60 beats a minute, she’s breathing intermittently, only barely, and occasionally moaning and writhing.
You don’t see the best veins for sticking a needle in, you feel them. They bounce gently against your finger in a way normal skin doesn’t. When you have a somewhat plump arm that’s not showing you anything vein-wise, you’re usually better off going by touch. If you know the body you know where to look: usually at the little depressed area along the wrist, just below the thumb or on the reverse side of the elbow are the best spots. On a really tough one, sometimes you can get lucky with a little veins swirling around the knuckles. This lady’s got some flesh to her, but my finger bounces off a nice one running along her forearm and the needle goes in with no trouble.
I push 2 mg of narcan, which will block her opiate receptors and break her out of an OD. The EMT tells us he can’t hear her blood pressure so I hang a large bag of fluid, run the line through and attach it to her IV. At this point, my partner decides to intubate. I’ll be honest, it wasn’t the move I woulda made. It wasn’t wrong either- she was only barely breathing and she had vomited so her airway was definitely compromised, and the best way to secure a compromised airway is to put a tube in it. On the other hand, the EMTs were moving pretty good air into her with the ventilations and most of all, when they tried to put in the plastic piece that slides into your throat to help the air in, the patient gagged. If she gagged on a little piece of plastic at the base of her tongue she was def gonna gag at a tube reaching all the way into her lungs. Also, if she was an OD, the narcan will bounce her out, and the last thing you want to do is wake up in withdrawal, puking and with a tube down your throat.
She gags on the tube, pukes again and then her heart rate drops from 60 to 50 to 40.
“Shit.”
The EMTs go back to giving ventilations. Her oxygen saturation is fairly high but she still has no pressure and now her heart is waaaaaay too slow. I push an amp of pure sugar into her, just in case she’s a secret diabetic or somehow dropped her glucose level, and then some more narcan. Nothing’s working. Generally, when young, healthy people’s heart rate’s start spiraling down its because of a respiratory issue, but also from stimulation of certain nerves, which I’ll get into in a minute. As long as there’s no underlying situation keeping their rate low, a few minutes of good solid ventilations should bring them up to speed, with or without a tube.

We start packaging to get moving, keeping an eye on the monitor. She slips up to 48, 52 and then falls back to 44. We musta looked like we were watching a sports game, the way our eyes followed those numbers on the EKG. My partner and the Lt on scene wanted to push atropine, a drug that suppresses the body’s ability to slow its heart but I wanted to give another minute or two to let her resolve herself before we shoved any more drugs in her. Atropine’s no joke, and if you give it too slowly it can actually do the reverse of what it’s supposed to and drop her heartrate even further, which would definitely kill her. I drew up the medication to have it ready, we lifted her up to the stretcher, explained the situation to the husband, sent someone to call the elevator up for us so everything was ready.
Her rate evened out at 42. I pushed .5 mg of atropine (quickly) and stepped back. Nothing happened. Then it went up to 50. Then 54. Long as it stays over 60 its ok w/ me. 58. Then 64. We all let out a sigh of relief and start wheeling her out. 68. In the elevator, the rate stays a steady 70 and our lady opens her eyes and pushes the oxygen mask out of her face irritably. In the bus, she tells us her name. By the time we in the ER she’s more concerned with how her husband will get home from St Lukes then the fact that she just basically died and came back.
“I was with it the whole time,” she tells me. “Praying. I could hear everything you were saying. I just couldn’t speak. I just prayed to the Holy Spirit to keep me around.”
So: wtf happened? I’ll tell you what I think.
There’s this nerve that runs from your brain down behind your eyes, past the back of your throat and into your heart. Because of its long, winding path, they call it the vagus nerve (as in vagabond, wanderer, vague, vagrant) . The vagus nerve slows your shit down. When you yawn you stimulate it, but most notably, and this usually happens to the elderly, when you bear down, like when dropping a deuce, you stimulate that thing like crazy. It’s called a vaso-vagal response and is responsible 99% of old people that we find unconscious on the can- they bare down, trigger the vagus nerve, slow their heart which drops their blood pressure and they pass out.
Probably, our lady had a mild allergic reaction to the painkiller, which caused the itchiness and nausea. She vomited, vaso-vagaling herself out. When the EMTs arrived and put the plastic piece in to keep her airway open, she gagged, stimulating the vagus even more. Then the tube added insult to injury, PLUS the painkiller may have already been boosting her parasympathetic system, which keeps everything depressed. The result: respiratory arrest, no blood pressure, unconsciousness, low heart rate.
Of course, it’s easy after the fact, when husbands and lieutenants aren’t running around screaming and women aren’t not-breathing on the ground in puke, to see all that clearly. What the job presented, much like the dude last week who coded, was a fluid, ever-changing situation. As a medic you’re constantly weighing what your options are, what the consequences of each one is vs the consequences of inaction. There’s a million different subtleties in between over-aggressive treatment and doing nothing, and somewhere in there is the path to reversing an imminent cardiac arrest. In situations like these, when there’s no one clear pathology or treatment plan, it takes a cautious trial and error to proceed, which sounds iffy from the outside but ultimately saved this woman’s life.

SUDDEN DEATH

The guy is almost fifty, skinny and white, tatted up w/ Buddhas and Asian letters and all in all has the general affect of an angry teenage hipster.  He’s squirming and whining, and I’ll be honest, truly irritating the shit outta me and my partner. There’s a younger Asian girl there that he’s bossing around and that’s grating me even more. Also: there’s nothing apparently wrong with him. His pressure’s 158/90 his pulse is 70, he’s breathing regular, has no chest pain, no signs of trauma, hasn’t been pissing blood or puking excessively. Nothing.  That much is fine, we get patients w/ nothing wrong with em all the time. But this dude won’t sit up. Then when he does he’s slouched over so we can’t get the EKG on him properly. Then he wants to put his feet up even tho he’s in a chair and clearly can’t.
We being calm, mind you. The curseout I had waiting in the wings remained lodged in the back of my throat, even when the guy decides to lay down on the floor and starts grabbing my partner’s arm and screaming “Why won’t you give my something for my legs!? My legs are tingly! I don’t understand why you won’t help me!”

I was sharp w/ him, as I pried his hand from Mr. C, but I kept it basically cool. We lift him up, put him on our chair and cart him out. The Asian chick looks anxiously after us but doesn’t come with.

Ok. Reassessing as we wait for the elevator: he has no medical problems, no allergies, takes no meds. Has no complaint of pain beyond his legs feeling funny, but he clearly feels it when we pinch him to make sure there’s no nerve damage. He’s moaning still. When we told him we don’t give anything for funny leg feelings he apparently ignored us, cause he’s still asking for something. He denies any drug use, not sure if I believe him or not, but he’s alert, oriented to where and who he is, knows his birthday, etc and his pupils are normal.

Something happens between the elevator and the ambulance. It’s a subtle thing, very hard to describe if you’ve never seen it, but at some point, a small change in his body motion sets off little alarms in me. I can tell Mr. C sees it too, the way he eyeing the patient and then looking back at me. The guy’s still talking but his motion is more sporadic. His arms just flop loosely up in the air every couple seconds like he’s a marionette being jerked around by some sadistic puppeteer.

When we lift him from chair to stretcher there’s no question something’s wrong. He has enough energy to grab my arm and make it more difficult to move him, but that’s about it. And he’s talking less. When people who won’t shut up suddenly shut up you need to pay attention- (unlike the non-asthma attack having lady who was so busy cursing us out we couldn’t listen to her lungs, but we didn’t have2 anyway, cuz if you can curse us out w/out taking a breath for five min straight you aint having an asthma attack…)

At this point, I’m thinking hemorrhagic stroke and I’ll tell you why: The typical stroke, the one they tell you about in all those PSAs with the droopy one side of your face and slurred speech and can’t raise one hand- that presentation is more commonly for what’s called an ischemic stroke . Basically, a bloodclot is cutting off flow to one part of the brain, much like the way a heart attack works. But when the blood vessel bursts, either from trauma or high pressure or whathaveyou, its called a hemorrhagic stroke and you’re head fills up with fluid, increasing your intcranial pressure sometimes to the point that the brain tries to escape through the hole at the bottom of your skull. These kinda strokes don’t often look like the other kind: the pressure doesn’t neccesarily go as high until later on, there isn’t always one sided weakness and one thing I’ve noticed time and again with these, the patient won’t slur their speech so much as speak in tongues. It’s like the way a baby will talk utter gibberish but with total conviction, and they look like they think they really saying something that makes sense, but they just saying “Blarga blarga blorp blaa! Blarg! Blegh!”  and so on. And they get irritable.  Now this isn’t all that different from the way certain people look when they drunk or hopped up on some bullshit, mind you, and so it’s easy to miss. (Diabetics when their sugar drops tend to moan more and are usually sweaty and cool to the touch.) The only difference is that certain something, a kind of lethargy that takes over that is really a grim late sign- the body is giving up.

When we load him into the ambulance he’s pale as shit, still mumbling and squirming but looking otherwise very corpselike.  I take a blood pressure while Mr C drops a line. Well- I try- but there’s nothing to hear.  A very late sign. The last thing I notice before I slam the back doors closed is his respirtations- his body can’t be troubled to open his mouth any more, so they come out in a rude snoring kind of way, all spittely and loud.

I jump in the front, let the hospital know we comin and blast off down Dekalb. When I open the back in the ER bay Mr C says: How fast can you set up my tube? And indeed, I see the patient has stopped breathing. His heart rate has dropped down to 40. I jump in the back, pull out the tube kit, throw him the laryngescope, which he uses to hold open the guy’s jaw and get a look at those vocal cords. I screw the syringe onto the little attachment on the tube and pass that over as the heart rate dips down to 20.

“Uh…tube quick he’s checking out.”

But Mr. C is no fucking joke with a tube, before I can count to 10 he’s slid the thing in, confirmed it with the stethoscope and I’m passing him the platic device that holds it in place.  The heartrate slides back up to 50, then 70. “Ok, we straight,” he says, but then the lines on the EKG go all squiggly. “He’s in V-fib,” I say, going for the pads and thinking if this dude takes one more damn turn for the worse… Before I get a chance to put the pads on the rhythm straightens out back to 50 and then starts dropping.

We load him out the bus and hustle him into the ER, yelling out the presentation to the docs as we go.  His heart’s at 20 when we wheel him in and stops completely as we reach the crash room, where they work him up for another half hour before pronouncing him dead.

Ok, a couple things w/ this job:

It startled the shit outta me.  I’ll be honest- it didn’t really bother me so much as it just caught us off guard. In the end we moved with what happened, didn’t get caught up in the tunnel vision and what it started out as vs what it became. It was definitely a solid reminder to stay flexible: even when something looks, smells and sounds in every way like a basic bs anxiety attack, some real shit can be lurking.

Was there anything we could’ve done to stop what happened? Nope not at all. What this dude had going on was beyond anyone’s capacity to stop. He didn’t show any hints to what might’ve been going on before he started crashing and once he did it was waaaay to late to stop. Plus, we have nothing with us that would’ve stopped it.

Sometime I’ll blog about dealing with death on this job, but that’s for another day.

A FAT GUY DAMN NEAR DIES

Some jobs you walk in and know exactly whats goinon and what’s gonna happen next and all the things you’re gonna haveta do etc etc. You can see the whole thing wind out in front of you like a damn roadmap, and you quickly fall into the rhythm and BAM it’s over before you know it.
This wasn’t one of those jobs.
A bigass dude, and I don’t mean big boned (all though he was that too) but Large and In Charge, looking a little worried and breathing kinda heavy. Our guy’s sitting on his bed in what’s called tripod position, leaning forward with his hands on his knees, puffing in and out like he just spent 20 minutes underwater. Still, I’ve seen much worse and he’s not blue, not lethargic, not gasping. At this point, could be a anxiety attack, a mellow dramatic head cold or a bad breakup.
He’s only 34 but has an enlarged heart- damn near the size of my head, the x ray later reveals- and i literally coulda crawled into his belly and taken a nap it was so effin huge, probably from the excess fluid buildup from his backed up heart.
When your ventricles are that gigantoid, they don’t work right. Sometimes they work so asscrappily that the blood doesn’t fully make it out and stays backed up, which causes the bodywide puffiness. That’s when the right ventricle backs up. When the left one goes the fluid ends up in your lungs, and that’s when you start drowning in yourself.
Neither of this dude’s ventricles were working well. You could hear the excess blood lapping up against his lungwalls, a rising inner tide.

Jumped into action. Checked his ekg (predictably fast but otherwise ok), found a vein and put an IV in. Put some nitroglycerin under his tongue to open up those tightly clenched blood vessels, lower that pressure some and get the blood flowing. Got ready to move.
Now there’s something bout moving patients that completely fucks em up. Even a relatively stable patient that we’re literally lifting up to put on the chair and carrying the whole way, no exertion whatsoever, can still end up like 5 degrees more effed up by the time you get em on the ambulance. It’s just the stress of moving, being moved, I suppose, plus the sudden rush of cold air when they get outside never helps. But it’s something you count on, so especially when it’s a dude like this, you treat a little aggressive before you move just to pre-empt the inevitable decline.
The problem was, this dude was getting worse and worse even before we started moving him. His mild discomfort had blossomed into a full blown freak out, which was causing him to stress his already taxed heart even more. The fluid was rising steadily higher and higher with each passing moment. My partner and i were doing the everything’s cool routine, without lying to him about what ws going on mind you, I’m just sayin we weren’t panicked, but there was no mistaking how fast we were moving. Dude was agitated.
So we get em on the chair but when I tell you I was eyeing it to see if it’d give out…Anyway, the other problem was that he lived DOWNstairs, which meant we were gonna havta heave him UP ‘em to get out. Plus he was in some weird basement complex, so we had 2 wind our way through a weird atrium, back into a building, over cracks and bumps and through a little tunnel b4 reaching the stairwell. And lemme tell you: the only thing worse than lugging hugeness is lugging hugeness that is freaking the fuck out and about to code. By the Grace of God we got to the stairs and then I swear it was like some serious epic shit, every single step. I was on the top part, yelling in Spanish at the patient “Tranquilo, papa, ¡calmate coño!” and a cop had the bottom bar, and he was just lookn copconfused and sweating. We heavehoe’d each step, letting out some real Neanderthal-ass grunts and there was a couple times i really didn’t think it was gonna happen but it did and we loaded him up in the bus and reassessed.
He was still bad, flopping and flailing bad, but not quite as bad as he coulda been. We’d pushed lasix earlier, which drains you out and makes you haveta pee something mean, and a few more nitros were working their way thru his system. My guess was that he’d make it (he did). Hopped in front, came up on the radio to let the hospital know were coming and what we had, drove the fuck off in a blur of blasting sirens and flashing lights.

DAPPER OLD DUDES GET DRESSED

Seems weeks run in themes. This week, for whatever twitch in the grand scheme a things, was the week of little ol’ dapper dudes. All three were more concerned with lookin’ slick than whatever medical issue may or may not’ve been goin on w/ em, but u know what? I really wasn’t mad at it. How could I be? After being around a swath of young people complaining about shit that wasn’t really all that bad or mommas worried about babybutt’s sniffly nose, a slowasmolasses geriatric dude with a wizened chuckle and mischievous glint in his eye is a welcome change of pace. Plus, old dudes like their apartments extra saunarific hot, so that extra 40 min on scene each time was like a freakin’ vacation from the brisk December wind.
One was tryinta make like he had something going on but really it was all about his appointment in the morning, and he was too old to be bothered with public transportation. He basically said as much 20 min into the job when we were all hangin’ out so he could put his jewelry on and get proper. While he inch by inched his way around the little one-bedroom on Lenox Ave, he explained that he’d tried to call the phone company to get his number changed cuz it had 666 in it (they refused) and how (oh wait, lemme just get my keys…) he’d lived in Harlem for 50 years and oh (hang on, not this vest, the other one, get me the red one…yeah) Daniel like from the lion’s den? Alright alright.
I blasted the old jazz station on the way to the hospital. I actually play it all the time anyway, but I played it extra loud so old dude could hear it in the back too, and he bopped his head and smiled his big smile all the way there. Of course, Mt Sinai gave him the grand welcome upon arrival: “Hey hey, Mr B, whats good?” “Whadup Mr B!” “He’s ba-a-ack!” Not even bothering to ask what was wrong this time, because obviously, like every other time, he was chillin.
Then there was Ol’ Joe, half dressed and aggravated in his swank Park Slope apartment. An ancient lady in a bathrobe let us in and then said, “Aight, Imma tellya whatall goin’on. Joe here and I been friends for damn near 40 years, and Imma tellya: Joe been prostitutin’ hiself again.”
“Uh…”
“Shaddup Margaret! It ‘aint true…”
“It is. I know it’s true. And thas why u can’t breath. Prostitutin’.”
“Um…can we focus on what’s wrong medically with Joe?”
“I’m just saying…”
“Quit yer sayin and help me put dese pants on!”
People: I honestly don’t know what the fuck was going on in there. And I wanted to find out, but Joe was gettn riled up with all the talk of his whoring ways. I think she meant he was going TO the prostitutes, rather than actually selling his own body, because, well… he was pretty frail, could barely make it across the room to put on his swank dress jacket and leather shoes, let alone earn his keep in a brothel. Anyway, we took his ass to the hospital and that was that.
Finally, there was the noise complaint dude. Said his upstairs neighbors call in a noise complaint on him every week, which I suspect may’ve been some kinda kick out the old play outta the gentrification handbook, cuz there was nothing in that aprtment to make any noise with. “I don’t see no drums,” I told him. “How you making all that ruckus?”
“I aint!” he said. “But I usedta play drums for Tito Puente, Joe Cuba, all the greats. Then I stopped.”
His walls were lined with photos of himself dapped up in slickass suits with pinky rings. Once he finished having his anxiety attack he was pretty cheerful and we hung out chatting for a while. The two female cops who’d shown up were yukking it up with us, and as we left Old Dude turned to the fine young one with big eyes and said, “Yo, ma, lemme getchya phone numba.”
We left before she answered, but she looked like she was seriously considering it.

GRAVEYARD WALTZ

Hey everyone- just published a short fiction piece about ghosts, graveyards and gentrification on this groundbreaking web journal, The Freezine of Fantasy and Science Fiction! Here's the link:

http://tinyurl.com/yact6yy