October 31, 2015

More Cops More Cops Get More Cops

A couple of years ago, my partner and I were assigned to a shooting. When we turned onto the address’ block, we found plenty of law but we had beat the fire department to the scene. A cruiser blocking the street pulled aside to let us pass. We parked in front of the response house and I grabbed the jump kit. 

We approached the front door and a police officer stopped us. “I only need one of you for a pronouncement,” he told us. More people in a homicide scene complicates the investigation, so police will occasionally ask us to just put one medic into the crime scene in cases of obvious death.

I turned to my partner with a smile. “Hold my kit, son.” I handed him the jump kit. My smile broadened – that jibe got to him. I essentially told him that I was the important one and he was like my assistant. It is probably something that you wouldn’t get if you hadn’t been there, but it still makes me chuckle. Especially the irritated look on his face. Hold my kit, son…

I stepped off the front porch into the living room of the house. It looked like a slaughterhouse. There was blood everywhere. I don’t think I had ever seen this much blood in one room, let alone splashed on the ceiling, all four walls, and the floor. The house was trashed, as well. Apparently the victim put up a fight for a long while before being shot several times with a shotgun. 

The victim’s body was on the far side of the living room, next to the kitchen and at the entrance of the hallway that led to the bedrooms. The cop pointed out the path he wanted me to follow to access the body and explained how he knew he only required one medic for a pronouncement: “Should be a simple pronouncement. I’ve been watching him closely and I’m sure he’s dead. He hasn’t taken a breath in at least ten or fifteen seconds.”

Are you shitting me? I turned and looked at my partner, slack-jawed with disbelief. Did he hear that too? He grinned and handed me my kit back. “You may need this.” I just stood there and stared at him for a second. “I’ll get the wheels and set the bus up,” he told me.

I made my way to the patient and reached down to feel for a carotid pulse. I felt a weak, tachycardiac carotid pulse, because of course this guy had a pulse. He was in rough shape. Without getting into specifics, a person can sustain quite a bit of trauma from a few shotgun blasts and a long fistfight. Dude was a mess. He had agonal breathing and had a mess of blood and teeth in his oropharynx. His trachea didn’t look quite right, either. 

I quickly checked and mentally cataloged his injuries and dug into my kit for the intubation equipment. I squatted at his head and threw down a flat gunslinger tube. It may still be the fastest intubation I have ever performed, to this day. Laryngoscope into his mouth, take a look, place the tube; bam, bam, bam. Three and a half seconds. Gunslinger.

I hooked the BVM to the tube and gave him a few breaths. I listened to the patient’s breath sounds and the tube was good. Boom shakalaka. I felt like I was at a spot where I could wait for more help. Firefighters should be on scene any time now to give me a hand with extrication.

It was at about this time that I noticed a door at the entrance to the hallway. It looked like it would lead into the basement. I can definitively say I noticed it at this point because the door handle on the basement door jiggled and turned a little bit.

The police officer lost all the color in his face. He turned white as a sheet, looked at me, and said one of the scariest things I’ve heard: “Oh. Shit. This house isn’t cleared yet.”

Wait. What?!? This horror movie scene isn’t cleared yet?!?

The officer drew his pistol, brandished it, and began screaming commands at the still-closed door. “Come out of the basement! Come out slowly! Show me your hands! Get out of there!” His voice was hitting higher and higher pitches.  This officer was freaked out. I was pretty sure he was going to put four or five blind shots through the door in a line from bottom to top. “Come out of the basement slowly!”

I stupidly sat there, bagging the patient with my mouth hanging open, and watching the officer scream commands at a door. I didn’t even think of moving to a safer place. Because I am dumb and, to be honest, I was scared. I just bagged the patient, dumbfounded.

Right then, the first of the firefighters walked through the front door. The following “conversation” occurred:
Me: “Cops! I need a lot of cops!”
Firefighter: “What?”
Me (shouting, with my voice cracking a little): “More cops!  More cops!  Get more cops!”
Firefighter (looking confused): “What do you mean?”
Me (shrieking, probably at the top of my lungs): “Badges! Guns! Get cops! Get more cops in here!”
Firefighter (muttering, shaking his head, and walking out the door): “These paramedics are assholes…”

The firefighters apparently thought I only wanted cops in the house, because they left. They got into their fire truck and went back to their station. They returned to service without telling anyone else that they had just saw a police officer screaming commands at a closed door with his gun out and a panicking paramedic was screaming the word COP.

Eventually, the scene got itself all figured out. In the end, it worked out that the door that jiggled wasn’t a basement door. It was outside door. Another cop was in the back yard checking it was locked. He never even knew that he caused so much drama inside the house. I'm glad the indoor officer didn't pop some blind shots through the door before he opened it. I bet he is too.

My partner returned and we extricated the patient with help from the police. The cops sent two officers in the ambulance to the hospital, so when the patient lost pulses I put them to work on CPR and bagging. For my part, I missed six IV attempts and handed off the patient at the hospital. (This was pre-IO and mid-ETTeveryone.) Definitely not my best work, especially communication-wise. 


Except for the tube. Man, that was an awesome tube. Friggin' gunslinger.

October 17, 2015

A Mystery for Dr Holmes

One of the occasionally frustrating aspects of being a prehospital provider is that you have to hand over your patient to other caregivers.  We try to do our best to relay our specific concerns and findings, but sometimes it can feel like something was missed in the handoff.  On occasion, it feels like the hospital doesn’t take your patient as seriously as you did.  Sometimes it feels like the receiving providers don’t see what you found compelling about your patient.
            “Hi.  What did you find about that woman with the Sick Sinus Syndrome?”
            “Huh? Which?”
            “The woman I brought to room three, three hours ago with tachycardia, bradycardia, sinus pauses, and so on.  It looked like SSS to me.  But she had no history.  What did you find out?”
            Shrug.  “She didn’t do that for us.  Completely normal rate the whole time.  So we discharged her and told her to see her doctor.”
            “Uh, thanks.”

Sometimes, though, they do get as interested in a patient's presentation as you are.*  Which is awesome.

I once responded to a high-end shopping district for a syncope.  We arrived to a home furnishing shop (which I could never buy anything from) to find a pale, diaphoretic, and supine woman in her fifties who had been shopping with a friend when she began to “act funny” and fell to the ground.  I found the patient to be generally atraumatic, but altered and difficult to arouse.  She was tachycardic, normotensive, and appeared to my eye to be hypoglycemic.  Her blood sugar, when checked, was 15 mg/dL.  I found it impressive that she was responsive at all. 

Rather than work her up and treat her in the store in front of everyone, we lifted her onto the pram and moved her to the ambulance.  A quick line was stabbed into her arm and 25 grams of dextrose woke her right up.  Simple hypoglycemic wake-up, right?  So now is where it gets a little weird. 

The patient had no history of diabetes.  As a matter of fact, the only medical history she had was a touch of hypothyroidism.  She was prescribed Synthroid for that and has not experienced other medical problems.  She reported no recent trauma or illness, nor did she report any kind of increased workload or changed exercise routine (e.g. she didn’t just run a marathon or just start trying out for Olympic weightlifting).  She had picked her friend up that morning, they went to an overpriced trendy lunch, and this all happened about two hours after that. 

It was weird to me that she was so hypoglycemic without a history of DM.  It was weird to me that she was so hypoglycemic within a few hours of lunch.  The whole deal was weird.  So I convinced her to go to the nearest ED to get checked out.  It took about 15 minutes of verbal convincing, but she agreed to go with me.  I was specifically worried about something like a pancreatic tumor that would cause blood sugar derangement, but I didn’t tell the patient that.  I could have told her to eat a full meal and call her doctor, but I thought her problem was more interesting than a “normal” diabetic wake-up.

We got to the hospital and I handed the patient off to the staff there.  The verbal handoff included a nurse and the physician, and on my way out I chatted with the doctor more specifically about my findings and my concerns.  We talked about mechanisms of hypoglycemia and worked through her history as it related to that.  She was on the same page as me, and seemed engaged in the patient’s mystery.  I gave her a card with my cell phone number on it and asked her to text me when she had any ideas about the patient’s diagnosis.  I left to run some more calls.

A few hours later I got a text from the physician asking me to call her, so I did.  The doctor explained that the abdominal CT, blood tests, and all other findings were normal.  It took hours of picking at the mystery to figure it out.  Eventually they figured out that the patient refilled her Synthroid two days before.  The doctor asked the patient’s husband to go home and bring the thyroid medication back to the ED.  They looked at the “Synthroid”:
Source

Yeah, that’s actually a 10mg tablet of glipizide.

Mystery solved.  The pharmacy had filled her thyroid prescription with glipizide.  The patient was lucky that she took the medication right after lunch.  Imagine if she took it right before bed. 

I have so much respect for that doctor and the rest of the ED staff that it is difficult for me to explain.  Think about how easy it would have been to monitor the patient for a few hours and release her to home with instructions to follow up.  Instead, the doctor and the rest of the ED staff worked the problem until they had an answer.


Awesome.

*None of that means that I am always interested in my patients' stories, or always catch when a case is interesting. I'm sure that the reverse complaint is true: "Prehospital providers never pick up on really interesting cases..."