Smooth Cluster

The nature of this business is, essentially, bringing order to chaos. It doesn't always go smoothly, but I love it when everything falls into place, all the jobs get done, and the team works together.

We responded to a report of a 25 year old male unconscious. No other information. Well, this could be anything. It turned out to be a combination of things. When we arrived on scene, we found our patient passed out in the driveway just outside the front door of the house. There were a couple of steps up to the door and at the top of the steps sat an empty wheelchair. According to the other people on scene, they were bringing him into the house in the wheelchair and he fell out face first on to the cement. They had rolled him over to his back which is how we found him. He didn't have any obvious trauma or bleeding of any kind although he was incontinent to urine (maybe more). I don't know how hard he hit the ground but he was out, out, out. I directed the firefighter to take manual c-spine and asked about the patients medical history and if he was perhaps diabetic. He was. I checked his sugar and it came back at 57. Now, this is low and low enough to be treated with IV glucose, but not so low that he should be this unconscious. So what was the real cause here? Did he fall out because he was hypoglycemic or did the fall knock him out and he also happens to be a little low on blood sugar? Chicken/egg, egg/chicken.

Well, the low blood sugar I can fix so we started there. Unbeknownst to me, while I was getting the blood sugar, my captain (also a medic but usually working the clipboard and not the patient) had begun setting up for the IV. I gave the firefighter the IV bag to spike and flood. He had to hold c-spine with his knees while he flooded the bag but the patient was so deeply unconscious he wasn't moving anyway. I started looking for IV access on the other arm just in case the captain didn't get it but since he had a headstart he got the IV (his first in about a year I think) before me. I got the glucose ready while the captain secured the IV and, warning the firefighter to be ready on the c-spine for when this guy woke up, pushed the sugar in. The ambulance crew arrived at this time and began setting up for full spinal precautions (rigid neck collar, long backboard, pads and tape for his head, and straps to hold him to the board).

The patient started to come around with the sugar on board and could now talk to us. I'm still not convinced this was purely a sugar problem alone since 57 really isn't that low, but it got our patient back to alert and oriented before he went off to the hospital.

There wasn't really any major chaos or anxiety, but I appreciated how all the jobs got done, and done well, with a minimum of verbal communication. Everybody knew what needed to be done and did what the other person wasn't doing. We had a bit of a confusing mystery, more or less solved and a patient who was deeply unconscious in the driveway talking and answering questions by the time the ambulance arrived. The firefighter was multi-tasking, the captain was using his rusty medic skills, and all the right care was being given. When scenes run smooth and the outcome is good it just make you appreciate professionals.

Decompression

This is not an easy job, for all the reasons I'm sure you've heard or can imagine and then some. I can't imagine doing it without the support of my family. From the time and effort put into training and traveling to take every test I could afford to reach to the heartache of constant rejection and struggling to achieve something I knew I wanted so much. But, having achieved my goal of joining the fire service, now more than anything it is having a place to go when things go bad on the job that, I believe, can make or break a fireman.

I responded to a call for a female, I'll say girl because that's the way I remember it although I can't recall her age, experiencing a miscarriage. I was on a crew with another medic but I was the lead medic on this call so I was the patient person. When we arrived we were led to the bedroom where the girl sat on a mattress on the floor bleeding. It was dark in the room and as I moved to examine her I could already see the umbilical cord. Worse, I could see something at the other end of the cord. This girl was only 18 weeks pregnant and with a baby that young there is nothing at all we can do. There would not be any attempt made at resuscitation. It was too late for that anyway. I used my pen light to examine the baby and found it to be surprisingly well formed and more identifiable than I would've expected. It didn't seem like a fetus, though that's what it was. It seemed like a miniature baby. I remember not knowing what to say and that it was so quiet in the room. Everyone just knew and accepted it. Not accepted it in the sense that they were okay with it but in the sense that they knew it was a time to mourn and be respectful.

The girl still had to be transported to the hospital as the placenta had not delivered and she needed further care. I asked the firefighter to get me an emesis basin from the rig while I wrapped the baby in gauze. When he returned I placed the baby in the basin, a beige square bucket about 10" by 10". This seemed so wrong to me, but it was really the best and only way to do what needed to be done. i tried to pad the basin and make it more like a bed than a receptacle but it still didn't feel right. The girl's bleeding had stopped and it was really just a matter of getting them to the hospital and consoling her now, though there was really nothing to say. The ambulance arrived and they all left silently.

When we returned to the station the captain asked us if we were okay and if we needed anything, like a stress debriefing. We both declined and said we were alright. I thought I was alright at the time too, sad but okay. This certainly is a part of my job. But it was a call and an image I couldn't shake. I couldn't help but think about it over and over again for the rest of the shift.

By the time I left work, I was just down. It was a weekend day when I drove home so everyone was home when I got there, my wife and all the kids. I didn't say anything and went about my normal routine when I got home. I was definitely affected and although I didn't realize it, I was projecting. My wife didn't get exactly what was going on but she could sense it. In fact, she started to get upset with me, saying, "God, you just got home and you're just thoroughly depressing." This is where it was vitally important to be honest and communicate. I could've gotten upset right back or ignored it but I didn't want to. I told her I had a really bad call last night and I couldn't shake it. I told her what had happened and she asked me what I wanted to do. I told her I just wanted to go out and have a day with the kids. We all loaded up in the van and went out to a park near the lake, had a picnic, played on the swings, and walked around the lake.

It was perfect. It literally made all the difference. I relaxed, I let it go, I enjoyed my family and my life. I believe that kind of outlet is essential to anyone in this type of work. Any type of work really. I don't know where I would be without it.

I will still never forget that call or that image, but it has softened considerably. I struggled to remember the details of the call as I wrote this; did I cut the cord?, what did the girl look like?, did she say anything? I don't remember. Those moments are awful. Those moments are heartbreaking. But, I'm glad to be the one to help those going through it. And I'm thankful for those in my life who help me move past it, re-energize, and go back each day to face it again.

Hey, look! A train.

A friend and co-worker recently blogged about a fire he had near the railroad tracks which reminded me of a call I had early in my career which taught me a valuable lesson.

In the back of the district I was working in then there is a business park. Behind the business park is a small sound wall separating it from the railroad tracks. Behind the tracks is an empty field that runs right up to a freeway overpass. This field and the space under the overpass is routinely used as a homeless encampment and subsequently catches fire just about once a year.

We responded to a report of smoke in the area of the business park. We drove to the back of the buildings along the sound wall. This district and the overpass happen to border the city limits so we had an engine from the neighboring city responding as well. They were a few minutes behind us.

From over the sound wall we could see that there was a tree on fire across the tracks and that the field was starting to take off as well.

With our not so great position and lack of a convenient water supply and the real potential for the fire to spread quickly, my captain decided that we should use our deck gun and quickly knock down whatever we could hit. The deck gun is a large, turret mounted, fog nozzle up on the top of the rig. It is capable of putting out 1000-1200 gallons per minute. The water tank on the engine holds 500 gallons and without a water supply that meant we had less than 30 seconds to accomplish our goal before we had to shut down or risk cavitating the pump on the engine. We had a pretty good angle of attack over the sound wall and decided to douse the tree and whatever grass we could hit.

As we began to put water on the fire, the engine from the other city arrived. We knocked down a good chunk of the fire on the tree but not a lot of the spreading grass fire. Our water ran out and the field was still burning, so this other engine crew pulled a line off their rig, climbed over the sound wall, crossed the railroad tracks and began putting out the fire. In their minds, I'm sure it was a cool, cowboy move and they would be able to brag about how they put out our fire.
\We, on the other hand, were thinking like the one smart kid from Stand By Me who said, "Anybody know when the next train is due?"

As if on cue, we heard the horn in the distance.

"Trraaaaaaaainnnnnn!"

The other crew had about 100 feet of hose stretched across the tracks, fully charged. Which meant they couldn't just disconnect it because the pressure was too great. We shouted to the engineer to shut down and to the hose crew to 'bleed the line' (that is open the bale and let the water flow to help drain the hose) and, of course, to drop the hose immediately. We then joined the engineer in frantically pulling the line hand over hand back over the tracks and the sound wall. It was like a game of tug of war where the loser, instead of falling in the mud, gets hit by a train. In hindsight, it was quite comical. Even in the moment it was funny but we were a little too busy racing the train to laugh just yet.

We literally pulled the end of the line over the soundwall about 100 feet in front of the passing train. So, the valuable lessons learned were:

#1 - Don't ever stretch lines over train tracks.

#2 - Cowboys are stupid.

We work on the tracks plenty, but we never stretch lines across an active railroad track. If we are going to work on an active line, we radio whichever railroad runs on it and have them shut it down. We then confirm it is shut down before we go to work on it.

One of the things I did find funny about that incident was the fact that in most Fire Department Entry Level Physical Agility Tests there is an evolution in which you pull a hose 100 or so feet and then hand over hand pull all the hose over the finish line as fast as you can. I guess I now know why that's in the test.

Breaking and Entering

There are a lot of times and a lot of reasons why we in the fire service might have to force entry into a building, vehicle, or what-have-you. We have a variety of tools to accomplish this, from simply kicking down a door, to using the 'irons' or haligan/axe combo, taking a circular saw to a roll up door, or using specialized auto tools to get into a locked car without damaging it.

For the most part we try to do as little damage as possible unless it is an absolute emergency. My favorite trick for avoiding damage was one my captain pulled out of his mental toolbox a little while back.

We were called to a house where the resident had locked herself out with her child still inside. Normally, we try to get in through a window or other entry point before we start destroying things, but there was no way into this place. We knew we were going to have to force the front door. This of course is usually quite destructive and costly no matter how well you do it. However, my captain figured out a great way to get in with the most minimal amount of damage. We took our reciprocating saw with a metal cutting blade and simply cut off the doorknob. This way we only had to use pliers to turn the inner mechanism and open the door (house thieves, please disregard the preceeding instructions).

The homeowner now only had to replace and re-key her doorknob instead of replacing an entire front door. It worked great.


The golden rule in all forcible entry, though, is 'Try Before You Pry'. That is, always try to open a door or find another way in before you resort to forcing anything.

Sometimes you need to try twice.

For example, I worked with a different captain and we responded to a report of an unknown medical. When we arrived on scene the captain went to the front door and tried it, only to find that it was locked. He radioed dispatch to see if they could call back the RP (reporting party) to let them know we were there and to let us in. The ambulance pulled up and I went around to the back of the house to look for another way in. I found that the sliding glass door to the backyard was unlocked. I went and got my captain and he followed me around to the back and we entered in through the slider. We moved through the kitchen to the living room where we ran into our firefighter and the ambulance crew. My surprised captain asked how they got in, to which they responded, "The door was unlocked".
So, maybe we need to revise our rule to Try Before You Pry And Then Try Again. Or, to quote my abashed and colorful captain, "Open the door with your man-hand like the firefighter did and not with your pussy-hand like the captain."

Of course, it turns out that our potential patient had decided to just drive himself on to the hospital. I guess he didn't want to wait the full 3-4 minutes it took us to get there. He was very fortunate that the sliding door was unlocked or he would have come home to a lot of damage and no one to blame but himself. If you call 9-1-1 and then leave, do us all a favor and call back to inform the dispatchers. It could save us all a whole lot of trouble.

Lost & Found

A little over a year ago, my small town, three station department merged with the County Department (now 28 stations big). When that happened, of course, all of our uniforms changed. Our badges, patches, t shirts, jackets, hats, etc. had to have the County name and logo instead of the old City name. The one uniform piece that the County FD didn't have that the City FD did was a Tilly or Boonie style shade hat. As a balding guy, I viewed my City FD Tilly hat as a piece of safety equipment and even though I'm not technically allowed to wear it, I held on to it. I carry it in my wildland bag and I will use it around my station if I'm out in the sun detailing the rig or doing yard work.
Today, I was out doing the weekly service of our reserve rig and wearing my shade hat. My captain told me we had to go out to a station a couple of districts over and retrieve some equipment left by the previous shift. I must have set my hat and gloves down on the sideboard of the front line rig while getting ready to go and forgotten about them. We headed out to the other station and just before getting there we got a call for an auto accident one district over from where we started but in the opposite direction. I put the Code 3 lights on and we drove all the way back to the accident. After treating one of the patients on scene we were released and set off back to retrieve the equipment. When we got to that station I noticed my gloves were on the sideboard and put them away. It didn't occur to me that my hat was missing. When we got back to our station I needed to finish up with the reserve rig and couldn't find my hat. I then put two and two together and realized what I had done and that the hat must have blown off somewhere while we were driving around. It's amazing to me that the gloves stayed put that whole time. We had gone all over and in and out of other districts so we couldn't just go retrace our steps to go look for it. I was pretty much resigned to the fact that I had lost my hat. I used that hat for camping and other things too and although I could always get another one of that style, it wouldn't have the fire department logo on it and it had sentimental value.

Later that night we responded to a small house fire and after going to the roof and raking shingles and checking for extension I decided it would be worth mentioning to the other crews in case someone turned in my hat to another station. Unfortunately, I don't think the hat had my name in it. Although, there were really only two of us who wore that style hat in my old department and the other guy is now retired. Well, as we were cleaning up I stopped the other engineer and told him what had happened. He started laughing and called his firefighter over. He then told me to tell the firefighter my story, which I did, and he started laughing and shaking his head.

They then told me the story of their day:

They had started off responding to the corner at the freeway offramp for the homeless guy in the wheelchair I have written about previously (see blog entry 'They Just Keep Rolling Along'). He refused ambulance transport and they went on their way. After that they responded to the next city over for an apartment fire. It turned out to be nothing and they were released to go back to quarters. They took the freeway back and as they came down the offramp they saw our wheelchair bound homeless regular giving them a big smile and a thumbs up while pointing at his head with the other hand. He was, of course, pointing at the fire department shade hat he was wearing. My hat! They knew it must have been mine but didn't know the story until I told them what happened while at the fire that night.

Now I'm very conflicted. I really like that hat and would love to have it back, but, knowing what I know about the person wearing it now, I wonder if there is any amount of washing and sterilizing that would make me comfortable about putting it on my head again. Plus, they said he looked so happy about having it I would almost feel bad about reclaiming it. However, this is not exactly the advertisement or endorsement I think is best for our department, now defunct or not. And who knows, maybe it does have my name in it.

The Dead Walk Among Us

"It is alive!"

I found out recently there is a guy in the next district over who is living without a pulse.

Here's how:

An artificial heart has been developed that involves the use of centrifugal pumps instead of relying on a pulsatile form of pumping. This results in a constant blood flow instead of the high and low pressures of a heartbeat.

If you listened to the patient's chest with a stethoscope, you wouldn't hear a heartbeat. If you examined the arteries, there's no pulse. If you hooked him up to an EKG, he'd be flat-lined. It's the strangest thing.

(Edited from the article):

The doctors who created the pump did not start totally from scratch. They took two medical implants known as ventricular assist devices and hooked them together. A ventricular assist device has a screwlike rotor of blades, which pushes the blood forward in a continuous flow. Thousands of people have these implanted in their hearts. By using two, the doctors replaced both the right and left ventricles — the entire heart.

The doctors say the continuous-flow pump should last longer than other artificial hearts and cause fewer problems. That's because each side has just one moving part: the constantly whirling rotor. But Cohn says they will still have to convince the world that you don't need a pulse to live because by every metric we have to analyze patients, they're not living.

"We look at all the animals, insects, fish, reptiles and certainly all mammals, and see a pulsatile circulation," he says. "And so all the early research and all the early efforts were directed at making pulsatile pumps."

However, the only reason blood must be pumped rhythmically instead of continuously is the heart tissue itself.

"The pulsatility of the flow is essential for the heart, because it can only get nourishment in between heartbeats," Cohn says. "If you remove that from the system, none of the other organs seem to care much."

The only thing I'm wondering is what we're going to do if the thing stops working. CPR won't do anything for him, he has no heart. Neither will any of the medications we use as most of them are designed to work on the heart itself. Maybe it's got a hand crank or something.

The times they are a-changing.

"Let Go Of My Eye!"

Head injuries are interesting. I can do without the secondary projectile vomiting that comes with some of them, but watching people's change in behavior is a curious phenomenon. I guess it's just a primal fight or flight thing but the universal reaction seems to be violence and combativeness.

We were second in on an auto vs. bicyclist (I drive the "truck" in my district so we respond to all auto accidents). In this case it was actually a bicycle vs auto since the guy on the bike was riding against traffic and ran into the side of the car waiting to make a right turn. He went right over the hood of the car and onto the ground.

The accident occurred at the exit of a housing development with one way in and one way out. I parked just inside the entrance and as we left the rig the engine captain came over waving us off. He said they only had the one patient and that they could handle it. We were free to leave but the accident was blocking the way out and cop cars were blocking the way we came in. We were stuck on scene so we walked over to see if we could help anyway.

The bicyclist was sitting up in the street with a bystander holding c-spine and the engine crew trying to talk to him. I put on my medical gloves and took over c-spine from the civilian. I'm glad I did because it was at this point that he started fighting us. I'll say this: people who are altered or scared are STRONG. I once had to hold down a 7 year old in the hospital who was getting stitches right next to his eye and it took everything I had to keep him still. This healthy twenty-something male took all of us (ambulance crew included). We put a collar on his neck and I tried my best to keep his head still while he cursed and screamed at phantom women who had taken his money and of course at us. He only had a little road rash to the side of his face (no helmet) but he obviously got his bell rung because he was completely delusional. While the firemen held him down the ambulance crew put the leather restraints on him, securing his wrists and ankles to the backboard.

He kept yelling, "Let go of my eye!" I looked down at him and told him I was holding his head still because he got hit by a car and that no one was touching his eye. He raised his right hand the best he could, spread his fingers, and yelled at me, "This IS my eye! Pay attention!"
Okaaaay, I'll put that down as altered level of consciousness.

Once fully restrained we tried again to explain to him that he had been hit by a car to which he responded "No, I wasn't". With that we put him into the ambulance and got out of the way in case the vomiting was coming next. His ranting makes me wonder what his mental state was like before the accident. Was he already a little nuts or was this all purely head injury related?

Wear your helmets kids and be safe out there.