Something here is not quite right.

I'm sure you all know that feeling where things just aren't adding up and you can just tell that something about the situation is not quite right.  We get that quite often actually, and this recent call was no exception.

We were responding to a call for a man in his mid to late 60's who had fallen and possibly had a head injury.  This is pretty much the typical in my district so I really wasn't in the mindset of expecting what we actually got.  But from the moment we pulled up on scene it became apparent that this was not going to be typical.  As I pulled the engine up to the address I saw a young woman crouched in the driveway who appeared to be (or at least had been) crying and who was just staring out at the street.  I stopped the rig, turned off the lights, got out, opened the back door and grabbed some medical gear and she had not moved or spoken to us.  Tip #1 something is not quite right. We often get incorrect patient ages or genders on dispatch so my first thought was wondering if she was the injured party.  As I grabbed some additional gear from another compartment I called out to her, "What happened?".  She said, "I don't know".  Tip #2.  As we approached her she got up and started leading us around the back of the house to a small guest room addition in the backyard.  She stopped short of going in, pointed, and said what I thought was, "He's in the bedroom".  She didn't lead the way or go a step further.  Big Tip #3.  There was obviously something going on here besides an elderly slip and fall.

As I, cautiously, entered the room I looked around for where the bedroom might be and off to the side I saw, in the 'bathroom', my patient.  Much like my previous code blue, he was slumped on the floor having fallen forward from off the toilet with a pool of blood around his head.  He was not moving in the slightest and I knew right away what all those signs had been pointing to.  He was face down but it was obvious he was not breathing and when I touched him he was cool and had pronounced rigor mortis.  He had been there for awhile.  I notified the captain that this would be a coroners case and got out my monitor.  I documented that the patient was asystolic (flat line) in all three leads, covered the body, and marked a time of death.

My captain had had the same sense that things were off when we arrived and had stayed with the young woman which was a good thing because she was, rightfully, distraught.  We made the proper notifications and did our best to console the family, more had shown up by that time.  PD arrived and we turned the scene over to them and went home to do the paperwork.

Intuition is a pretty powerful thing and should probably be listened to a lot more than we do.  Fortunately there was no danger to us in this situation but it is a good lesson in paying attention to your environment, the people around you, and trusting your instincts.

I Hate Having To Do That

There is a very fine line between respecting a person's wishes and getting them the help they need. Sometimes it can be very difficult to walk that line, especially in our overly litigious society.

We recently responded for an elderly male who really put us to the test. Apparently he had been seen the night before for a possible stroke, refused service, and had been AMA'd by the ambulance crew. When we arrived, the family told us he had not been interacting with them as he usually does and after the episode the night before they were very concerned. Unfortunately the patient was very stubborn and was still refusing to be seen at the hospital.

There are only a few circumstances in which we can make a patients decision for them and send them to the hospital without their consent: if they are altered in any way, heavily intoxicated, or a danger to themselves (that is, wanting to hurt themselves). Our patient was able to answer all of our questions appropriately and was not drinking so that ruled out the first couple. However, he was not making decisions that were in his best self interest.

In addition to the possible stroke symptoms the night before and a pretty distinct one-sided weakness, he had a new onset irregular heart beat and rectal bleeding. He was not in major distress right now but he should really be seen at the hospital. We just couldn't force him to go. His family was very upset and pleading with him to go, but he wouldn't listen to any of us. We had spent the better part of a half hour trying to convince him and finally my captain told him that the decisions he was making were going to cause him harm. The patient said he understood, so the captain said, "So you do want to hurt yourself?" The patient said yes. He said yes in front of the ambulance crew and us, which is all we needed. We called the police to put him on a 5150 hold and allow us to take him to the hospital. It felt almost deceptive, like we tricked him with logic, but it was ultimately in his best interest. I just hate doing that.

I really feel that, for the most part, if someone wants to refuse service (even at the detriment of their health) they should have the right to do so. Unfortunately, that's not the world we live in; especially when so many have been sued by someone who refused help and then they or their family claim we should have done more.

Usually, when our patients are put in a situation where they have no choices left or have to choose the lesser of two evils, they cooperate. For example, patients who have a choice of going to jail or to the hospital, usually choose the hospital. Our patient was told that he was now going with the ambulance no matter what, so why wait for the police to come and fill out the paperwork? We could just get in the ambulance and go now. He still refused. He completely understood what was to happen and was stubborn enough to ride it out and make us jump through all the hoops.

I had been in and out of the room, talking to the patient and to the family and had missed some of the conversation. Somewhere along the way, my crew had been told that the patient had some weapons in the room. I didn't know this until the police arrived and said they wanted to clear the weapons before we proceeded. They ended up taking two pistols from the nightstand and a Rambo style commando knife from the dresser. I don't think he would have, or was in any condition to use them but I wish I'd known they were there.

After the paperwork was done, the patient got on the gurney and went to the hospital. The family was tearful and very grateful and understanding which made it a little easier. But, man, I still hate having to do that.

Why didn't you say that to start with.

We were toned out for a medical call for a 67 year old male who had a syncopal episode at one of our local businesses.  The business was right by the station and this call really didn't sound like it would amount to much.  Syncopal episodes happen all the time and they usually aren't a big deal unless the person actually falls and gets hurt.  That is the kind of information I like to know when I'm going into the scene:  is the patient conscious?, did they fall or hit their head?, are they talking?, etc.

We were met by some wavers directing us through the parking lot to the entrance.  As I gathered up my gear I asked what was going on and was told, "I don't know, he passed out in the bathroom."  We headed into the building and were met by the next set of escorts who started us down a long hall.  Each step of the way the people we saw seemed more and more tense and hurried.  I asked this new escort if the patient was talking and he responded, "No, they're doing CPR on him."  Well, shit, why didn't somebody mention this rather important fact from the get-go.  I immediately sent my firefighter back to the rig to get the Lucas Device (our automatic CPR machine) and headed into the bathroom to see my patient.

I found an adult male on the floor of the bathroom stall, the big one fortunately, and another employee standing over him doing compression-only CPR.  I think he was very happy to see me arrive and started to step out of the way.  My firefighter wasn't back yet so I told him to just keep doing what he was doing.  He probably doesn't like me anymore.  I cut the patients shirt off and put the defibrillator pads on him as my firefighter came in with the Lucas.  We quickly got that set up and went to work getting an airway and oxygen into him as well as establishing IV access.  He had surprisingly good veins for pretty much being dead (thanks probably to the Lucas device) and I quickly had my line in and flowing like a champ.  The ambulance arrived and put a King tube in him (it was a tight space and not very conducive to trying to put an endotracheal tube in).  I did a heart rhythm check and he was in asystole.  I then found out that the last time he had been seen was an hour prior to someone discovering him on the floor of the bathroom.  That didn't sound promising.  I pushed three rounds of epinephrine and atropine into his IV and he never changed from that initial asystolic heart rhythm.  We made a declaration of death in the field, stopped resuscitation efforts, notified PD and the coroner, and began cleaning up.

It's weird, sometimes, to realize how different your perspective can be when your job is dealing with this kind of thing.  For me, I was mostly thinking about how smoothly the code ran and that it was relatively clean.  Not only was there only a minor amount of blood (from falling forward off the toilet) but there was no vomit and even the amount of garbage and debris we usually produce during a code was kept to a minimum.  I headed out to the rig to get some cleaning supplies to decon our equipment when the receptionist asked me, "Is he okay?".  I can't legally discuss any confidential patient information and everyone there was going to know he was dead in a minute anyway, but I couldn't really stop and politely explain the situation in a grief support kind of way.  I simply said, "No.  They are making some notifications right now."  A few minutes later a manager asked me how long it usually takes for the coroner to arrive so she could decide what to do with her work force.  I told her I couldn't really estimate because it just depended on how busy they are and how many people they had working that day.  It struck me as an odd question though.  My first reaction was: close off the bathroom, inform the staff, and go about your business if possible.  But I do realize that while I see this often, most people rarely have people die during their work day and it is liable to be upsetting.  What I don't get is how that changes depending on how quick the coroner comes?  If they move the body quickly everyone can stay at work but if they don't then everyone goes home?  No matter what, while we go back to our station and have lunch and move on with our day waiting for the next call, they are stuck with the aftermath of a traumatic event and a dead co-worker or friend.  It really is just two entirely different worlds.

We are not uncompassionate in any way.  On the contrary most people who do this job are here because we are compassionate and we want to help and make things better.  But we also enjoy what we do and like using our skills, even if it doesn't always work out in the end.  My firefighter even commented that, as morbid as it sounds, since codes are going to happen anyway, he's glad he gets to work them because it keeps up his skills and keeps his hands on the equipment.  In this case, even though there was nothing we could have done for this man and it is quite sad, as a crew we did an excellent job and that feels good.  We can't always control the outcome but we can be happy and proud that we did the best we possibly could for our patients.

Caution: Children At Work

I really like chemistry and I have sometimes thought that it might be fun to go to HazMat school.  But, more often than not, exceedingly more often, Hazmat calls are long and boring and uninteresting and don't involve much chemistry.

As a general rule, it's not a good idea to keep a group of adult 12 year olds (AKA firemen) bored and uninterested.

This time we got called out for a hazmat involving a rail car full of dry carbon powder, the stuff that goes into computer ink cartridges.  The product was somehow smoldering or having some form of reaction inside the container car.  It had actually melted the vacuum tube that was being used to offload the stuff into the warehouse.  We took some temperature readings with our TIC from the outside and it was definitely heating up in there, plus the car itself was warm to the touch.  That's not good.  As a precautionary measure we got some hoselines in place.  The hydrant was about 200 feet away so we stretched 225 feet of 5" large diameter supply hose and then pulled 150 feet of 1 3/4 inch attack hose to one side of the car and 250 feet of 2 1/2 inch hose to the other side. 

The hazmat team arrived, suited up and went up on top of the car, popped the hatches and took some readings of the product itself.  It was over 700 degrees inside.  There was no smoke, flames, or gasses present though.  It was essentially acting like a giant powdered charcoal briquette.  After much deliberation and contacting of subject matter experts it was decided that the rail car should first be moved to a more open space away from the building before taking any action.  This involved moving two other cars first.  The only means of moving the cars was to push them on down the track using forklifts.  And since firefighters live in a state of suspended adolescence and we'd been standing around with nothing to do for far too long we started rifling through our turnout pockets for loose change to put on the tracks as the cars rolled slowly past.  Yes, we are children and yes we get bored easily.

 

To steal a line from a fellow fire blogger: A child stopped a firefighter in the store and told him, "I want to be a fireman when I grow up".  The firefighter responded, "Sorry son, you can't do both".

In the end the car was moved, the hazmat team sent home, and an employee was sent to get four to five hundred pounds of dry ice to put in the car and create a CO2 blanket to cool and smother the product.  That part I actually wish I could have seen.  Instead, we reloaded our hundreds of feet of unused hose and went back to the station.

We were on scene for a little over five hours and had to return a few hours later to make sure the clean up company showed and that they had posted a fire watch.  I think I'll skip Hazmat school after all..

Did She Just Say What I Thought She Said?

 This is one of those stories that sounds funny at first but really wasn't.  It turned serious real quick.

I was working at one of our outlying stations with a captain I'd never worked with and a probie firefighter I'd only met once.  This station is in a district with a lot of wildland interface, hilly roads, freeway responses, and a long canyon road leading out of town.  We had had a pretty slow day but then started running calls about 4 a.m.  After unsuccessfully trying to get to sleep for the third time we got dispatched to a traffic accident on the canyon road.  It was about 5:30 in the morning now.

I hopped into my turnout gear and was ready to jump on the rig when the dispatcher stated we were responding for a motorcycle vs. cow.  Seriously?  Where the hell am I?  Motorcycle vs. cow???

The location of the accident was mid-way between us and the neighboring department so they sent a rig down the canyon road and we went up.  We reached the reported location and found no cow, no motorcycle, no anything.  Dispatch reported that the other department's rig was on scene of the accident (further up the road) and needed us to continue in for traffic control and manpower. In reality, I knew from the initial dispatch that this would probably be a bad scene.  If a motorcycle hits anything it is usually bad, but if one hits a cow then it is certainly bad news for the rider (and probably the cow).  The fact that the other department still wanted our help for just one patient did not bode well.

I drove on up the canyon until we found the scene of the accident. I positioned my engine to block the area from traffic and headed over to the rider.  I still didn't see a cow, but I did see a motorcycle on the ground, a helmet on the ground, and a busy fire crew working on the unconscious rider.  I glanced over at the helmet to assess the level of damage.  Thankfully it looked in good shape, no big dents or cracks....but...it was full of blood.  We joined the other crew who had just extricated the rider from under the guard rail and cut his shirt and jacket off.  He, like the helmet, looked physically undamaged...but...he had a large amount of bubbling blood pouring out of his mouth as he struggled to breathe.  He was definitely bleeding into his lungs, at a minimum.  We finished stripping and stabilizing him and got him into the ambulance.  My paramedic firefighter jumped on board also and the ambulance crew still wanted another rider.  I jumped in too and my captain said he would drive the engine to the hospital to pick us up.

En route I tried to get an IV in his arm and couldn't find any good access.  I wound up putting an IO in his leg (drilling a large bore IV into the bone).  The ambulance medic got him tubed and, combined with the fluids going in the IO, we got a passable blood pressure and good capnography numbers.  We were constantly suctioning blood from his mouth though.

 It was a seriously bloody mess.  My gloves were covered in blood, but my firefighter (who was doing the suctioning and bvm) had to put his turnout coat in a hazmat bag just to get it back to the station to be cleaned.  I truly have no idea how the rider is going to fair.  If it is just chest trauma and they got him to surgery quick enough, he could be fine.  If he has multiple organ or system injuries, spinal damage, or a head injury it could be seriously bad news.  Hopefully we'll get a follow up and find out how he did.


So, did you forget about the cow?


I bet you're still wondering about the cow, right?  I thought so.  Well, it turns out there was no cow.  There was a fawn.  Now, after reading what the rider went through, let's don't be all, awwwwww the poor fawn.  The fawn was dead but intact (no blood) and knocked clear across the roadway onto the shoulder with what appeared to be (at a quick glance) a broken neck.  My guess is that the fawn was killed instantly.

What I want to know is who the hell reported this accident and mistook a fawn for a cow???

Can you spot the difference?

A Shocking Tale

The lights and tones woke me up at about half past midnight for a medical call.  It was for a 28 year old female complaining of a heart problem.  As I pulled on my gear and found the address on the wall map I thought to myself, this is either some ridiculous panic or drug/alcohol induced nonsense or someone with a congenital abnormality or other serious cardiac issue.  Because it was the witching hour and I had been asleep I was grumbling and leaning toward the former. 

En route dispatch updated us that the patient had a cardiac defibrillator and it had fired about ten times in the last fifteen minutes.  Okay, so I was wrong...it's the latter.  We arrived at the apartment and found a young woman lying in bed with her arms crossed around her chest and her eyes  closed.  She told me she was just trying to be still and relaxed so the defib wouldn't fire again.  She said she has had an AICD (Automatic Implantable Cardiac Defibrillator) for thirteen years and has never had it fire.  This was her second AICD (which she's had for the last five years) and as it turns out this particular model has a recall notice for some possibly faulty wiring.  That had to be disconcerting.

I assessed vitals, ekg, and got some additional history from her.  She was awoken from sleep by the fist shock but had no prior symptoms, stress, or unusual activity. Her ekg actually looked fine although we would have to wait for the ambulance to get a more definitive 12 lead ekg.  This is a little frustrating because I am a 12 lead trained medic but we don't yet have the cables on our monitors to allow us to do them.  My department is currently training all of our medics in 12 lead acquisition which is excellent.  But, until that's done I have to wait to use my training.  In any case, the scene was calm and my patient was cardiac symptom free: no pain other than residual pain from being repeatedly electrocuted, good BP, good pulse and rhythm.  It was certainly looking like she got one of the defective defibrillators.  Unfortunately there wasn't much I could do for her.  Her chest pain was only a three out of ten and only caused by the shocks, she couldn't have morphine and my other pain management drug wouldn't do much in this situation.

The ambulance arrived and we were disconnecting our equipment from her when she suddenly screamed and sat bolt upright.  The AICD had fired again.  I was at her side and my firefighter had his back turned to her and was trying to coil up the long ekg wires when she screamed.  In my peripheral vision on one side I saw my patient clutching her chest and rising up and on the other side I saw a tangle of wires flying into the air as my firefighter jumped like a startled cartoon cat.

 

It would have been funny except my patient was now crying and scared to move.  This means she didn't want to get up and onto the waiting ambulance gurney.  This means we have to pick her up and carry her to the gurney.  Which means I have to get behind my patient and wrap my arms around her holding onto her wrists and pulling her arms into her chest while another firefighter holds her legs under the knees and we take her down the hall this way.  She was young and light and I wasn't worried about the lift.  I also wasn't too worried about the defib, it shouldn't really be strong enough to hurt me even if it fires while I'm carrying her (at least I hoped it wouldn't - I didn't really know how powerful the thing was).  I just didn't want either of us to drop her if she suddenly screamed and jerked again with the sudden shock.  Fortunately we made it to the gurney and the ambulance took off without any more shocks.

All The King's Horses

"Engine 41: Respond for a 22 year old female with an eye injury".

This call was pretty close to the station and we arrived very quickly. So quick, in fact, as to not get the update that the eye injury was caused by an egg. Yes, an egg.

Don't worry if you're feeling confused, I was too. All will be made clear.

We arrived and were greeted at the door by a young woman holding a wet cloth to her eye. I led her into the nearest room and had her take a seat. The nearest room happened to be the kitchen where she proceeded to tell us that she had been microwaving an egg and when she set it on the counter it exploded in her face. And yes, I realize there are numerous jokes and puns to be made here, like "I guess the yolk is on her", etc, but I'm not going to stoop that low. I glanced around the kitchen and saw bits of egg shrapnel everywhere. There was exploded egg all over the ceiling and the counters.

She didn't say so and I wasn't going to make her feel worse by asking if she had actually placed a raw egg in the microwave to hard-boil it, but that is obviously what had happened. The same principle behind popcorn popping and tanker truck explosions is at work here: it is called a BLEVE or Boiling Liquid Expanding Vapor Explosion. Simply put, the liquid inside a closed container vaporizes and expands thereby increasing the pressure inside and causing a failure of the container and a subsequent explosion. She had somehow nuked this egg for the perfect amount of time so as to not explode harmlessly in the microwave but to delay detonation until she had crossed the kitchen with it and set it down on the counter. The flash-bang of egg grenades if you will.

I removed the cloth to see the extent of her injury and found her eye to be completely swollen shut. I could just barely get it open enough for a cursory examination. It was bloodshot and irritated but I couldn't see any actual shrapnel. We spiked an I.V. bag and tilted her head to the side and just used the tubing to run cool saline into her eye to her great relief. She had already done a pretty good job of flushing it with cool water when it first happened but she was still in pain.

By the time the ambulance arrived she could almost open her eye all the way, although only briefly. We passed off our irrigation contraption to the ambulance medics so they could keep flushing her eye en route to the hospital. I got back in my engine, shook my head, and headed back home.


Here's a link to an exploding egg video on youtube. Just imagine looking right at the egg in a bowl when it blows:
http://www.youtube.com/watch?v=xCT039Pdrag