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.

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.

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 responded 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.

What! No Helmet ?

There is always additional adrenalin pumping through the blood stream when responding to a child hit by a vehicle. The tone sounded and dispatcher stated a child on a bicycle had been hit by a car in an area of town that is on far edge of our response district. I knew it would take extra time to arrive on scene. We respond to that area of town for fire alarms almost every shift rotation. Now a child is hurt and traffic is heavy. We can't get sloppy with our response and cause an additional accident, more injuries or worse. That will delay help for the child that's laying on the road now waiting for us. I know the child is frightened and if the parents are on scene time is dragging very slowly, it will seem like forever if the child is in serious condition.
We arrive to find a crying child laying on the edge of the street. I'm already relived...crying means mostly good things when it comes to children and trauma. After a quick glance over the patient my anxiety was mostly gone. I could see a probable fractured leg and a scared child reacting normally. 
The lead medic was talking to the child explaining what was being done and what would be done for him. I spoke to the mother and found out the child was not wearing a helmet, had no past medical history or allergies, was not taking any medications and the name of their family doctor. Information that is useful to the lead medic for good patient care. 
I grabbed the the vacuum splints while my firefighter held manual stabilization of the child's' leg. The lead medic was holding manual stabilization of the c-spine while his partner readied the ped immobilizer (a mini back board for children). I gently removed the child's shoe and sock on the affected leg. I then checked for capillary refill and a pulse before we wrapped the leg with the vacuum splint. Since the vacuum splint was introduced in pre-hospital care in 1993 it has proven to be a very effective tool for splinting and conforming to the body in a way that avoids impeding circulation or manipulating the bones unnecessarily. The child was then secured to the ped immobilizer and loaded onto the cot for transport. 
On the way to the hospital an IV was established and the child was calmed down. A lower tib/fib fracture and that was the extent of injuries. Hopefully a lesson learned by both the child and the mother. It happens fast so ware a helmet and remember cars can hurt, mam and kill.
It's always easier to sleep when you don't have to think about how a mother and/or father will deal with the loss of their child or how the driver of the vehicle that just killed a child is going to move on with their life. Both sides of the story are not the story book ending you see on TV or typically read in a book.

A Lovely Day for a Motorcycle ...Wreck?

The weather was clear and the temperature was warm. A beautiful day in the canyon, a beautiful day for a motorcycle ride. It appeared a lot of people had the same idea. I counted cars to motorcycles as we sped up the winding canyon to the call for help. There were easily four motorcycles for every car or pick-up truck on the road. Some riders with all their leather on, some with helmets, some with shorts a T-shirt and no helmet. I wondered what we would find when we arrived on scene. The call came in as a motorcycle wreck with injuries but that was all dispatch could get out of the caller. The approximate location was twelve miles from the mouth of the canyon and would take us about ten minutes to reach the scene due to the winding road and traffic.
As we rounded the corner we found a small crowd of people gathered on the side of the road. There were three motorcycles parked in the gravel and one bike on it's side with a man laying on the ground. We parked the engine on the same side of the road facing traffic and positioned to provide us some protection, just in case someone comes around the corner too fast and looses control. I verified with dispatch that law enforcement is enoute and let them know we would need traffic control. We grabbed our medical bags and rushed to the patient as my driver finished securing the engine and set out traffic cones. As we approached the patient we could see he was alert and talking to the other riders gathered around him. We began a rapid trauma assessment and found the patient was extremely tender on the left side of his pelvis. He denied head, neck or back pain and said he was wearing his helmet. The helmet had a few scratches on the face-shield but that was about it. A c-collar was applied and the patient was moved slowly onto a back board. After the patient was secured to the board and moved into the ambulance where his hip was exposed for further evaluation. There was bruising and abrasions and the area was still very tender. He was given some medication to help with the pain and transported to the hospital.
He told us,"when I came around the corner there was a van on the side of the highway and I slipped in the gravel". The skid mark on the asphalt was at least 75 feet long with gouges in the highway.

This is a lucky man!

Down and Out in The Man Cave.

Lights and sirens to the scene for the engine and rescue who are dispatched to an unconscious male found in the shop behind his house. We arrive and are directed by police officers down a long driveway that leads to the two bay shop behind the house. The engine company parks out on the street and makes hast to the shop. While the rescue pulls down the driveway, grabs their medical bags and goes inside to the patient. As I enter the shop I see a pickup truck in the first bay, it's hood is raised and the front wheel is off. I smell exhaust from an engine. There is an empty beer can on the grill of the engine compartment and tools on the floor. I notice a 50 gallon barrel off to the side with crushed beer cans in it, it's completely full with a few cans on the floor next to it that did not stay on top of the heep.I walk through the doorway into the other bay where the rest of the team is gathered around a man laying on the cold concrete floor between snow mobiles. The man has fallen down and has a laceration on the back of his head, there is blood and vomited on his face. He is very slow to answer questions and is disoriented, cold and lethargic. I asked the crew what I hear beeping near one of the medics. He tells me it's the alarm on the airway bag. I asked what is was reading and he told me it was at 360. That's the CO alarm we clip to the airway bag for just such an occasion. I directed one of the firefighters to open the roll up doors and I told the rest of the team "we needed to expedite this excitation we are being exposed to high levels of carbon monoxide". We placed a c-collar on the patient and rapidly rolled him onto a back board. He was strapped down and moved to the cot just outside the door. The patent was then moved into the rescue ambulance where oxygen was administered by mask, an IV was established and the heart monitor was applied. During transport the man was passively warmed with blankets and by turning up the heat in the back of the ambulance. We arrived at the hospital and gave report to the emergency room nurse. Meanwhile, the engine crew monitored the air in the shop until is was ventilated and safe again.
Indeed, we were being exposed to high levels of carbon monoxide. The patient was found to have blood levels of carbon monoxide of 35 and was flown by medical helicopter to a hospital with a hyperbaric chamber for treatment.
Carbon monoxide binds to hemoglobin, which is the principal oxygen-carrying compound in blood, this decreases the oxygen-carrying capacity of the blood and inhibits the transport, delivery, and utilization of oxygen by the body. The affinity between hemoglobin and carbon monoxide is approximately 230 times stronger than the affinity between hemoglobin and oxygen so carbon monoxide binds to hemoglobin in preference to oxygen. Treatment in the hyperbaric chamber changes that and the carbon monoxide is released so the blood can return to it's normal function of transporting oxygen and releasing it to the cells.