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 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.

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.

I Don't Like Science Tests!

To the third floor of the business building on campus we respond for a 20 year old having a seizure. When we arrived the class room is empty of students except the one we're here to help. The professor tells us they were taking a test when this student started shaking and went to the floor. The patient is alert and oriented to time, place person and date and is now complaining of abdominal cramps and neck pain. The patient is not from this country and speaks good English except when answering certain questions, then she can't understand. We explain she needs to be scene by a doctor and should go by ambulance to the hospital and she agrees to being transported. A c-collar is applied and the patient is log rolled onto a back board with straps in place she is carried down the stairs to the cot. After the patient is loaded into the ambulance a detailed assessment is preformed, she is placed on the heart monitor and an IV is established. The lead medic calls the hospital and informs them we will be arriving soon and gives the RN on the line a patient report. Suddenly the patient decides she does not want to be transported. We explain the possible complications of not being evaluated by a doctor and the danger of further harm and even death as a result of this action. She insists and answers all questions appropriately. We have no choice because it's her choice. So after twenty-five minutes of work and hauling equipment up and down stairs, we put some clean sheets on the cot and tidy up the back of the ambulance. Ready for the next one!       

The Third Time...Really a Charm?

At about 2am we respond to ground level fall. We arrive to find an extremely obese elderly male who can not get up off of the floor. His sweet wife all of about 140 pounds, who has cared for him for many years, couldn't begin to lift her 380 pound husband from the floor. His legs and feet are purple from celluliteus and he is being treated by a doctor for it. He has lost about 100 pounds since my last visit when he fell in the tub and had taken a laxative to treat his constipation. What a mess. It seems to be the case, they are in a small room, a tight spot, in an older house usually upstairs or in a basement. This gentleman has huge laps of skin left over from weight loss, you always wonder what's lurking in them but never want to find out. It just adds to the difficulty of maneuvering the dead weight. We decide to bring his wheel char close and bear hug him from the back while my partner moves his knees then his feet under him until we get him in the chair. After his denial for any other treatment and a patient assessment we call the ER Doctor and gain approval for a scene release.
We return to quarters and crawl back into bed it's now 0315 and it takes a few minutes to winde down and fall back to sleep.
The next night the call came earlier. This time about 11pm a call to the same house for the same patient. He has decided his legs hurt too bad and he wants to be taken to the emergency room for treatment. His legs are a deeper purple and his feet are almost black. His wheel chair is too wide to get through the bedroom door so we move our cot into the hallway and carefully move him from the chair to the cot. That takes about 20 minutes because he is very unsteady on his feet even with our help he wants to move slow. Now comes the fun part. The hall way is narrow with two turns before we get to the front door. We only lift the cot about half way to keep a lower center of gravity as we roll it on the carpeted floor. We sit him up as far as he can tolerate so we can make the cot shorter and still the turns are very tight. I don't want to put gouges in the walls while trying to turn the corners so we very slowly make our way through them. Now the front door and down the  seven steeps with a landing between three and four, but don't think for a minute the landing is long enough for the cot to fit on. We had an engine company respond with us this time for extra hands. We four corner the cot (one person on each corner) and slowly move down the front stairs. The patent is loaded into the ambulance and transport is initiated. On the way to the hospital a set of vitals are found to be in normal range and the patient's condition is unchanged. Now we get to move him out of the ambulance and onto a bed. Again all accomplished with multiple people and lots of 1-2-3 go! He expresses his appreciation for our work and offers to make us brownies. A nice gesture but it conjures up some not so appetizing images of my first trip to his house. We politely decline and say good-by.  
I successfully predicted the next trip for our patient that was toned out at 0130. Now we pick him up at the emergency room and transport him home. Another trip up the stairs and through the tight turns of hallway and into the back bedroom. His good wife has changed the sheets on the bed and the patient is now resting on them. It's a work out but at least the man is appreciative of our help.
Back to the station to clean up and take a nap before the next call.

I'm Addicted but I don't Take Them!

We were dispatched to a possible diabetic problem. On the way across town dispatch advises us the patient has been feeling dizzy for the past few days. We arrive to find an adult daughter at the door who directed us to her mother who was on the couch. The patient was alert with normal breathing. As we continued to asses the patient we found her blood glucose level was slightly high but not concerning, she had some slurred speech and she had a decreased reaction time. Her vital sighs were in normal range and her heart rhythm was regular and normal, she was assessed for a possible stroke with no apparent indicators. The patient stated she was only on one medication for her heart. As I interviewed the daughter I began looking around my immediate area and found a prescription medication bottle that was for a popular sleeping pill, prescribed and filled only 18 days ago with 30 pills and was now empty. The patent was questioned about the bottle and she said she was addicted to them before so she doesn't take them now and only flushes them down the toilet. OK. She was walked down the stairs like a drunk woman and packaged on the cot for transport to the hospital. An IV was established on the way to the hospital and the patient was delivered to the emergency room without any complications.
It's a sad commentary for a woman with an addiction to prescription drugs, we will probably transport her again. 

A Little Boy, his Mother and a Secret

A little boy doesn't want to see his mother die. A young single mother calls for help when she contemplates suicide. We arrive on scene after the police have made sure the scene is safe. You never know when someone is thinking about committing suicide if they want to take someone else with them. In this case, a young African American women wanted to drink bleach to end it all. As it usually happens, most people need some encouragement to go to the hospital even though they called 911 for help. As my partner tried to reason with the patient and talk her into going with us to the hospital for help, I entertained her three year old boy with a puzzle and did some observation, looking for clues. Three year old little boys can make a mess with very little effort and this apartment was clean and picked up except for the puzzle and a piece of chicken the young boy was nibbling on. After the boy left the piece on chicken on the carpet and seemed uninterested in eating it I used a tissue from the kitchen counter to pick it up. I went into the kitchen to find a trash can to dispose of it and found an empty trash container under the kitchen sink. The woman had child safety latches on the cabinets and it was spic and span under the sink. I started looking around and the whole apartment seemed immaculate, every thing in order and clean. It seemed a little odd to me, a single mother with a three year old living in an apartment that looked like a model house. It's not unheard of, just atypical. My partner was successful in his endeavor and we began making preparations to transport her to the hospital. It was cold outside so, the little boy was excited and directed me to the closet to find a coat for him. I carried him out to the ambulance and he was strapped into the car seat. His mother walked out and was seat belted on the bench for the ride to the hospital. On the way to the hospital the young mother started to open up and talk. As she did, she told of an incident that happened a week ago. Two men came to her door and said they had a package to deliver to her. She was expecting something from her family that live out of our country. One of the men went to get the package and never returned while the other man proceeded to rape her. She had told no one of the incident until now. She was not physically hurt but the mental toll was more than she could bare. She was severely wounded and until now it had not affected her little boy. He was asleep in another room when the rape occurred, but now the ambulance came to help mom and the young boy didn't understand why his mother had to go to the hospital. He didn't know how close he was to becoming an orphan. She felt filthy inside, the bleach is a cleaner and there is no doubt she had been cleaning her apartment thoroughly for the past week. His mother was going to be alright, she would get the help she needed so she could deal with the pain. The police now have enough information, they will find the perpetrator and he will pay a price for his dirty deed. Bleach will not clean his insides ether.

100 Years and Counting

She took a fall in her apartment and called for help when she started having trouble breathing. We arrived and the First Responders were on scene. She is a frail lady lying on the floor thankful someone has come to help. We took all the usual precautions to protect her neck and back. My partner was patient man so he obtained a history while the rest of us obtained a set of vitals and secured her for transport. Her oxygen saturation was 85 so an oxygen mask at high flow was placed on her. It's funny to listen to people talk to elderly patients. The care givers tend to raise their voice and assume the patient can't hear them. They also assume the patent has never been to the doctor and doesn't know what a heart monitor is or a blood pressure cuff is.  I've found that getting a little closer to their ear and speaking in a normal tone keeps them calm and just seems more respectful. After all these people have been around the block and have most likely been to the doctor more than we have. I have a tender place in my heart for elderly people. I lost my mother to Alzheimers about ten years ago. It was hard to watch her dwindle way. As I listened to this patients lung sounds I found she had almost no air movement in the lower right lung. As we continued to gather information it was apparent she had at least one broken rib on the right side. Her lung was most likely collapsed, a pneumothorax, she could be in real trouble if it was left with no treatment. We loaded her into the ambulance and as we started transporting to the hospital I started an IV in her right arm. Her skin was very thin as would be expected with someone that is 100 years old. She was hooked up to the heart monitor and much to our surprise she had a text book normal sinus rhythm. As we made our way to the hospital I asked her a question that always intrigues me, "In the last 100 years,  what is the craziest thing you have seen?" Her reply was quite comical "The President's State of the Union Address last night." She didn't have to think about it and she seems very serious. We arrived at the hospital and transferred her care to the nurse. We bid her well and I went to clean and remake the cot.

I'm Off but I'm not OFF.

Today I 'm off duty but I have to go into the station to re-certify in PALS (pediatric advanced life support). Last rotation on we were busy running calls and I did not have time to get it done. Although, we did run some practice codes for adult patients. I will have to pick up a medication order before I go to the station. We are running low on a few medications and one of my duties is to order and inventory all of our medications. We have seven ambulances, two paramedic squads and four paramedic engines to keep supplied. So it begins.