TB Or Not TB...That Is (Truly) The Question

Every once in a while in this job you get a scary moment. I don’t mean a fire or a threat of personal danger or injury, I mean a dark cloud, ominous, oh crap, scare.

We responded to a report of a patient feeling dizzy. See? Sounds ominous and scary already doesn’t it?

There turned out to be a few factors that added to the difficulty level of this call when we arrived. First, there was a bit of a language barrier. The patient spoke broken English but was difficult to understand. Secondly, his wife was of no help and after letting us in she disappeared to the living room which reeked of dog and unkempt living, which was the third problem.

The patient himself was in the family room using a walker to get around when we found him. He said he was feeling dizzy and I told him to have a seat on the couch so we could check him out. He tried to maneuver backwards to the couch but the walker hung up on something and he tumbled backwards, landing (fortunately) on the couch unharmed. Not a great start though.

Our evaluation showed that our patient was pretty warm to the touch although not truly feverish, he was dizzy and stated he had thrown up. While taking vitals and checking his blood sugar he coughed a little bit though otherwise he didn’t seem to be what we call “big sick”. He was not a great historian about his medical history or medications he was taking so the captain went to the kitchen to try and get some info from the wife.

Our ambulance company arrived and one of the medics went to join the captain in the kitchen to help sort out the medication question. At this time the patient said he felt sick and needed something to throw up in. We gave him an emesis bag and he began to vomit and cough into it. It wasn’t a copious amount but it was a decent amount of blood thrown up into the bag.

It was about this time that the ambulance medic came back in from the kitchen holding a pill bottle. He asked the patient what he was taking this medication for. It was a powerful antibiotic. It took a minute to sort it out but we finally determined it was for TB.

Crap.

So we’d been in a smelly house with a patient who was coughing and/or throwing up blood and NOW we find out he has tb? The ambulance crew put a mask on the patient and themselves to load him up for the trip to the hospital. We were already outside and away from the patient now but the medic came back to tell us he would call us from the hospital when they know the patients status so we can figure out what to do.

We rode back to the station in that charged eerie silence of worried people. Back at the station we began looking up the protocol for exposures and whether what we had would be something that would require testing or treatment.

We all went and took showers and shortly after that we heard over the radio that our ambulance was going “out of service - administrative”. Ohhhhhh that can’t be a good sign. We let the captain know what we had heard and after filling out the exposure reports we decided to head over to the hospital to find out where things stood.

The ambulance and crew were still in the parking lot and came to meet us right away. The first thing the medic said was “good news”. What? Really?
The patient was on antibiotics for tb but it was latent tb possibly from an old vaccine. He also had an unrelated GI issue that was causing the coughing and vomiting blood.

This was all incredibly relieving news.

The whole incident had taken place over the course of an hour or hour and a half but it was still harrowing. So many awful thoughts go through your head: health, family, career...where do they all stand? I’ve only had to be treated for a potential exposure once before in my career and that is one time too many.

That's What Happens When You Get Mandoed

Well, I suppose I was due. I hadn't been on a nasty wreck in a long time. It just doesn't happen in my district very often. So, of course, this happened when I was working a mandatory overtime. And even at that the rig I was on was covering in at a different station so I was out of place twice.

The call came in for an auto accident at an intersection quite a ways down a two lane road that led into a neighboring jurisdiction. It was reported that someone was trapped in a vehicle. It took a little while driving until we found the wreck.

As I pulled up to the scene we could see a chp officer yanking on the damaged drivers side door of one of the vehicles trying to get it to open. It appeared that one driver had drifted over the line while coming around a bend on this two lane road and had run head on into the other car.

With CHP and bystander vehicles stopped in this small space we couldn't really get a good view of the other car or the true extent of the damage. We got out and my firefighter started to grab the extrication tools so we could free the one trapped victim we did know about and of course stop the CHP officer from continuing to rock and shake the vehicle with the injured driver in it regardless of his good intention.

As I came around the back of the engine I was met by a man who was holding a bloodied and dazed two year old girl in his arms. An ambulance medic was holding manual C-spine and a firefighter from the neighboring jurisdiction was walking beside them. Despite the fact that the girl did not look in good shape I was encouraged by the fact that apparently an ambulance and another fire engine were already on scene. Although if I had really thought about it I would have wondered why the girl wasn't being taken to the ambulance and instead was being carried to us at the back of my engine. But I was a little more focused on what we were going to do for this kid.

I was told that she was in a car seat in the rear of the vehicle but that was all we knew. She had a bloody nose and mouth, unequal and non reactive pupils, was staring blankly ahead, and was unresponsive to anything we did. We set up to suction her mouth and found her jaw clenched down tight as well. None of these are good signs. The kid obviously had a pretty major head injury.

To add to the confusion, the man was just a bystander and not involved in the accident at all. So....why was he holding someone else's kid? And where was the parent or driver?

Turns out that the ambulance medic holding c-spine was just coming off duty in his own car and still in uniform when he encountered the accident and stopped to help. The other firefighter on scene had the same story so we actually didn't have any other help on scene. Just then however, Truck 15 arrived and went to work on the extrication which was pretty simple actually. Our first ambulance arrived right after that.

We knew this kid was critical and one of us would be riding into the hospital with the ambulance. My firefighter was also a medic and not a driver so he agreed to go with the ambulance. Fortunately for us the off duty ambulance medic said he would go ahead and ride in with her which left us free to help with other patients on scene. He left his keys with us and when all was said and done we drove his car back to the station with us so he could pick it up there.

Once the girl was loaded and secured on the ambulance and they had taken off I turned my attention to the rest of the scene as our second ambulance arrived. The truck crew had the drivers door off already and the patient assessed - multiple fractures at least but alert, oriented, and pretty calm considering. They were waiting for the ambulance before they took her out of the vehicle so their engineer and firefighter had moved on to the third patient.

This was the driver of the first car and presumably the mother of the kid. She was laying on the ground and the crew, with assistance from yet another off duty hcp (a nurse), were cutting her clothes off and getting ready to secure her to a backboard. I helped them get her in full c-spine precautions and loaded up for the third ambulance when it arrived. I also got an IV established with the nurse handing me tape and other supplies as I worked.

It's awfully nice to have professional help you can actually count on helping out on scene. This call could really have gone sideways if the patients were flipping out and there was no help around and if our other resources hadn't arrived as quickly as they did.

As it was, the husband and father of our two patients arrived on scene and he was understandably pretty worked up. I ended up with the job of filling him in on what was happening with his wife and daughter and keeping him calm. He was collected enough to understand and devise a plan for where to go and how to get there safely. Tough spot considering his wife was going to one hospital and his daughter to another. Where do you go first? We got him sorted out and calm, all patients off to hospitals with their ambulances, bystanders and helpers thanked, the cars moved, the road reopened, and were able to return to quarters.

Still...there was the girl. It's part of the job of course and, all in all, the rest of the call went very well and smoothly but it does suck when you just know a patient is going to have a bad outcome. When the medic came back to pick up his car he said they had to divert to a closer hospital because they couldn't secure her airway due to her jaw being clenched shut. A doctor got on the ambulance and got the girl was intubated using sedation to loosen her jaw and allow for tube placement. They were then able to continue on to a children's trauma hospital.

It's rare that we get any follow up on our patients nowadays with tighter HIPPA laws and all, but a month or so later I worked with that firefighter again and he said he ran into the ambulance crew and they had just learned that the girl left the hospital with no deficits and neurologically intact. She had some seizures in the hospital and may continue to have them periodically throughout her life but she has no permanent or debilitating brain damage.
This really blew me away as I hadn't expected to hear anything like that or even to get any news of this patients outcome. I was quite surprised but definitely relieved. It's nice to get good news now and again.

A Tale Of Three Shitties

I've seen some horrific things in my career, no doubt. But I've also been spared some grizzly sights and while there is always some morbid curiosity I'm sure there are plenty that I'm better off not having rolling around in my memories.   

When I was a student and doing my college work experience program with a busy local fire department I had my first one. I can thank the captain for that one. I may have written this one up before but the gist of it was we called to a house for an unknown medical. The house had no power and was next to a vacant lot. There was an in-law suite in the back and that's where we found the body. I was the equipment mule so was following behind the crew. It was about 2 in the morning and as the captain rounded the corner to the room and shone his flashlight inside he just said, "Okay, back to the rig." He told me there was a monster in there and I didn't need to see that. Apparently he'd been dead for a long time and animals had been eating at him. I was more than okay with just turning on my heels and heading back to the fire engine.

A few months ago my crew was called out for an unknown medical again. This time it was early afternoon and sunny. We arrived at the address to find the police on scene. Apparently the patient was inside but couldn't get to the door and they could not find a way in. After talking to the patient through the door and searching all around for an alternate way in, we had to force entry through the front door. My firefighter did a great job and did very little damage, leaving the door usable.

However, what we found inside was far from it. The small room was knee deep in trash and filth. Everywhere. You couldn't really get through anywhere without wading through it. Our patient, a heavyset man with a cane, had fallen down and was unable to get up or get to the door.  We were able to get him standing and then we retreated to the doorway to continue the conversation. He refused ambulance transport and said he was fine and that he just wasn't able to get up. We couldn't force him to go but we obviously addressed the elephant buried somewhere in the room. He proceeded to explain that he just moved in and the prior tenants left this mess. His landlord was giving him the first couple of months rent free if he arranged for the clean up. He was unable to physically do it himself and so was going to get a company to come do it. This story did not seem entirely credible especially when coupled with the fact the car in the driveway, which obviously had not moved in a long time, was filled to the brim with trash as well. Did the previous tenants leave their car behind too?

           

Today we got called out for a well-fare check on a known diabetic who no one had seen for a week and was not returning calls or texts. I did not recognize the address from the dispatch but I knew it instantly when I pulled the rig up to the house.

Yep, same house and still locked up tight. PD was on scene again and one of the same officers was there. We discussed how we got in before and if there were any better access points. All the doors were locked but there was a louvered window in the front that opened but we could not remove the panes and get in that way. Looking into the house it was remarkably cleaned up.

We moved around to the side yard and to a sliding glass door which again showed the place to be cleaned up and livable. There was one room we could not get to or see into though. We were able to force the slider by smashing off the deadbolt and turning the throw with a pair of pliers. Again, amazingly the door did not shatter and remained usable. However, as soon as we began getting a purchase on the slider the smell hit us. We knew where this was going. The ambulance was on scene and the crew brought us all masks to don before going in.

We masked up and removed the door from the tracks. One officer, my firefighter, and one of the ambulance crew headed in and I followed. They stopped as they got to the door of the room we hadn't been able to see and I heard them all say, "yeah, okay", and then my firefighter declared obvious signs of death (meaning we didn't have to go in and run an ekg strip to determine death in the field). At that point I stopped and headed back outside. I decided this was just one more thing in my career that I did not need to see. I could handle it and I was curious but I knew the best course of action was to just go. I can surmise enough from the descriptions provided by those who did go in, which I will not repeat here.

It's sad that he was able to get help and get the place cleaned up and back on track but couldn't do anything about his own health to save himself. For us it was a blessing in disguise, as crass as that may sound, in that we didn't have to work the code blue or deal with the mess again when we arrived.

We put the slider back on its tracks, gathered info from and for the cops, and cleared the scene to hit the grocery store to shop for dinner and then went back to the station for lunch.