Right Before My Eyes

We were responding for an elderly female with breathing problems just before eight o'clock in the morning.  When we arrived we were led to a room in the back of the house where my patient was sitting in a chair unresponsive. She was moving her lips a little, drooling (her dentures were still on the dresser), and had pretty shallow respirations with no palpable radial pulse.  I asked the first obvious question of "Is she diabetic?" and was told by the family that yes she was.  Bingo, no problem. I quickly took a blood sugar reading and it came back well into the normal range. Oh, okay, time to start thinking and acting quickly. My firefighter had obtained vitals and had the patient on oxygen by this time. Her blood pressure was quite low and we weren't getting a very good reading off of the pulse oximeter (to read pulse and blood oxygen saturation).  She was completely unresponsive but was still breathing and had some purposeful movement. I checked her pupils which were smallish and not very reactive. The ambulance arrived and I gave them a quick rundown and suggested that we not muck around on scene getting the IV and 12 lead ekg but instead move straight to the ambulance and work there on the way to the hospital - I didn't like the way this was going. The ambulance crew went to ready the gurney and my firefighter and I picked the woman up and carried her outside to the waiting gurney and in so doing apparently killed her.

By 'we killed her' what I mean is, when we set her down on the gurney I noticed that she was no longer breathing and after a quick pulse check discovered that she was also pulseless.  She must have coded right in our arms. My firefighter had immediately headed back into the house to gather up our gear and clean up. I called after him to get the Lucas (CPR) Device but he didn't hear me. I sent the captain off to the rig to retrieve it while we started chest compressions and quickly loaded the gurney in the ambulance.

The captain and I climbed aboard the ambulance and put the Lucas on the patient and fired it up. At this point my firefighter arrived back from getting our gear and, not seeing us anywhere by the fire engine, popped his head in the open door of the ambulance. He of course had no idea that any of this was going on and was quite surprised to see that we were now working a full code in the back of the ambulance. He merely said, "Oh" and got to work helping us out. I wasn't able to get an IV so went quickly to the IO, easily screwing the needle into her tibia and got the line flowing. The ambulance medic got us a good ET tube and we were off to the races. I administered one round each of Epinephrine and Atropine and after circulating the drugs for a couple of minutes we stopped CPR for a rhythm check and found our patient to be in a sinus tachycardia (rapid heart rate) with a corresponding carotid pulse. A quick blood pressure check yielded results of almost 200 over 100 and her capnography (CO2) numbers were dead on - no pun intended. She still wasn't breathing on her own so we continued with the assisted ventilations but stopped the IV fluids and chest compressions. The hospital was only about five to ten minutes away so it was a pretty short trip. The ambulance had rung down the ER and told them what we had and the staff was waiting for us when we arrived.

When we moved the patient to the ER bed, the ambulance medic gave a rundown of the call, and before I left the room I heard the ER doctor saying something to the effect of "they did an excellent job" - rare praise from an ER doc. Five minutes later we were deconning our equipment outside by the ambulance when my captain came out and told us that our patient was now breathing on her own and had a BP of about 140 over 80.

This call definitely demonstrates the truth and importance of the Chain Of Survival:

This woman had no down time since she coded right in front of us, had immediate and proficient CPR, an advanced airway, IO access, and medications all within a matter of minutes after she coded.
I still don't know what the underlying cause was, although the ambulance medic said it sounded like she had fluid in her lungs, and I don't know if she will leave the hospital neurologically intact or if she will leave the hospital at all. But, leaving the scene with a dead patient and arriving at the hospital with a live one is a pretty good run for us.

Hello? Fire Department!

We had two distinctly different Life Alert calls this tour.  Most of the time these calls are accidental activations, requests for lift assist only, or minor injuries. Rarely are they serious medical calls.

Often people who have these monitors know enough to leave a hide-a-key for us or have a KnoxBox on their house.  A KnoxBox is a small box like a little safe requiring a fire department specific key to open it. They are usually mounted near the front door and contain a key to the house or business or what have you.

Dispatch will give us the key info on our update: "the key is located under the ceramic turtle on the porch" or "the code is 2742" or "the knox box is on the delta side of the building". Without these keys we would most likely be forcing entry into the house and doing damage.

This time it was the ceramic turtle kind. We found the key, knocked loudly and called out "Fire Department. Hello?" We got no response so we unlocked the door and headed in, again calling out loudly as we went. Still no response. We had worked our way back to the bedroom with the captain leading the way. From the doorway of the bedroom we saw a 90 year old woman wearing nothing but a shower cap, her back to us, inching her way extremely slowly out of the bathroom which was still steamy from the shower. We had been calling out the entire time and did so again from the doorway. Still no response. At this point we knew we were likely to terrify this woman when she finally turned around and saw us, so myself and my equally brave firefighter began backpedaling our way out of the room leaving my poor captain to confront the naked woman alone.

(But...you know...90. And with no towel.)

We retreated to the living room but heard no cries of alarm or objects being hurled - a good sign. This woman, though startled, responded rather calmly to appearing naked before a strange man who had entered her home without her knowledge. It was confirmed that it was an accidental activation of the panic button and we went on our way with only a sarcastic, "Thanks a lot guys" from our abandoned captain.


The second call ran much the same way but with the addition of the captain ordering us not to leave him alone this time. We got no response to our calls initially but found our patient down on the floor in the hallway pretty quickly. She was very out of it and was definitely having a medical emergency of some kind (possibly a seizure or a stroke). The ambulance had arrived right behind us and by the time we had made entry and found the woman they were on our heels. Although her eyes were open and she did not appear to have any obvious fall related injuries she could not respond to us appropriately and we got her going off to the hospital pretty rapidly. I never followed up to find out what had actually happened to her. In any case, we turned her lights off and locked her doors and returned the key to the KnoxBox.

I have run a lot more medical monitoring calls that turned out to be false alarms than actual emergencies. But when it is a true emergency those things are definitely life savers.

EMS With Staging

My firefighter was off on vacation and we got toned out for his favorite type of call:  EMS with staging.  Usually, this means that the police need to secure the scene before we can enter and do our jobs.  Sometimes, it involves a larger police action.  This time it was the latter.

We were called down to the waterfront, where we usually launch our boat, for a person with a gun.  We staged about a block away from the location they gave us and tuned into the police radio frequency to listen in.  An off duty officer had spotted this guy sitting on the rocks by the water with a pistol.  Turns out that where I parked the rig (facing a T-intersection) was dead ahead of where the guy was sitting on the other side of the water.  I busted out the binoculars and got a good view of him.  He was sitting down and not doing much of anything, at least from my view.  The police had a fixed wing in the air with a high powered camera on the guy and they could see that he also had a knife and was cutting at his arms and bleeding.

It took a while to discreetly evacuate the park next to where he was sitting and call in the police rapid response team.  That's when it got exciting.  An armored vehicle (BearCat), K-9 unit, and SWAT team arrived.  Suddenly there were armed men belly crawling over grassy knolls and taking up sniper positions.

We heard over the police band that they were calling for a PD boat from a neighboring jurisdiction to come to the Marina in case he went into the water.  There was no way we were going to have another agency pull someone out of the water in our Marina so we called for our boat which was literally just down the street.  They were suited up and in launch position in no time.

We got a report that this was a missing, at risk, young man who had posted a farewell/apology on facebook and was known to carry a BB gun.  The police action was in full swing and we moved our rig down to the command post, closer to where we could move in to help if someone got hurt.  Now that the park was clear, the BearCat and the K-9 unit started moving in.  The suspect started shuffling down the path towards them shifting the gun from one hand to the other and in and out of his pocket.  We were standing in a parking lot watching through the binocs as this all went down.  From behind the BearCat they told him to drop the gun.  I couldn't tell exactly what happened next but I saw him stagger back a couple of steps, flinch a couple of times, double over and then stand still.  They had shot him a few times with plastic projectiles (picture a solid nerf dart shot from a real shotgun).

They ordered him to remove his jacket and lay down which he did.  He was then cuffed and we were called in with the ambulance.

When we went to bandage him up, I expected to see some superficial, 'cry for help' type cuts on his arm (which there were) but he had also done a legit job of slashing his wrist.  That is, he cut deep and he cut up his arm, not across his wrist. That explains why he was shuffling, he had probably lost a decent amount of blood.  He also had some damn good welts from the non-lethal bullets they shot him with.  All in all the whole thing took about three hours and was pretty damn interesting to watch.

One of the most interesting things to come out of it, though, was what I learned later.  The K-9 officer is a friend and he comes by our station frequently with his dog.  The next day we asked him a practical question, "If you get hurt or shot on a call and we have to help you, will the dog let us?"  The answer was, of course, "No."  The dog will most likely be very protective and won't respond to commands.  If the officer can talk he might be able to get the dog to obey, otherwise, this is what he said we should do:  Go to his patrol car and grab the leash, then pop the trunk and grab the 'sleeve'.  One person holds the leash and gets ready to clip into the dogs collar.  The other person puts on the sleeve and gets attacked by the dog!!!

Yes, that is the plan. Now, as I said, this guy is a friend so if his life is in danger then that is what we are going to do, especially since the alternative is shooting the dog.  I'm just not sure how we will decide who gets which job, Rho-sham-bo? I'm the medic and will have to go treat the officer afterwards, so, maybe I shouldn't be the one to be eaten by the dog, just sayin'. Although, if it worked, that would be one awesome story.

If It Weren't For The Courage Of The Fearless Crew or Why You Should Always Monitor The Radio

                  

At my station we not only hear the departments fire dispatch radio for my battalion but, since we are one of the two rescue boat houses, we also monitor the Coast Guard hailing frequency.  I was on the front office computer placing an ems order when I heard traffic over the CG radio.  Now, most of what we hear over that channel are mariner notifications, vessels overdue, and other non emergency traffic as well as info for distant locales that aren't in our response area at all.  This time what I heard was an unexpected Mayday distress call, not from the CG, but from a capsized boat with people in the water.  A man and his kid in the water!  In the water in our part of the bay!!  My captain was walking by at the same time and as I started writing down the info he jumped on the phone to the BC to tell him we needed to respond.  We got the go ahead and quickly loaded the boat and took off for the marina.

We launched the boat and I came up on step, speeding down the channel.  I was able to do about 32-34 knots even though the water was pretty choppy.  As I drove, the captain worked the radios, and my firefighter got suited up to go in the water.  I was very grateful to have one of the regular water rescue captains that day since he had to listen to, monitor, and talk on three different channels: the fire radio (main channel and tactical channel) as well as the Coast Guard radio, responding to the BC, the CG, and the other responding rescue boat; very confusing.  We got such a jump on this call that CG was way behind us in their response plus they were coming from farther away.  The capsized vessel was reportedly a mile South of the bridge and it took us about 15 minutes to get there.  The waters really changed on me as I got closer to the bridge.  The swells dramatically increased to about 4 feet, the wind had picked up, and the tide was going out.  It was like being in a washing machine there for a bit.  

I was just slowing down to pass under the bridge when suddenly the CG helo flew over us and out past the bridge to try to get an eye on the vessel.

(Okay, maybe, it wasn't that dramatic, but it felt kind of like it.)  

I passed under the bridge and the captain grabbed the binoculars to search for the victims.  The CG helo was nowhere to be seen.  After driving on a bit further we spotted the capsized boat off to our 11 o'clock.

( Kind of like this but way more 'sinky'.)

A second later we spotted the pair in the water about 200 feet off of our 2 o'clock.  There was an adult male and a teenage female in the water.  They both had life jackets on and were clinging to each other and just bobbing in the swells.  I moved the boat toward them cautiously.  The swells were big enough that they couldn't even see our boat until we were almost right to them.  I stopped a short distance away and threw both motors into neutral and my firefighter went into action, "Swimmer in the water".  

He swam out and made contact with the pair and had both of them hang on to our flotation tube.  His plan was to swim them back to the boat but the current was just taking them all farther away and he couldn't swim against it.  I had to power the motors back up and circle around to where we could throw a rescue rope to him.  I put the engines in neutral again, we threw the rope and hauled them to the side of the boat.  The captain and I pulled the two castaways aboard and our swimmer climbed in after them.  The man and his daughter had been in the water for just about an hour, but other than being a little hypothermic they were fine.

We put them down in the cabin, gave them towels and blankets and water and cranked up the heater for them.  Before leaving to bring them ashore I drove us up to the capsized boat and marked it's lat and long position.  The captain radioed this info to the CG who would be able to come out with Vessel Assist and retrieve the boat.

Now, the title of this entry does not refer to my crew (though they did an outstanding job) but to the crew of the capsized boat.  The father, in this case, made a very difficult but excellent decision that probably saved both of their lives.  The seas got too rough for their tiny boat and they were heading home when they got caught in the swells.  Their boat began to dolphin, nose diving into the waves, and took on water faster than they could bail.  Eventually the whole thing went over sideways and they were tossed.  They were able to hang onto the boat initially but all their gear was jettisoned and was now at the mercy of the current, including the small bag containing their marine radio.  

They made the decision to abandon the boat and swim out together to get to the bag and the radio.  There was no one out on the bay that day and if they had not retrieved that radio they would have been doomed.  The other smart thing was that they stayed together.  If the father had swam for the radio there was no way he could have made it back to the boat against the current and they would have been separated.  So, I applaud him for not only being prepared but for making the right calls.

We delivered them to a dock across the bay, warmer and in good spirits (considering), where we were met by a fire crew from that city, two ambulances, a fire chief, a couple of cops, and a very friendly brown pelican who decided to join the circle of conversation.

                    

We said our goodbyes and headed back home at a slightly less hurried pace.  Once back in quarters we washed the boat, readied all the gear for the next call, and ordered ourselves a pizza.  Needless to say I was pretty excited to get my first real legit water rescue out on the boat and that it all ended well.  Makes for a great day at work.

Just Another Day - Typical But Good

So, here's just a slice of life in the fire service.  Nothing particularly dramatic or hilarious, but I had a good time.

I was working with a newly promoted captain who hadn't worked in my district before.  Right out of the gate at about 09:00 we got a medical call.  It was for a sixty something year old male with abdominal pain.  From the smell of the apartment his "medical" marijuana wasn't helping with the pain.  He was not in major distress in any case.  The ambulance was right on our heels so I pretty much got all the pertinent info and vitals taken care of and that was about it.  Once we got him sent off to the hospital, we began discussing amongst ourselves the layout of this apartment complex.  It had some pretty unique features and we spent some time planning out what we would do in the event of a fire in different areas of the complex.

We returned to the station, cleaned up the breakfast dishes,  and then I got my workout in.  Just before lunchtime the structure tones went off and I recognized the address as the same complex from the morning medical call.  The report was of black smoke coming from under the door of one of the units.  It sounded pretty legit and we had it all planned out from this morning so we were pretty excited.  There was no visible smoke when we arrived but you could smell it clearly.  It had the distinct smell of a 'pot on the stove'.  Now, a 'pot on the stove' doesn't necessarily mean that the kitchen isn't on fire, but it's usually not.  The captain and firefighter headed over to the unit with tools and an extinguisher.  There was no one home but the apartment manager was on hand with a key which meant they didn't get to break down the door (err...I mean 'have to' break it down).  I had my rig angled for an easy hose pull and had the pump running just in case when the captain confirmed 'pot on the stove' and that only smoke removal was needed.

 

This meant that the IC could keep the truck on scene for positive pressure ventilation and release the balance of the assignment.  It was a great dry run for us though, and really shows the importance of preplanning.

There was one minor medical issue from a neighbor who had hurt his arm hopping over the back fence to open the unit's patio slider.  I'm not sure if he was making sure no one was home or just letting smoke out.  In any case he refused service.  We talked for a bit with the neighbors and the apartment manager and passed out fire helmets to the kids (and some of the adults).  One of the neighbors brought out a bag of homemade chocolate chip cookies and gave it to the truck guys.  For as much ice cream and desserts there are at some firehouses it's funny to watch guys try so hard to get rid of sweets.  The truck guys passed the bag off to the second engine who then stuffed it into the jacket of my firefighter who wound up giving it back to the truck guys.  When the other crews had left and I was putting my gear away I found the bag of cookies sitting in my jumpseat on the engine.  Sneaky bastards.

The afternoon was spent catching up with the new captain and studying up on building construction.  We also went out on a medical alarm called in by a remote monitoring company - you know - I've fallen and I can't get up.  Turns out that's exactly what it was.  Our patient didn't have any medical issues he just couldn't get back up from the toilet to his wheelchair.  The firefighter and I each took an arm and helped him to his feet and hoisted his pants up for him and got him situated in his wheelchair again.  We wheeled him out to the living room and repeated the process to get him set up in his recliner in front of the tv.  Some people find the lift assist thing a pain but sometimes they are the best calls because the folks just need a hand and are usually very grateful and friendly.  Often those are the people we get to chat with and joke with and learn more about because we're not treating an emergency situation.

 A little before dinner time we got toned out for another medical call.  The dispatch was for a 'sick person'.  Can't get much more vague than that so I really had no idea what we were going on.  When we arrived we were met by a young Asian woman who led us to the kitchen where the family had apparently just sat down to dinner.  Still sitting at the table and looking distressed was an elderly man who was Cantonese speaking only and wasn't saying anything anyway.  The language barrier and the fact that the family didn't know anything about his medical history or meds or pretty much anything about him made the assessment a little challenging.  Most of his meds (that we found anyway) were cardiac drugs and I got enough info to determine that he might be having chest pain.  He was quite hypotensive and bradycardic.  I had my firefighter spike an IV bag and we were about to move him to the floor when the ambulance showed up and we decided to just move him straight to the gurney and treat him in the ambulance.  When we picked him up he began dry heaving and I thought for sure he was going to puke on us.  The good news was the nausea led credence to my diagnosis of a cardiac issue.  The ambulance requested a rider (a fire medic to ride along in case the patient codes en route).  As I hopped in the ambulance the medic was telling his partner that he was going to have to go for an EJ (that's an IV in the external jugular vein in the neck).  That's usually a last resort if there is no peripheral access.  I looked at the patients arm and even without a tourniquet on I could see a vein worth trying for.  I told him to hold off and let me try first.  I squeezed in beside the gurney, slapped a tourniquet on his arm, and slid the catheter into the vein.  With the patients legs up and some fluids going in his pressure and pulse rate improved.  The ambulance medic decided he was comfortable without the rider and I got to go back to my engine and home to the station.

We picked up Thai food for dinner and settled down with a DVD I had brought in on adventure travel by motorcycle.  We had one more medical call that night for a man with back pain and constipation as well as one more lift assist which came in around midnight (this time from the floor to the bed, a little bit tougher).  After that we went to bed and slept  until 7a.m.  Then it was time to get up and start day two of the 48 hour tour.  Like I said, it wasn't very dramatic, but it was a good day and pretty typical of a lot of our shifts.

P.S. - Just to continue with the day in the life theme:

I went home after a quieter day two on the job and arrived home about 09:30.  I normally have four days off after a two day tour but I was scheduled to work overtime on the last day of my four.  I was looking forward to my 72 hours off before 72 hours back on.  After putting kids to bed that night I got a phone call at about 8:30 pm.  It was work saying that an engineer at Station 51 had gone home sick and they had to mando me back in for the rest of the shift.  I made the mistake of answering the phone so there was no getting out of it.  Fortunately my gear was all packed in my car already in anticipation of my overtime shift.  I was out the door in about 5 minutes and on my way back to work.

The Terra' From Unda'!

The welcome and unique, though infrequent, tones for a water rescue sounded at about 11pm.  There was a vessel in distress with 9 people on board just a couple of miles outside of our marina and the water was too shallow for the Coast Guard to approach.  We jumped into our foul weather gear, loaded up Rescue Boat 41 and took off for the marina.  Rescue Boat 40 (smaller and equipped for towing if need be) and the BC were responding as well.


We arrived just before RB40 and prepped our boat for launch.  Details were still coming in from the Coast Guard as to the nature of the problem and the vessels position.  We got the lat and long coordinates and were advised that the vessel was now taking on water and there were no life jackets on board.  RB40 has a shallower draft and could tow the boat in if needed so they launched first.  We launched right after in case we needed to offload the people onto our boat or possibly pull them from the water.

 

We headed out of the channel right towards the CG vessel.  The vessel in distress was a couple hundred yards south of us and were heading towards the rocky shore.  They had been headed out fishing and had lost engine power.  I'm not sure how long they were out there because I don't believe they had a radio either.  They were woefully unequipped to be out on the bay.  The only thing they appeared to have had in abundance was beer.

RB40 made contact with them and determined that they were not taking on water or at least not much and would attempt to tow them in.  RB40 had their navigation electronics go out on them in the middle of the operation so we came along side and had them follow us back to the channel and into the marina.  As we came up to them and my spot lights lit up the rescued vessel it looked like we were about to assist a group of refugees enter our country illegally.  There were nine guys stuffed into a boat built for four or maybe five max.  They were so packed in there I don't see how they even thought they would be able to fish.  And if they caught something, where would they put it?  As I said, they had no business being out on the bay.  It did make for a great night drill on boat ops for us, so no complaints from my end.

And speaking of pretending to be nautical.  The most humorous part of this call actually did come from our end.  Our BC was on scene for the operation in the capacity of Incident Commander (from the shore).  This is good because he can help communicate and coordinate with the Coast Guard or assist in getting extra resources if needed.  However, he is not water rescue personnel and the operation is pretty much left up to the crews of RB40 and RB41 who have trained for this.  Even at that, when talking on the radio we use simple terms and plain text and don't try to get too nautical as it can just be confusing.  Once RB40 had the boat in tow and we were all headed back in, the BCs voice came over the radio, "Rescue Boat 40 - what's your tera frumunda?"  Myself and my crew all just stared at one another in disbelief saying simultaneously, "What did he say?"  Meanwhile the captain aboard RB40 came back with, "I have no idea what that means so I'm just going to use plain text.  We have the vessel in tow, no medical, and we are in the channel at Channel Marker 14."  It took a minute or two of discussion amongst ourselves to figure out that what the BC must have wanted to know was their ETA to Terra Firma.  Now, I don't know if this was meant to be a joke on his part, but it certainly became one.  It would have been confusing regardless since he left off the ETA part of the question, (Hey good buddy, what's your terra firma?  Uhhh...I don't know...Earth?) but we don't even use terra firma in our terminology anyway.  I couldn't stop myself from laughing when my Captain went on the radio and reported that the vessel was secure at the dock and we would be Tera Frumunda in about thirty seconds.  Hopefully the Chief didn't hear me in the background.

All Hands Working

 
My captain for the day (there is currently a vacancy at my station) was in the shower when a call came in for the neighboring district.  I was working in the apparatus bay and didn't hear what the call was for.  The captain came out wrapped in a towel then headed quickly towards his dorm while calling out, "You guys want to go help them out?"  We asked what was going on and he said there was a code blue in the next district over, pretty close to the border.  As a medic, I usually appreciate an extra set of hands so we suited up and headed over to the address.

When we got there the first in engine, an ambulance, and a paramedic supervisor from AMR were on scene.  I kind of figured there wouldn't be any work for us or even room in the house for more people.  We made our way inside to find out if we could help anyway.  CPR was in progress, manually, and the Lucas device was still being set up.  The patient had an OPA in and was being bagged with a BVM.  There was still space in the room so I moved in and took up a position at the drug box and asked if an IV was in progress.  It wasn't but I was down at the patients feet and wasn't in a good place to try for one.  I gave my firefighter the IV bag and he flooded the line while my captain picked up the clipboard and started scribing.  I started setting up for an IO just in case and got some meds ready.  The ambulance medic made one attempt at an IV in the arm but the vein was blown.  I immediately drilled in the IO and started passing meds to the other ambulance medic.  While we were establishing the IO the original engine crew was getting the patient intubated and securing the tube.  We pushed a couple rounds of drugs, shocked the patient two or three times, and packaged him for transport.  I started gathering trash and managing the pile of sharps (IV needles, glucometer lancet, medication vials, etc) as they got the patient on a backboard and out to the ambulance.

I can't believe that we fit all nine emergency personnel and one patient (and one family member who wouldn't leave) in one bedroom and kept all hands busy and productive without getting in eachother's way.  Amazing.

 

I don't know the patient outcome or circumstances leading to the cardiac arrest but, as for me, I got to do an infrequently used skill and the best part of all was I didn't have to do any paperwork.  Success.