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.

Johnny On The Spot (prose edition)

For those who may have been confused by last entries open verse poetry stylings...here is the story.


My engine was called out to assist the police department with a wellfare check. This was in the retirement mobile home park and the resident hadn't been seen by neighbors for several days.

PD was unable to find an open door or window to make access into the home and so called us - so we can do all the damage. Following the preeminent rule of forcible entry which is try before you pry we took a lap around the house to see if we could find a way in. Now, I'm not in the business of showing up the police department but it can be fun when it happens and you get some points in the sibling rivalry game between cops and firemen. As we made our way around the house trying doors and windows it appeared that the pd was right and the place was locked up tight. But just before we committed to breaking down a door I looked again at the window to the sun porch and thought it looked just slightly off. Upon much closer inspection it was open just a fraction of an inch and I called out that we had a way in.

My firefighter popped off the screen and I slid the window open. The window was maybe four feet off the ground and not very big. So we would need a ladder to get in. My firefighter started to leave to go and get the attic ladder when I reached through the window to see if I could clear some space. The first thing my hand blindly fell on (and pulled out of the window like a rabbit from a hat) was a step ladder, just the right size.

I called out again to my firefighter and told him I didn't need the ladder. Two for two. I climbed up the step ladder and shimmied through the window which led to a sun porch/deck area. I proceeded to the door to let my crew in. We were still not inside the house so may still have to force entry. My captain went to the side door and I went to the slider. The captains door was locked. The sliding glass door opened easily for me and I again called to my crew, "I'm in." Three for three.

Normally PD will take over at this point and go clear the house and make sure it is safe for us to enter. But for some reason they had not come through the door with my crew. I waited for a second to see if they would be coming along then decided, as I heard nothing from inside the house, that I would just go in and check it out.

I announced my presence loudly, "Fire Department!! Anyone home?"
I got no answer and so proceeded through the kitchen looking for the occupant. As soon as I cleared the kitchen I looked down the hallway into the bedroom and saw the elderly gentleman dead on the floor. Even from such a distance I could see that rigor had set in and his hands were actually up in the air like Blue from Old School.

I let my crew and PD know what I'd found. Luckily, much like this mans immaculate home, the scene was surprisingly clean. There was no smell of days old death or any of the other unpleasantness that comes with wellfare check bodies. The police still needed an I.D. or SSN/DOB info and began searching around the house which as I stated was probably the cleanest and most organized house I've been in in a long time. They weren't having any luck finding what they needed however. That's when I saw several envelopes on the lower shelf of the nightstand from AARP. They were perfectly stacked and in chronological order. I opened one up and read off to the PD all of the pts pertinent info that happened to be on page one of the first document.

Four for four (or 5 for 5 if you count the body).

We put the step ladder away, closed up the window and replaced the screen and cleared the scene.

And while it was a sad call overall, as far as those types go, it was an easy one. And I got to be Johnny On The Spot at every turn and one step ahead of the law.

Johnny On The Spot

called for a well fare check
pd couldn't find a way in
found a window just slightly cracked
removed sceen and opened window
couldn't climb in easily
reached in and pulled out a step ladder
climbed in to sun porch and opened main door for crew
inner door unlocked
PD? anyone? okay I'll just go
there he is

Well that is kind of the point of the exercise isn't it?

The last several years I have taken part in a huge two day, multi-agency exercise/competition as part of the water rescue team portion. I have been a proctor for the rescue swimmer station, a competitor on the team, and this year I proctored the towing and search and rescue stations.

Day 1:

The search station involves plotting coordinates and the proper search pattern for the area given and to find and "mitigate" three different objects (mannequins as victims, barrels as hazmat containers etc). The designated search area was just a ways off of one end of the bridge. It had been joked about many times already that if we got a jumper this would turn into a real exercise.

Shouldn't have said anything.

We were just starting the exercise for the second crew of the day when the radio reported a jumper from our end of the bridge. We immediately abandoned the exercise and began to haul ass back towards the bridge.
On the way we could already see the smoke from the signal flare. When someone jumps from the bridge the bridge workers drive out to the location the person jumped from and toss a smoke bomb over the side. This gives us a good idea where to start the search and also shows drift and current. There wasn't a ton of current and the smoke wasn't going far.

As we headed towards the smoke we could see a couple of boats in the area that had stopped under the bridge. On the rear deck of one boat a woman stood pointing into the water several yards ahead of her.
We quickly spotted the object she was pointing too and made our way to it.

Now, I've been on a few searchers for jumpers and others lost at sea but I've never been on the boat that found them or made the recovery. At least not of anyone who wasn't alive. I've pulled cold and thankful victims of capsized boats out of the water, but never a body.

Approaching so the body was drifting towards us we could see that the person was face down...and shirtless. Not sure exactly how that happens or what the mechanics are. Wind as you fall from height? I really don't know. The waves were enough to make the approach somewhat difficult and we had to use the gaff to hook a belt loop and bring him close. One firefighter used the gaff and I laid down flat on the deck reaching down to hold on to the body so it didn't go under the boat. That's when I noticed that the victims arm was separating at the shoulder. Not quite deep enough to be severing but enough that I probably couldn't use it to pull him into the boat. Goes to show how strong an impact hitting water can be though.

 

As we were maneuvering the victim towards the back swim deck the coast guard vessel arrived. As they are much better equipped to handle the body and all follow up we were able to pass the body over to them for recovery. Which was just as well by me.

We were requested to search under the bridge a bit more to see if we could locate his jacket in the hopes of finding some identification.

 

As we continued our search we noticed two porpoises (maybe dolphins) approaching the boat from the ocean side of the bridge. They moved, side by side, jumping their way in unison along the surface of the water. They passed right along side our  boat and continued on into the bay. it was a beautiful sight and a very surreal moment; standing on the deck of some other agencies boat, some other agencies area of operation, having fished a tragic suicide out of the water, witnessing these animals as I've never seen them before, and simultaneously loving being out on the water doing this job.

 

We never did find the jacket and so returned to the search and rescue scenario to save a mannequin and a plastic barrel. It didn't quite have the same sense of urgency after the jumper though.

Day 2:

Our second long day out on the water started out much the same as the first with great weather and mostly calm seas. There was of course continued talk of yesterdays events and maybe this time we should talk about getting a boat fire or something else instead.

We were just starting the second group our station (again) when a report came in for an unconscious male in a dinghy in the next harbor up from where we were conducting our drill.

Here we go again.

We broke from the exercise and headed off hauling ass up to where the reported victim was. We had pretty limited information but received a report when we were almost on scene that the victim had been picked up by a passing boat. Shortly after that update we were flagged down by the crew of that boat. They told us that they had towed him in to the docks. I asked if he was talking and if he was okay. They told me "yeah he woke up".  Well that's not really a good enough answer for us so we still wanted to follow up and make sure everything was okay so we headed in to the docks. We still had only "white dinghy" as a description and there didn't appear to be any vessels of that description there. Fortunately there were some people at the docks who had seen the boat get towed in and told is it was down at the dinghy dock at the end of the next pier over. They also gave us a description of the boat.

As we turned the corner around that next pier we could see the boat floating loose by the shore. Even through binoculars the boat appeared empty but we couldn't be sure. So, we tied up at the dock and made our way ashore and around to the dinghy. Sure enough there he was. Completely passed out in the boat. The good samaritans had apparently taken him as far as the dock and said farewell. This guy never tied up or got out of the boat and just passed out again. He'd been out in the sun for quite some time and was shirtless. He looked exactly how you would expect a castaway to look. However he was just drunk and no Tom Hanks by any stretch.

 

The crew waded in to the water and got hold of his boat and pulled it up on shore. They then proceeded to perform a medical evaluation on our intoxicated and disoriented patient.

Upon finding our patient still in the boat we had radioed for the local fire agency to respond with fire and ambulance. The firefighter on the engine that responded turned out to be one of the guys on the boat that had picked up the jumper with me the day before.

We still had time to finish up the scenario and rescue the mannequin and the barrel and get back to the dock.

Waiting for the next contestants to arrive I wondered what else could possibly happen.

Ch-ch-ch-changes

The guys from the next station over were at our station for fuel and we were catching up when we were called for an elderly patient with ineffective breathing. Uh oh. Not a dispatch with a good prognosis. It was a very close by address so it took us no time to get there.

On arrival the patients wife met us at the door crying and severely agitated, near hysterical. She had a land line phone in her hand and gave it to me as soon as I walked in the door. I didn't even know where the patient was yet or what was going on or who I was talking to. I said hello and heard no answer so just set the phone down on the nearest surface.

 

I rounded the corner into the kitchen and to my surprise the patient was sitting at the kitchen table. To my next surprise I was pretty sure he was dead. He was so pale and lifeless that the first thing I did was check to see if he had rigor to see if I even needed to work this code.  He was an even waxier and a paler shade of white than Bono here, if you can imagine that.

As I checked for rigor and felt for a pulse he moved his arm much to my continued surprise. He actually responded a little bit to my voice as well.  I looked at his face and he had a profound facial droop. I called to my captain, who was in the other room dealing with the hysterical wife, to find out if my patient had any previous stroke history. He was trying relatively unsuccessfully to get any meaningful medical history from the wife and I got no response. 

The firefighter and I got to work assessing vitals, checking blood sugar, getting an ekg, and setting up for oxygenation and IV access. With all of this manipulation and management going on the patient actually became a little more alert. 

Within a few minutes the ambulance arrived and as I was giving them my report I noticed that the facial droop was almost gone. His vitals were all pretty good actually although his blood pressure numbers were questionable and would have to be repeated for verification.

We quickly got him moved to the gurney and to the ambulance to do a couple more tests and determine where he would be transported to, depending on whether there was a cardiac component or if he simply needed a stroke center. As the tests were being performed another family member arrived and I was able to determine that my patient had had a mini stroke just a couple months ago and had a couple of stents put in. Definitely good info to have although I already had a good idea of what was going on.

I popped my head back into the ambulance to update the crew on this new information and found that the patient had zero facial droop and was now talking to the medics. He was still pale and hypotensive but was quite a different picture from the deaths door patient I encountered when I walked in.

It is pretty amazing to see the change in patients like diabetics or those with TIAs (transient ischemic attacks or mini strokes) in a very short period of time with some simple interventions. Sometimes it works against us when we try to explain to the ambulance crew or the hospital that this perfectly normal seeming patient was circling the drain just ten minutes ago. No, really, I swear...I thought he was dead. But I guess he got better.