Vicissitude

vi·cis·si·tude

1 – one of the sudden or unexpected changes or shifts often encountered in one’s life, activities, or surroundings

2 – a difficulty or hardship attendant on a way of life, a career, or a course of action and usually beyond one’s control

3 – unpredictable changes or variations that keep occurring in life, fortune, etc.; shifting circumstances; ups and downs

4 – a difficulty that is likely to occur, esp. one that is inherent in a situation

We walk up to the front door of the house. The diesel engines of the ambulance and the fire engine rumble behind us and their strobes light our way — and the rest of the quiet residential neighborhood. “This should be our last call. Let’s just bang it out fast so we can go home.” As soon as I said it I got that familiar sinking feeling in the pit of my stomach. Why the hell did I just say that?

It’s late at night in my mostly urban county and Louis and I have been working the last four days straight. To top it all off we’ve been held over every day due to the high call volume associated with the sudden heat wave. It’s not like we can just clock out when our day is done. If there are calls pending and not enough units are available to take them then our dispatcher will hold us over. After the exhausting week that we just had we are finally seeing the light at the end of the tunnel with the idea that this could be the last call of the day.

That is of course until I said what I did. EMS personnel are some of the most superstitious people I have ever met aside from possibly baseball players. I resisted it for years until I just couldn’t ignore the trends. If I’m sitting in the front of the rig just passing the time and talking about a really bad code that I worked last year I’m practically guaranteed to get a really bad code on the very next call. When that happens once it’s coincidence. When it happens continuously for five years you start to respect the EMS gods by paying homage and doing everything possible not to piss them off. Well, I just pissed them off with a simple comment and I’m starting to get nervous as I walk through the front door.

It takes a second for my eyes to adjust as I enter. Standing in the front room of the house I know this is going to be a challenge. The multi-colored strobes from outside are casting harsh shadows in the poorly lit and cluttered living room, which is deserted. I’ve been inside the houses of ‘hoarders’ and this isn’t too far off; not the worst I’ve seen but the clutter is starting to pile up. I hear voices from the back bedroom and head that direction. Why is it always the back bedroom?

Standing in the bedroom are the LT and engineer. LT is writing down medication names on the run sheet and the engineer is just standing there. Their bags and monitor are sitting by the bed, still closed. They haven’t done anything for the patient yet. Down a tiny hallway is the fire medic standing outside of the bathroom. Finally I know where the patient is — the furthest possible location from the front door.

I can hear the fire medic doing an assessment down the hall as the LT brings me up to speed. “That’s Susie down in the bathroom there. We ran on her about four days ago for a lift assist after she fell. She refused transport last time. Today she’s been on the toilet for six hours because her legs are so weak that she can’t stand up. She was basically trapped back there until her sister came by to check in on her. So, first off, we have to figure out how to get her out of there because she’s really big. Second, we need to get social services involved because it’s obvious she can’t take care of herself anymore.”

I thank LT for the heads up and walk back to talk to the fire medic. I’ve run calls with him before and we have a casual familiarity. Turning the corner to the bathroom I see Susie sitting on the toilet. She’s maybe five and a half feet tall yet I estimate her weight to be 350 pounds.

Todd, the fire medic greets me, “Hey, how’s it going? This is Susie — she’s 81 years old. Basically, she doesn’t have any complaints — just increasing general weakness since the fall a few days ago. Her legs are too week to stand up right now and she needs a lift assist. But she said it’s okay to go to the ED to get checked out for the weakness.” Looking at her I can see that’s a great idea.

She’s pale — one might even say ashen — or it could be the harsh florescent lights in the bathroom. I’ll reserve judgement on that one. She has skin tears on her arms and legs with the discoloration of many bruises in various stages of healing. She’s breathing a little fast but otherwise seems to be in good spirits. There’s no visible distress. One of the skin tears on her leg looks fresh with the bright red sheen of an undressed wound.

I ask Louis to get the stair chair from the rig and he takes off to get it. There aren’t any stairs in this house but I can use it as a wheel chair to try to navigate the piles of clutter with Susie instead of trying to walk her out of here. I saw the walker sitting next to the bed on the way in so I know she doesn’t walk too well by herself.

The bathroom is very tiny so when she sits on the toilet the door is held open by her knees and she takes up the whole room. The firefighters haven’t really been able to access her to do an assessment because of the confined space. We’ll have to extricate her from the house as there isn’t any floor space available here, and get her to the rig before I can check her out. That’s fine by me — I work better in the comfort of my own rig. But it would be nice to have a set of vitals before we attempt to extricate her. Just as I’m thinking that Louis shows up with the stair chair.

Todd an I are able to assist Susie to transfer from the toilet to the stair chair. It must have been a comical sight as we’re doing our best to support her while reaching through the door. Once on the chair it’s up to Todd and I to do all the work and drag it out of the house — because of the clutter no one else can reach in to help us. Eventually we get her to the gurney that waits outside the front door. We now have a few more hands to help as we transfer Susie to the gurney and finally into the ambulance.

I throw some packs of disinfecting wipes to the firefighters — I know everyone feels dirty after being in that house — and then I start to assess Susie. This is the point that everything starts to go downhill as the EMS gods have their final say in the matter.

I clip a finger probe to her finger to read her oxygen saturation and heart rate but I can feel that her hands are too cold — so it probably wont give a reading. I put the stickers on her limbs to get a look at her heart and immediately see that she’s in a very fast rhythm — it’s not lethal but it’s not good either. I need to check her blood pressure as it can’t be too high with that fast of a rhythm. I can actually hear the EMS gods laughing at me — like gremlins in my stethoscope — as the needle coasts below 100 without the slightest hint of a systolic auscultation. Pulling the stethoscope off of my ears I hear the fire engine accelerate away from us. That’s just great!

In the last thirty seconds this call went from a simple lift assist and social services call to a Code-3 trip to the ED. With my assessment done I tell Louis to light it up and get moving towards the ED that’s only a mile away. Susie has a blood pressure of 92/64 with a heart rhythm of Supra Ventricular Tachycardia (SVT) at 172 beats per minute. She’s stable for the moment but she actually may have been this bad for the last six hours. I’ll need immediate attention as I get to the ED. That’s the only reason for the Code-3 return — if I do a Code-2 (without lights and siren) I stand the chance of getting stuck in triage for an hour waiting for a bed. At this point it’s more of a statement to the ED than a way to blow through traffic faster.

As we start to pull away from the house I lean down to try to reassure Susie that this is all just precautionary. Her smile and jovial attitude from before has been replaced by a frown and morose mood. I was careful not to voice any concern as i was discovering one bad vital sign after another, but she knows something is wrong. With siren blaring in the background she knows that her life has just changed. She may never be able to return to her house or to live alone again. The simple act of sitting on the toilet may be the single moment that will affect the rest of her life, and she knows it. I can tell from the look on her face that she knows life will never be the same again.

As much as I would like to talk to her right now I have work to do and only two minutes to do everything I can for her. I can attempt to convert the rhythm to a slower one if I can get IV access. A quick look at Susie’s arm tells me that’s not going to happen. She’s too fat and the veins are buried under an inch of bruised and torn skin. So I abandon the search and check my vitals again.

The finger probe still hasn’t registered her oxygen saturation. I pull out a tape-on probe and tape it to her ear lobe in the hopes of getting a reading by the time we pull into the ED. Taking my hands away from her ear I see an external jugular (EJ) vein that looks good enough to sink an IV into.

I don’t usually start EJs as most times I can get an IV started on a peripheral vein and I don’t like sticking needles into people’s necks, especially in a moving ambulance. But this looks like my only access. I tell Louis that I’m doing an EJ and not to bounce me around too much. I can hear the siren change tones as he’s navigating through intersections. I put the head of the gurney lower which allows the blood to distend the EJ making it a better target for my needle. I turn Susie’s head to the side and sink the needle in and disconnect the catheter. At this point I’m holding pressure just below the catheter in the neck so I don’t get sprayed with blood. I look over at the monitor which is right next to my head as I’m kneeling at the head of the gurney. The rhythm starts to fluctuate and drops to 60 beats per minute. What the hell! As I’m connecting the IV tubing and taping it down I see the rhythm on the monitor speed up again and resume it’s previous rate. I’ve got a little smile on my face as I realize what just happened but I don’t have time to dwell on it right now as I hear the beeping sound of the rig while we back into a parking space at the ED doors.

I reach in a cabinet and grab a preload of 6mg of Adenosine and a 10ml flush. Hitting print on the monitor I clamp off the IV tubing and fire off the Adenosine followed by the flush just as a nurse opens up the back doors of the rig.

“Did you convert her?” She’s standing at the back door with another crew that was at the ED; they are there to help us out if we need anything as they saw us come in with the lights on.

“I don’t know, we’ll find out in a second.” All eyes are on the monitor as the fast and regular rhythm starts to get uneven and finally goes to Asystole — flatline. As the last organized complexes trail off the left side of the monitor everyone holds their breath waiting for Susie’s heart to start working again. Adenosine induces a few seconds of Asystole in an attempt to restart the heart’s electrical impulses in a slower rhythm. It’s like rebooting a computer. It’s also the longest five seconds in anyone’s EMS career as you stare at the flat line and hope the EMS gods are in a good mood.

On the right side of the monitor a few organized complexes start to march across the screen, followed by a few more, and then like someone stepped on the accelerator they speed back up to the 170s. I look back to the door as four people let out a collectively held breath. “No, I guess I didn’t convert her.” I pull the cables off of Susie and the other crew helps us get her transferred into a critical room as I’m giving a report to the MD who’s waiting for us.

After filling out my paperwork I go back into the room to drop it off. They’re still working Susie up. I suspect the more they look the more they are going to find that’s wrong with her. I found out later that she finally converted after two more rounds of Adenosine.

I’m sitting in the front of the rig watching the full moon rise over the city and listening to the dispatcher dishing out calls every minute or so. We’re already an hour past our off duty (OD) time but I recognize the call signs of other units getting sent to calls who are over two hours past due to go home. I can tell this is going to be a long night.

I have a bit of a laugh at myself as I recall the drop in heart rate when I started the EJ. After spending 25 years practicing Chinese Kung Fu my fingers sometimes have a mind of their own and place them selves where they are needed. We did extensive study in acupressure both for healing and in knowing which points on the body affect different aspects of physiology. When I was holding the IV catheter down on the neck to prevent blood from spraying me I actually had my finger on a fairly reactive acupressure point called Stomach-9. It happens to be the one spot in the body where the vagus nerve is closest to the surface and vagal stimulation is actually possible from the outside. I’ve watched people get knocked unconscious as Stomach-9 was struck in a sparring match. Academically I know that vagal stimulation drops the blood pressure and heart rate through vasodilatation. Yet this is the first time I’ve ever watched this effect inadvertently stimulated while someone was on the heart monitor.

I feel a little sad for Susie as her life has just changed. I can only hope it’s for the better and she’s able to find herself in a decent place where she is taken care of. I ask the EMS gods to look out for her as I’m watching the full moon rise.

The dispatcher comes up on the radio again, “Medic-40, you’re clear for OD, have a good night and drive safe.” The EMS gods have been appeased…

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~ by KC on September 27, 2010.

One Response to “Vicissitude”

  1. Wow, what an interesting ‘cross training’ reference, kung fu to EMS, along with the opportunity to technologically monitor such an event! Gotta love it, confirmation is good, happy gods, better!

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