STAKING OUT A POTENTIALLY DEAD GUY'S DOOR

Last night they sent us to some vagueness at Tracy Towers. By vagueness i mean the job just said "MALE DIFFBREATHER" and not much else. Gave an apartment number but the dispatcher came up to let us know the patient would meet us downstairs. Fine, that's always more pleasant than lugging 40 lbs of equipment up to some stuffy apartment. Thing is, Tracy Towers is this monstrosity of a project made up of many unmanageable somewhat connected ginormous buildings. There's ramps, tunnels, construction areas, elevators that only go to some floors, cross over bridges to nowhere. All the post-apocalyptic Wonderland features of PJs that make it hard to find anybody. So when we finally find the building we need, which involved going the wrong way up a windy-ass ramp and through a cloud of pot smoke, the dude's not there. A few cats are throwing dice in the parking lot, some ladies are smoking menthols on a bench and coughlaughing about the dudes throwing dice. A couple security guards are walking around looking more lost than we are.

We ask dispatch for a callback. There's some confusion. Fire gets called to take down a door that we haven't knocked on yet. The apartment might be A and it might be H, no one's sure. We shrug and hang around with the dicethrowers waiting for someone to make sense of this mess. Somehow, Fire gets on scene and up to the apartment without going past us, surely by going up another series of MC Escher stairwells, and when we show up at the apartment they're all irritated.
-We knocked on Apahtment A and they said they didn't call.
Okay, I say, well we have to...
but they're already in the elevator and gone before I can finish. Thing is, if someone might be sick or dead in apartment H, we can't leave. So we put in a call for the grumpy Fire guys to come back, which surely pisses them off even more and causes them to fake mechanical troubles or whatever, because what happens next is we wait. And wait. And wait some mo'.

A lieutenant shows up. Makes angry gestures and mumbles about Fire. Puts down his stuff and commences pacing with us after he makes some phone calls. Ominously, there's a tv blaring inside apt H but no one answering our incessant pounding. Stakeout the possible-dead guy's door time always becomes storytime, so we recount our other mishaps and victories, like the time some cop decided not to take a door in and they found a dude with his throat slashed in there the next morning.

We wait some more.

Eventually, Fire comes back and it is, predictably, a different crew. They take the door and inside we find an apartment that is almost completely empty except each room has a large screen TV blasting infomercials and Glen Beck at full volume. And the windows are open, a draft blowing the curtains around, givin the place a chilly, semi-alive feel. No body though, so we pack up our crap and begin to work our way back through the serpentine impossibleness of Tracy Towers.

GUEST BLOG!

Was so honored to be asked to write a guest post for The Rejectionist's blog, which i have been reading and enjoying for a while now. Here's a link: http://www.therejectionist.com/2011/07/special-guest-post-daniel-jose-older.html drop by and leave a comment! :)

3RD PARTY CALLER NOT ONSCENE

I was sleeping on the stretcher early this morning and the rain was falling in sheets on the roof of the ambulance. The job they woke us up for, sometime before dawn, sounded like either nonsense or a complete mess: "FEMALE 80 DIFFBREATHER 3RD PARTY CALLER NOT ONSCENE." that usually means someone somewhere doesn't know what to do with their grandma so they call EMS and say she's having trouble breathing and let us handle whatever family crisis was going down. Usually.
In this case though, the patient had called her daughter, gasped "I can't breathe!" and hung up. The daughter was on the way but when we got there it was 4:30 am and no one was answering the door. We buzz, call dispatch for a callback, buzz some more, wait. Nothing. Finally, the daughter shows up, lets us in and there's her mom, laying facedown on the kitchen floor. You can tell right away when a body's a corpse. It's not just that they're not breathing, there's something else; a total inanimate quality to a dead person that even the comatose don't have. She was quite dead, but had been alive at least 15 minutes earlier, so we brought her into the front room (because there wasn't enough space to work her up in the kitchen) and began CPR.

If you're gonna work up a cardiac arrest, the thing you really need that'll let you do your job is more hands. This is because CPR has to be going on throughout, and meanwhile you have to be starting IVs and intubating and pushing medications and all that, so really it takes at least 4 people to do it right, but preferably more. Since this job came over as a DIFFBREATHER and not an ARREST, it was just us. I come up on the radio to call for our backup, as I'm pumping up and down on this woman's chest, and nothing happens. No staticy reply, no other units chattering. Nada. My partner tries too and gets nothing. One radio keeps shutting off and the other gets no signal whatsoever.
Mumbling and grumbling and still pumping up and down while my partner gives ventilations, I call the dispatcher, but of course, the number i have in my phone still goes to the Brooklyn desk, and for whatever stupid reason they won't transfer me.
-i can give you the last four digits of the number you need, the dispatcher tells me helpfully.
How bout you go ahead and give me all ten?
-Oh, I don't know them.
There was a pause then as a million unfathomable curses swung through my head.
Meanwhile, I'm panting, and the phone is cradled in my shoulder and I'm trying not to let it slip and fall onto the patient and the daughter is watching from the kitchen, trying not to burst into tears.
-But I can tell you the first six numbers are the same as the ones you just called for the Brooklyn board.
what. numbers. are. they?
-Oh! I don't know. Whatever you called!
I think I growled at that point. Fortunately I had been repeating everything back to her throughout the whole conversation, including the last 4 digits that we needed, so my partner took out his phone and put everything together.
"We have a cardiac arrest and we need backup..."
In the meantime, I get busy with the IV, which involves doing a whole bunch of chest compressions, stopping to put on the tourniquet, a whole bunch of compressions, finding the vein, which is all the harder when someone doesn't have blood pumping through them, compressions, swabbing the site with alcohol, mad compressions, tearing open the plastic wrappers on the saline lock and the syringe, pushing saline into the lock and unwrapping the catheter, mad compressions, and finally putting in the line, compressions, and securing it down with tape. Whew. Fortunately, backup showed up right around then so I was able to go head and push the first line of medications without stopping every five seconds.

Amidst all this, I'm trying to explain, without being too grim or falsely hopeful, to the daughter that her mother is in cardiac arrest and what exactly that means. I do this because all too often, people believe the crap they see on TV with dead folks popping back alive every time someone bounces on their chest for a few seconds. Without obliterating all hope, I want the family members to understand the gravity of what's going on. It can get even messier when we're forced to transport the patient, for one reason or another, and then people really believe they're going to make it, when in reality they so rarely do. So, I'm panting away, holding the calmness in my voice, and the daughter is taking it really well, nods, seems to get it, although I do see the moment of painful realization flash across her face and for a second she looks like she's going to break but then she pulls it all together.

I start running the cold fluids, part of the new hypothermia protocol we do for cardiac arrests patients now that lowers the core body temperature with a flush of near frozen saline to preserve the tissues. But when my partner goes to intubate he finds the airway full of pink, frothy sputum. The patient had been in pulmonary edema, a fluid overload in the lungs. Pumping more into her at this point will only aggravate the situation that caused her death so we discontinue and move on to the other medications. 

At some point the daughter remembers there's a Living Will that specifies the patient doens't want to be resuscitated. Technically, we can only accept a true Do No Resuscitate order, but at this point we've already pushed all the first line meds and are ready to call the online telemetry doctors for a consult anyway, so I make the call, give the presentation and then let the doc know about the will.
The patient's been flatline the whole time, hasn't shown any change towards making a comeback and the will speaks for itself, so when the doctor asks if I'm comfortable pronouncing I tell him I am and he gives me a time of death.
And that's that.
We extubate, pull out the IV, slide a sheet under her and heave her onto the daybed in an adjacent room. One of her cats comes out to see what all the fuss is about and then somberly walks away. We close her eyes, tuck her in and leave her be.

It takes a while for PD to show up, again because the job didn't initially come over as a cardiac arrest, so I end up sitting at the kitchen table with the daughter, sipping water and chatting about life, death and cats. She's calmed down a lot, made a quick peace with it, perhaps to grieve later. Her husband showed up and took on the grim task of alerting her estranged sisters about the death of their mother. Outside the rain is still coming down and the sun is just beginning to rise.

GO TO PRISON OR DON'T SAVE YOUR BUDDY

Ok, that's not a real choice anyone should ever have to make.
I just liked the title and I chose it because people seem to think that's the deal. I'm here to dispel that myth.
Let me explain:
I was speaking on a panel this weekend for the Audre Lorde Project's summit on keeping Brooklyn safe for LGBTQ folks and it was pointed out that a lot of people have trouble figuring out who's the cops and who's not. This is very true- we all wear the same navy blue uniforms with many pocketed pants and have blaring radios and that self-important strut. It can be a lethal mistake though, because, as happened the other day, people are less than willing to speak to cops about things they really do need to be telling paramedics.

At daybreak we found ourselves in a shwank lower-east side condo looking down at a middle-aged hipster who was literally blue. When you're upset and trying to pretend you can't breathe to get back at your girlfriend or whatever, you turn red. When you actually can't breathe and are about to die or already did, you're blue. Elmo vs. Grover. This dude was blue, not breathing, out. While we start getting set up to put some air in him I yell over to his buddies: "What'd he take last night?"

Now look- it was kind of a formality, i admit. There's really only so many things that'll do that to you and most of them are heroine or some family of it. His pinpoint-ass pupils confirm that it's some opiate involved, but whatever, it's always good to ask.
"Uh," the friend yammers. "I mean, some beer and some weed, that's like it really."
The thing about a heroine OD that's awesome is we have this drug narcan that I've already blogged quite a bit about and it whups you out of that high so quick you don't know what hit you and go into withdrawal in the blink of an eye. It's not fun, but still better than respiratory arrest and death.
So, I'd like to think most medics would give that Narcan shot regardless of what dude's dumbass friends said, but the friends don't know that. For all they know, we'll swallow whatever dumb story they invent and be on our merry way while homeboy codes in the back of the ambulance. Of course they were all high as hell too and surely we were interrupting their pleasurable afterparty. As it happened, another medic on the scene DID go for their story (he was pretty new) but we talked him out of it and of course we gave the shot and the dude came back all irritable and groggy and 'Oh my god I just died' and all the friends gawked and we hauled the dude out and that was that.

The point is, EMS is not PD. Patient confidentiality laws prohibit us from telling cops anything pertinent about the patient, including what drugs they did to make them that way. If anything, you can usually take one of us aside, away from all the po-pos and have a word in private. Do that, because the alternative, letting your friend drop dead because you don't want to face too many questions, is much much worse.

TO TUBE OR NOT TO TUBE

The guy's ancient, all flaky skin and withered bones, body permanently contorted like a gnarly tree. Plus, he's in a nursing home, and quite frankly when we get any job in a nursing home we're surprised to find the patient alive at all. This fellow is indeed alive, but only barely. His lungs are gunked up with pneumonia, his blood pressure's low, his temp is high and his heartrate is all over the map. He's septic and probably has been for a while. Sepsis becomes lethal when the body feels so threatened that it opens the entire vasculature up nice and wide in an attempt to flush out whatever nastiness has entered. The blood pressure drops and the heart eventually gives up when it can't find anything to pump. It's similar to an allergic reaction but the patient's already in a weakened state and becomes febrile and lethargic.

To top it off, our guy had almost no oxygen saturation. That means the percent of o2 getting to his blood stream, which in a healthy person is upwards of 96%, was down around 82%. This number is complicated by the fact that he suffered from chronic lung disease, which keeps your sat numbers down even when you're not acutely ill. He's moving air, although not much, and his mental status is impossible to really gauge because according to the staff he's either agitated or vegetative but never makes sense. Right now, he's agitated and makes no sense.

So what we have is a decompensating patient. We have a few things we can do for him to keep him from checking out on the way to the hospital but really he needs lots of antibiotics and to have his position in bed changed more than once every couple days. To keep his pressure from bottoming out, we put two of the biggest IVs we can on him and start dumping fluid through them. This helps fill those wide open vessels and gives the heart something to pump.

His breathing though, is another matter. Even with a mask blowing high-concentration oxygen straight into his face, that sat is still hovering in the mid eighties. By some standards, that number alone would get the guy intubated but most medics know better than to treat a patient by numbers or monitor readings. The problem is this: intubation is an invasive, complicated procedure. When you do it on a live patient it often requires sedation, which means further depressing his respiratory drive and mental status. If he's far enough gone to be intubated without sedation, you still need to lay him supine, which is a bad position for patients struggling to breath, open his airway enough to see those vocal cords, wait for them to open when he takes a breath and then put a tube between them, all the while depriving him of oxygen. Either way, you risk stimulating the all important vagus nerve, which runs behind the throat and slows the heart rate. In such an unstable patient, vagal stimulation could easily spiral them into bradycardia and then death. Also, intubation comes with added risk of infection, especially in the pre-hospital setting.

Of course, a tube means a secure airway, and this patient's breathing is far from stable. Once the tube is in your pumping oxygen directly into the lungs. The question then becomes: is his situation unstable enough that it's worth risking tipping things even further with intubation or will he hold out to the more stable environment of the ER, where they have paralytics, other airway options, bright lights, non-swerving through traffic surroundings, etc etc...? Of course, it's case by case, there's no one answer.
I try to gauge how acute a situation is based on how the patient responds to our lesser invasive treatments, how the pathology changes in the short time we're one scene. A lot can happen in 10 or 20 minutes. Someone in Acute Pulmonary Edema, for example, can go from mild distress to having fluid filling up to the top of their lungs and coming out their mouth in a matter of seconds. Or it can take hours, days even. With septic patients, especially in nursing homes, it's particularly hard to get a good history because they're often not with it enough to tell you (and neither is the staff).
So you look at what you have. If I've been on scene for half an hour and the patient hasn't declined sharply I tend to cautiously put more aggressive treatments to the side. I say cautiously because an unstable patient is an unstable patient, so the tube kit is never far from my grasp.

My partner wanted to intubate this one. I see where he was coming from but to me, it was an unnecessary risk. I've seen medics go to tube very similarly situated patients and ended up pumping on their chest. We went back and forth a few times in that respectful, quiet way that you have to use when you're on scene and there's other people around. I had a sense that the patient wouldn't put up with much tinkering around since he kept pulling the oxygen mask off; we agreed my partner'd take a look and see how it went but not push it. When he went to open the airway, the guy slapped him across the face. Sometimes, the patient will tell you all you need to know about a situation. If they're messed up enough to consider tubing but strong enough to deck you, they'll probably make it to the hospital, which this dude did.

BEYOND MANNING UP: An NYC Paramedic Speaks Out About Men's Violence Against Women

When I first started in EMS, I was struck by how many domestic violence calls we got. Within weeks, it became a regular part of the night, just another bloody dispute amongst the asthma attacks, strokes, shootings etc... I'd like to say there was a moment that shook me out of complacency - the woman whose father had beat her so badly she couldn't open her eyes but she still wouldn't go to the hospital or press charges, the decayed body of a nameless girl we found wrapped in trash bags in the backstreets of East New York - but revelations don't usually come in single sudden bursts. It was a slow and painful movement towards recognizing that the everydayness of men's violence against women, the sheer normalcy of it, is the most insidious, dehumanizing part. That something must change.

They say that understanding privilege is a process much like accepting death - you cycle through a haze of stages from Denial to Bargaining to Blame and finally Acceptance. But of course, nothing's ever that linear. As the ugly truth about what men do played out in my ambulance night after night I got angry, I tried to separate myself from all that mess by holding tight to some concept of being a "good man," I tried to invent some perspective that would make it all a little more okay, make it make sense, rationalize it. My social scientist side kicked in and tried to fit it into some theories that'd water down all that blood but I kept going in circles, bouncing between all the stages, overlapping a few at once and getting nowhere.

Acceptance came when I finally shut up and listened to what women around me were saying, what they'd always been saying, what my own life was telling me: that the physical, mental, spiritual violence that men commit against women is so wrapped in the fabric of society that it seeps into our subconscious, poisons our relationships to each other and ourselves. It's a matter of life and death, not just because of the enormous amount of men that kill women every year but because of the lethal fallout of the patriarchal mindset, which asks us to make insanely unhealthy choices in the name of 'manning up.'

Even though it's the last stage, Acceptance is only the beginning of the struggle. I finally got to a point where I could put words to my process, make some more sense of privilege and responsibility than just being speechless or awkward, move forward. Fell into a collective of like-minded people of color working on intersecting oppressions - true, brave hearted people that I learned along side, laughed with and argued with and stayed up all night unfurling crazy plans with - and we started doing workshops in schools, churches and community organizations around Brooklyn.

We  used the Gender Box exercise that they outline in Beyond Beats and Rhymes, which looks at the way we play out stereotypes even today and what forces keep us in those boxes. We broke down how male privilege plays out on institutional and interpersonal levels and how white power plays on images of manhood to turn us against ourselves. We taught in Riker's Island and the District Attorney's office, spoke with judges, doctors, business people, priests and gangmembers, but mostly we worked with young black and brown kids, and this is what i learned:

Despite what we're told, people are hungry to talk about how privilege and power keeps us apart and holds us back. Young men know what's going on, feel the strain of what they're supposed to be, but our institutions won't give them the language of how to talk about it, how to make sense of it, how to survive. What we're left with is locker room banter and bad tv, an epidemic of crap media culture telling us how to be who we are.
This is what I believe: in our heart of hearts, men are not the monsters we've allowed media to make us. We are infinitely wiser, more compassionate and more complex than that. Fighting against gender violence really means ending patriarchy, which for men means finding that place beyond what we're told we're supposed to be, beyond "manning up," and becoming what we really are.

¡ECLAMPSIA!

I was working BLS this weekend, which basically means I'm lugging 30 lbs less equipment and they send us the stupid nonsense calls on purpose instead of by mistake. Except this one: comes over as your average boringass 'SICK' call, which can be anything from 'My nose hurts' to 'I'm upset.' This one was 23 year old female with headache. No further information. Fine. When we get there a dude's flagging us down from outside the building looking real urgent. "She's having a stroke or a seizure or something! Come quickly! Please!"

I've already mentioned that people love to hurry us along for even the lonliest little toothache or whatever, but as time goes by you can kinda distinguish between the guy that is just wants to someone around and the person who really and truly fears for their loved one's life. This guy was definitely the second. Then he mentioned, as we hustled through an outer open area and up some stairs, that his wife had just delivered a baby five days ago.

Now here's where any medic or EMT worth their salt should have the word 'eclampsia' dancing through their mind. Not as a definite, cuz we gotta wait till we see the patient and all that, but between the call information and the husband's story, you have a pretty textbook eclamptic patient. What it is is an obstetrics disorder where the blood pressure shoots through the roof causing blurred vision, massive headaches, edema in the extremities and sometimes blood backing up in the lungs. All that is pre-eclampsia, when the patient actually goes into a full tonic-clonic seizure it becomes eclampsia proper, which is gets its name from the Greek word meaning "shining forth."  It's rare we see even a pre-eclampsia in the field and rarer still to see a fully seizing pregnant woman, but sure enough when we walk in we find the patient just finishing her last convulsion and settling into a postictal stupor complete with snoring respirations, drooling, rolling eyes and occasional tremors. (I've heard varying reports but apparently it can happen up to 4 weeks after delivery.)

So, like I said, I'm BLS and don't have any medicines with me and really there's nothing worse than being at the scene of some magnanimous disaster and utterly helpless to do anything about it (See previous posting for more on that...) The family is going through all the motions of utter freakout, from screaming that she's going to die (her mom) to trying to shut the gloomy screaming lady up (her husband) to bawling and pointing (her nieces and nephews). The pregnancy wasn't high-risk, plus it's over, and she has no medical problems so you can see they were all taken totally off guard when she suddenly seized after complaining of headaches and blurred vision all day. I call for a medic bus to back us up and my partner and I start getting her ready to go. Baby's sleeping quietly in her crib the whole time.

The medics are waiting for us downstairs. I give the story as I'm fighting the stairchair with the lady in it over some bumpy pavement, praying she doesn't seize again and topple. We're on the bus and let me tell you, when I'm working BLS and medics show up I generally make it my business to be quiet and stay out the way, mostly because the worst thing in an emergency is three alpha medics yelling three different things. Plus, the guy working was a friend of mine and knows what he's doing. HOWEVER, just when it seems like we've fallen into the whole swing of the job and everything's moving along smoothly, he goes for an utterly different medication, Dextrose in fact, which would infer a treatment modality for a whole other situation than what we're dealing with.
"Wait!"
I really don't like doing that, especially when there's a student, another medic and an EMT all right there. The guy looked at me cock-eyed. I ran down the list of symptoms and watched it dawn on him. "Why didn't you say all that when we got here?"
"I did!" I had!
"Oh! I didn't hear you. And I figured my partner'da given me the story." She hadn't.
A moment went by where we all kinda looked at each other. Then I don't know if anyone said anything or what but we all just fell back into the business of treating the patient, now truly on the same page. Magnesium Sulfate relaxes the smooth muscles and can ease/prevent the eclamptic seizures. We also treat asthma with it and a rare form of v-fib called Torsades de Pointes. You have to mix 2 gms of it up in a 50 ml bag of saline and set the drip rate to deliver it over 10 minutes, which is a little project unto itself, so while the other medic is doing that I get on the phone with our telemetry doctor to get clearance to give the medicine.
Talking to telemetry can be an outrageous experience. There's a medic that you have to get through to actually speak to the doctor and he's always angry about the fact that he's wasting away in an office while you're out there having fun in the street and he always manages to find something to pick a fight over. I brush through him as quickly as I can, doing everything possible not to take the bait of his irritability. Then some absurd pop song comes on, because I'm on *&*&#^#*! hold of all things and finally the doctor gets on. I spit the situation out quick to him and make it very clear with my tone that I know what I'm doing, because certain doctors enjoy verbally shredding medics when they smell uncertainty. "Alright give the mag," he mumbles, hangsup and returns to his cave.
When I get back in the bus I see the medic has asked the student to draw up the 2 gms of Mag, which he's done, but now he's got the syringe full of medicine and is reaching for the patient's IV, about to mainline it. I can't say for sure that his would kill her, but anytime you dilute a medicine in saline and drip it over 10 minutes it's for a reason. Both me and the other medic yell "NO!" and lunge at the student who realizes his mistake and cringes. We gank the syringe from him. "Sit down," the medic says.
"But..."
SIT.
he does.
We put the mag in the bag and I hop in the driver's seat while they set the drip rate. Get on the mic to give our notification as I peel off into traffic. She saves her last seizure for when we roll up into the ER bay, which makes getting her out of the bus and into hospital but we eventually manage and the doctors swirl in on her as we yell out the story once again. After some messiness, they break the seizures and she's sleeping quietly when I leave, her worried husband holding her hand and shaking his head.