Wednesday, June 11, 2014

Man's Grave or Man-hole?

We respond to a call for breathing difficulty to find a lady who is lonely and breathing just fine. She denies having any chest pain shortness of breath, abdominal pain or a head ache. Her vital signs are within normal range. The primary and secondary exam is unremarkable. As the Company Officer I am monitoring radio traffic and hear a call being dispatched in our response district for a man unconscious in a man hole. I advise the paramedics on the ambulance that the engine is going to clear and respond to the next call. They can stay on this scene until they call the hospital and get a release from the emergency room doctor.
My engineer driver and I quickly clear the scene and respond to the call along with another ambulance from the downtown station. We arrive first to find the supervisor pulled the man out of the man hole and he is now on the ground still unconscious. We quickly assess the patient and find he has a pulse and is breathing. He only responds to painful stimuli and the supervisor advises us he was in the man hole using a gas powered saw. The only fresh air he had was supplied through a 1/4 inch air hose from an air compressor on the truck. He further advises us that he (the supervisor) went into the man hole to pull the other worker out. Both individuals are assessed using a sensor that reads blood CO levels through a finger probe. The unconscious patient has readings of 38-40% and the supervisor has readings of 12-18%.Supplemental oxygen is given to both patients with a non-rebreather mask at 15 letters per minute.

We now have two patients, patient A is unconscious and patient B has also been exposed to high levels of CO. As part of the scene survey we get a quick CO reading in the man hole, we stick a small tube into one of the small hole of the man hole cover and get a CO reading of 300-350ppm. A very dangerous place to be working with insufficient fresh air. As discussed in an earlier post, CO binds to the blood hemoglobin and takes the place where O2 molecules normally adhere. This means the blood cannot deliver needed oxygen to cells throughout the body including the critical areas of the brain, heart and lungs.
Patient A starts to regain consciousness but he is combative and uncooperative. After his supervisor explains he will lose his job if he refuses to go to the hospital he reluctantly agrees to go. He and his supervisor are loaded into the ambulance where oxygen therapy is continued and an IV is established for patient A. After arrival in the emergency department the doctor performs a quick assessment and sends patient A for hyperbaric treatment. This will speed the process of releasing the CO from the blood hemoglobin and allow the oxygen its rightful place. A close call that could have ended in a tragedy. A related post.

Wednesday, June 4, 2014

No Time, Under Where?

2230 hours should be time to wind down the day. A day full of training and business inspections. I'm in the shower and just got soaped up suddenly the strobe on the wall starts flashing and the station tones sound. Its a vehicle rollover on a curvy canyon road. Hurry! Hurry! rinse off as much soap as possible grab the towel and dry off while I'm running to grab my coveralls. No time for the normally essential clothing, zip up the coveralls and quickly pull on some socks over wet feet. Now I'm running to the vehicle where my partner waits. After pulling on my bunker paints, we're en route with very little delay.
The dispatcher's voice comes over the radio and declares there is a patient trapped in a pick up truck and extrication will be needed. We arrive to find the pick up truck with its driver side on the ground. After a quick and careful scene assessment I kneel down to find the driver's arm coming through the door window and moving. I start talking to the the man who declares his side hurts and his arm is pined under the truck. I continue my assessment by asking questions because I can not see the man yet. The ambulance arrives and one of the paramedics takes over patient care as my crew prepares for the extrication.
We quickly develop a plan and start by using stabilizer struts on the underside of the truck which now faces the canyon wall and another set on the top of the vehicle, which faces the river. This will prevent vehicle from falling over onto its top or back onto its wheels while we move the victim to safety, protecting the responders and the patient.

The next tool used are air bags specifically designed for lifting heavy objects at emergency scenes.  We stack two of these under the side at the "C" post (back corner) of the truck cab. Here is an example of how these bags work to lift.

 After the vehicle was stabilized one of the medics climbed into the top of the cab through the passenger window to gain access to the patient. This is an important part of helping the patient remain calm and assisted with the extrication from the inside. We slowly lifted the truck and the medics gently slid the the victim out and onto a backboard. The patient's neck was protected with a c-collar while he was strapped to the backboard and then moved onto the cot. On the way to the hospital the medics performed a detailed assessment, started IVs and oxygen treatment. With a mechanism of injury like this, the patient may have fractures in his arms, skull, chest, legs or internal injuries of the chest or abdomen. In this case, the patient was fortunate and only sustained rib fractures and minor head lacerations. A few stitches and some time in the emergency room for observation and he goes home, me, I return to quarters for a rinse and the clothing i didn't have time for earlier.     


Saturday, September 7, 2013

Falling with Grace or Without?

The tones sound for a man who has fallen from a two story roof. As the ambulance maneuvers through traffic the other drivers seem to intuitively understand this is a true emergency and they move to the right for the ambulance. Unfortunately, this is not always the case and just getting the ambulance and paramedics to the scene is a dangerous venture.

During the response, the 911 dispatcher relays the information they are receiving from the caller, it sounds like the patient is unconscious and bleeding from his head. As we arrive we find a man laying near the sidewalk next to his house. There are family members tending to him and they have a look of fear in their eyes. The scene is chaotic with blood on the sidewalk and the victim still unconscious as neighbors look on and ask if they can do anything to help. My partner moves into place at the patient's head and manually stabilizes the patient's cervical spine, I ask if anyone saw the accident. A young man comes forward and explains the victim is his dad and he saw him fall from the upper roof and landed on the garage roof. He landed hard and then rolled off of the garage roof and landed on his head on the sidewalk. The boy was crying and asks if his father is going to die. I hate these questions. I understand why they ask but the only response we can give is "we will do everything we can to help him" and then try to extend some kind of hope to the loved one with the most positive aspect of the patient's condition. Sometimes the only good thing to say is "he has a pulse" or "he is talking to me". If I say "he's going to be ok" or "don't worry he's not hurt badly" and the patient dies or suffers with chronic long term injuries I could have a lawyer knocking on my door asking what I did to change the patient's out come.

This patient is carefully rolled onto a back board with a cervical collar in place and loaded into the ambulance. While en route to the hospital a physical exam reveals the patient has a suspected skull fracture and fracture of the left collar bone (clavicle). Two IVs are started and fluid resuscitation is imitated as oxygen is given by mask. The patient begins to move and starts responding to questions about the event. He is confused but answers most questions appropriately. 

Later we find out the patient has a skull fracture, a fractured shoulder blade (scapula) and his clavicle is fractured. He also has an epidural hematoma

                 An Epidural hematoma is a type of traumatic brain injury (TBI)  where a buildup of blood occurs between the dura mater (the tough outer membrane of the central nervous system) and the skull. The condition is potentially deadly because the buildup of blood may increase pressure in the intracranial space causing delicate brain tissue to be compressed and the brain to shift. Between 15 and 20% of epidural hematomas are fatal.

Saturday, January 15, 2011

Triple AAA is not a Road Side Service

We respond to an Alpha level call for an elderly lady who is feeling sick.
The triage program dispatch uses helps to determine the level of response and resources needed to handle the 911 call. The cards go from Omega to Echo with six levels of response, Omega level being someone with no injuries they just need help. Like they slipped and fell but have no injuries they just need help getting up off the floor, an engine company would respond. An Echo level call would be a full cardiac arrest. In our city an engine company with three personnel and an ambulance with two personnel would respond. At least two paramedics would respond with the Echo call. 

My partner and I arrive to find an elderly man in the driveway directing us in. He leads us into a back bedroom where is wife is sitting on a chair next to the bed. I notice she is slightly pale and she states she doesn’t feel good. As my partner begins asking her questions I am listening to the answers. Her back began hurting about an hour ago and she did not sustain any trauma. She feels nauseous and weak. My partner is relatively new and we have previously agreed if any call we are on needs to have paramedic level care I will step in and take patient care. This is starting to feel like one of those calls. My partner turns to the patient’s husband and begins asking him about medical history and medications for the patient. I apply the heart monitor, automatic blood pressure cuff along with the pulse oximeter to the patient and assess her vital signs. This confirms in my mind, this will be my patient. Her pulse rate is 40 bpm, blood pressure of 84/40 and saturation is at 92% on room air. I apply oxygen by a nasal cannula and start asking more questions about the back pain, she indicates it to be on her right lower back in the flank area. She states it went up one side of her back and then back down the other side of her back and settled in her right flank area. She describes it as being “sharp”. I ask her questions to rule out a possible kidney or bladder infection. There is a high probability she may have a dissecting abdominal aneurysm, too many indicators to rule it out.
Since there are just two of us on the ambulance and an engine company is at least six to seven minutes away we notch up into fast mode. We load her onto the cot and into the ambulance. As my partner drives us to the emergency room I get an IV established and continue to monitor her vital signs. I continue to reassess her back pain and find it is now in the center of her back. As we arrive in the emergency department I discreetly advise the doctor of my strong suspicion for a triple AAA. We get her moved over to the hospital bed and she vomits. The ED staff ramp up their response to her as well. 

An hour latter while we deliver our next patient to the emergency department I follow up on this one and find they are still having trouble getting her blood pressure up and they still have not confirmed a diagnosis. The next day as I leave my shift for home I drop by the hospital to deliver some paperwork and follow up again, this time the expected news. She has passed on to the next life we call death.

 An abdominal aortic aneurysm is a localized dilatation (ballooning) of the abdominal aorta exceeding the normal diameter by more than 50 percent. Approximately 90 percent of abdominal aortic aneurysms occur below the kidneys, but they can also occur at the level of the kidneys or above the kidneys. Such aneurysms can extend to include one or both of the iliac arteries in the pelvis. Abdominal aortic aneurysms occur most commonly in individuals between 65 and 75 years old and are more common among men and smokers. They tend to cause no symptoms, although occasionally they cause pain in the abdomen and back (due to pressure on surrounding tissues) or in the legs (due to disturbed blood flow). The major complication of abdominal aortic aneurysms is rupture, which can be life-threatening as large amounts of blood spill into the abdominal cavity, and can lead to death within minutes.

Friday, December 24, 2010

Is that the Smell of Oxygen in Use?

 As we pull up to the assisted living center with lights flashing and anticipation for the smell that seems so common as you walk in the door, we breathe a sigh of relief.  There is oxygen in the air and friendly people to greet us.  The call is for breathing problems and a possible stroke and we are taken to a room  and find an elderly germen man sitting up in a soft chair with two care workers, a family friend and the patient’s wife all in a small room. My paramedic partner begins assessing the patient and finds him to be very lethargic and not answering questions. His airway is open and he seems to be maintaining it on his own. A field neurological exam we refer to as a Cincinnati Stroke scale is used to find he has some weakness in his left side. A blood pressure and pulse are taken and found to be normal. He is a diabetic, so a blood glucose is taken and found to be 137, not bad for a diabetic. I notice an oxygen machine in the corner and see a long tube with a cannula on the end. I ask the care givers if the patient is normally on oxygen and I’m told he has not needed it for the past few days. The patient is loaded onto the cot and as I move I can now see the heart monitor and notice the patient’s SpO2 is 84%, not good. I point this out to my partner who has been asking questions to the care givers and family. He hands me an oxygen mask and we apply it with 15 LPM. As we wheel him down the hall and load him into the ambulance we witness a miracle. The man begins to come around and by the time he arrives at the hospital he is talking to us and answering questions appropriately. Was it a mini stroke, a diabetic issue or something else? 

The symptoms of generalized hypoxia depend on its severity and rate of onset. In this case it may have taken hours or perhaps a day for signs and symptoms to be revealed. In the case of altitude sickness, where hypoxia develops gradually, the symptoms include headaches, fatigue, shortness of breath, a feeling of euphoria and nausea. In severe hypoxia, or hypoxia of very rapid onset, changes in levels of consciousness, seizures, coma, priapism, and death occur. In cases where the oxygen is displaced by another molecule, such as carbon monoxide, the skin may appear 'cherry red' instead of cyanotic.

Saturday, July 10, 2010

A Doll Falls Through the Window.

The neighbor said as she looked out her window across the complex she saw a doll falling from a window. She looked again and the doll was moving on the ground and she heard crying. She ran out and found a child on the ground below the second story window. The child’s dad called 911.
The call is toned out at the station; a toddler has fallen from a second story window.
Here comes the anxiety again. Of course it’s on the other side of town on a busy afternoon with plenty of traffic.
What’s going through your head as you roll down the road to another child in trouble? Knowing just days before another crew responded to a child that was killed in an accident involving a bicycle.
Is it our turn for the bad call?
Anyone in this business for very long has to take their turn, “please not today”.
Some people wonder when they hear an emergency responder say, “that was a good call”. You will never hear that in reference to a child that is really sick or injured. They are never “good” calls. Sure we all like to use our skills to help people but we don’t hope for tragedy to befall anyone. The “good” calls are the ones you can mitigate and make a difference in the out come, that’s a good call.
We arrive on scene to find the father leaning over the child who is lying on the grass crying, below the window she fell from. First glance and overall scene assessment brings a measure of relief. Crying and purposeful movement, on the grass not concrete, no obvious injuries, all brings a quiet sigh of relief.
Extreme mechanism for injury, so all the normal precautions are to be taken.
The screen broken and on the ground, I’ve seen this many times before. The child climbs on the bed, dresser or chair to look out the window leaning on the screen not realizing there is no protection. Out of the window the doll falls, sometimes from the ground floor but most of the calls we get are from the second floor or higher.
The child is secured to an immobilizer and transported to the emergency room. A follow up later that day revealed the child was virtually unharmed with a swollen lip and sprained wrist.
That’s a good call. 

30 Feet to Impact..

We’re dispatched up the canyon for a male that fell and is off the highway. We respond with technical rescue equipment and an ambulance not knowing how far off the road the patient will be or what kind of terrain we will have to cross with him. Even with lights and siren it takes us twenty minutes to arrive at the location on the highway where we need to be to access the patient.
A man stands on the side of the road waiting for us and ready to guide us in to the patient. I grab a bag of equipment and my paramedic partner grabs another bag and we follow the man up the steep side of a hill that is covered with thick trees. About forty yards up the hill, we find a collage age male lying at the bottom of a cliff. I look up at the cliff and recognize this climbing wall. I climbed this wall about eight years ago with some friends. It was not an easy climb. There are anchors placed in the wall of the cliff to increase the safety of the difficult climb.
As a climber ascends the wall they place a carabineer in the anchor and run their climbing rope through the carabineer so if they loose their grip and fall they will only fall a few feet. They get banged up against the rock wall but they should not fall to the hard ground below. When you are in the out doors safety should always be at the forethought, there are diverse ways to get injured. Climbing, repelling, hiking, spelunking (caving), rafting they all involve risk. In this case it turns out to be inexperience and lack of attention to detail.
The patient is alert and speaking in full sentences. This is a good sign after a fall of about thirty feet onto hard ground with rocks and not wearing a helmet. Yes, that’s right another lucky one. He landed about two feet from a huge bolder that would have surly cracked his head open like a watermelon. His complaint is his right foot and rightly so. It’s attached only by the skin around the ankle. Another tib/fib fracture but this one almost severed his foot off.
 I leave my partner and quickly get back down the hillside where the rest of the crew including a few chief officers, are just arriving. One of the officers asks me what we will need to get the patient down to the waiting ambulance. I tell him we will need to set up a lowering system for the stokes-basket and that our patient is not critical but has a serious fractured ankle. I grab the stokes-basket and give the other crew members some direction as to what needs to be done and head back up the hill. We use the stokes-basket to remove patients from off road areas. Shaped like a basket that an adult can lay down in and be immobilized while the rescue workers move them out of the back county, sometimes miles, to an ambulance.
One of the chiefs brings rope and equipment up the hill and starts setting up anchors for the lowering system while another chief helps my paramedic partner splint the ankle. One of the firefighters hold manual stabilization of the head and neck. I ready a bag of IV solution for one of the firefighters who is starting an IV. We administer pain medication through the IV. As the patient receives relief from the pain we roll him onto a backboard and secure him for the stokes-basket. He is placed carefully into the basket and lowered down the hill side. The basket is tied into the lowering system. Six of us hold up the basket and the chief gently lowers us all down to the waiting ambulance. The patient is removed from the stokes-basket, placed on the cot and readied for transport. The ride down the canyon was uneventful with repeat vital signs and reassessments.
He tells us that he side loaded an unlocked carabineer and that was the cause of the fall. I don’t say anything to him but I noticed when I removed his pelvic harness on the hill it was not secured properly. It didn’t fail this time but he will have plenty of time to learn the right way to lace it before he climbs again.
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