Street Medicine in the ED

Aside from the fire department, some of the most professional fun I ever had was working for Caritas Norwood Hospital. So, since the commute to Quincy was killing me I applied to St Vincent's Hospital in Worcester in order to work as a critical care technician in the emergency room. I figgured it would be a good time and a nice way to occupy myself until I tested for paramedic.
I took my old job at New England back, it was nice to go back. New England is my version of Cheers. Everyone knows me there, I know everyone and I'm comfortable with virtually all of the partners I work with there. While I am no longer full time there, I still manage to pick up a decent amount of hours in order to supplement my time at St. Vinny's.
Eleven am to eleven pm, three days a week with benifits is not a bad deal at all. I basically do everything I do in the back of my ambulance with just a bit more oversight. In the back of my truck, I'm the doctor, the nurse and the respitory therapist. At the hospital I still do my own thing but now I have physians looking over my shoulder and nurses stealing my IVs.
Thinking St. Vs would be fun is just about the biggest understatement there is. I love working there and I am already learning a lot. Paramedics and EMTs work under a scope of practice in the field, we can only do so much without having to ask permission which usually means calling via radio or cellphone to talk to a doctor or if the shit is really hitting the fan, doing the procedure and hoping that the doctor will back you up afterwards.
But in the emergency room, the doctor is right there, in the two weeks that I have been at SV, I've simply had to stick my head out the door and say "Hey I'm gonna do this...." and the doctor just nods. In the back of an ambulance you have one patient for about a half hour or so, that patient is your soul concern and your life for those thirty minutes. I love being on the street, working on the bus but at the same time I want to be able help more people so the hospital gives me the oppourtunity to use more of the long term care (upwards of ten hours) that being on a transporting unit does not allow.
Normally my job consists of starting IVs, taking vitals, EKG monitoring and rapid transport to the closest facility at which time I say "Good luck, have a nice night....where can I find a soda?" Now I am part of a team of three nurses and two techs, assigned six to eight patients for a 12 hour shift in which time I am responsible for everything from emergency cardiac care to toileting. I start IVs, read EKGs and do all of my ambulance stuff but now I can perform blood tests, urine tests, culture for pathogens that help me diagnose and treat ailments that I would be unaware of in the truck. I insert Foley catheters that allow me to siphon urine dirrectly out of the bladder and thus test it. I can draw blood and order labs and have the results so as to provide a higher, more long term level of care.
But I still have my habits from the street, hell I still work the street down in Rhode Island and I probably will until a fire department takes me on again. I love being in the back of an ambulance and it spills over into my tech time.
Two days ago Worcester EMS brought in a 50 year old HIV positive, Hep ABC junkie who ODed on coke, crack and heroin. The narcan they gave in the back of the bus knocked out the heroin so when he shows up in my trauma room, he's going absolutely bullshit, screaming in Spanish and trying to hit anythign that moves.
I grab his arm and struggle to hold him still while calming him down while a nurse blows his AC with a 20 gauge needle. He was jumping so its not really her fault but he needs an IV badly. So I switch places with another tech and get down on my knees, time it just right and pop a 16 into his left hand.
When he starts coughing up pus we decide to knock his ass down and tube him, he's decomping quickly and as long as he's fighting, theres nothign we can do. So we hit him with versed, etomidate and prophonol, making him a zombie hooked up to our ventilators. I start bagging him with a BVM while singing:
"I'm Nick Nick the ED Tech. I got arms like Popeye cuz I bags me patients. Woot Woot." I'm a bit tapped but thats okay, it helps me do my job. Any sane person probably couldn't do this and probably shouldn't either. The doctor gives me a sideways glance before laughing and calling the CCU for an admission.
Once we finally get our junkie squared away, we need to rush him out of the room for an incoming STEMI from way down in North Brookfield. The medics bring him in and I pop a Foley cath him before we ship him up to the Cath Lab. Our door to balloon time, the time it takes for a patient to walk into the ED to the time it takes him to get on the table is supposed to be a half hour. We had him shipped upstairs in five minutes, a new record for SV. They gave us all free coffee.

Football Sunday

"X Ray up," the radio crackles to life as I'm just starting to doze off. "I need an X Ray." Quincy PD is calling for an ambulance. With a groan i grope for the portable laying on the table behind me.
"X Ray, you on the air?"
"X Ray Three on, go ahead Control."
"Respond with PD for a well being check." She gives an address as I pull on my boots and tuck in my uniform shirt, coffee. My cup of stale java is the next thing I grab on my way down to the bus. Its around ten am but still, I was napping.
My partner's name is Tex, an old school Italian guy who is perpetually hung over. We make it to the address, a dinky high rise on the South end of Quincy and find a police car sitting out front.
The first four rings on the buzzer give us no response so I just start pushing buttons waiting for someone to let us in. Finally someone unlocks the door and we find our way in.
A very very tall police officer meets us at the door and says: "I didn't know what else to do with her." I nod and ask if he wants to tell me why she needs something done with her. "O just wait, I don't want to rob you of the experience."
Tex rolls his eyes and we go into the spartan but well kept apartment to find a cute little old lady dressed in her Sunday best perched on the couch. I use the same opening line with old women on virtually every call. "What's up, dear?"
Her face goes stoney and she practically spits the words at me. "You don't know?" I shake my head and her face turns warm and serene. "O well then, I'll tell you. Nine years ago they came and they stole my money. One hundred thousand dollars."
"O I'm sorry, dear, thats terrible."
"Now they're back, they live upstairs." Shes on the top floor. "They keep coming down in the middle of the night. They want my blood, they have a procedure to use my blood to find out where I keep the rest of my money. I hope they didn't get any of my blood."
I nod, "Yeah, me too. But hey, we can go to the hospital and they can check to see if any of your blood was taken."
She looks like a kid on Christmas morning. "They can do that?"
"Mmmmhmmmm. Come on, hun lets go down to the truck, shit I'll even use the sirens and we can get you there really fast to find out if all your blood's there."
A devilish grin cuts across her face. "Ooooh lets do that." I guide her down stairs and ten minutes later we're at the QMC. After getting her situated I hear her screaming and yelling about the nurse coming to do a blood draw.
"No fucking needles! Thats how they steal my blood!"
I stick my head in the room and say "Maddie, how do you think they check to make sure its still there? They're not stealing anything. I told you they're gonna help ya."
As if this makes perfect sense, and to her it probably does, she stops braying and calms down telling the nurse a story about her son and some sort of recipe for a jelly.
Now the game is set to start, Pats and Browns.
"X Ray up?"
Mothafucka! "X Ray on the air, go for Control."
"Unknown medical, China District. No English."
"X Ray has it."
In the China District of Quincy, virtually every house is three floors or more, none of them have elevators, just windy staircases that seem to climb into infinity. Despite the fact that the room is four hundred some odd degrees and there is a grey skinned woman vommiting violently into a bucket, it smells great. Some sort of rice and chicken meal sits untouched on the table.
"Okay, whats this all about?" I ask the son of the woman. In broken English he tells me that she's been vommiting all night. I can tell looking at her she can't walk.
"All right, bud, hang on." I reach over and key my microphone. "X Ray Three for Control. Roll an Engine, we're gonna need a lift assist here." Two guys and a stair chair is all well and good but three flights of winding stairs is just asking to fall and hurt yourself without a spotter.
I go over and feel the woman's head, even through my glove I can feel her burning up. Tex took a quick pulse and said: "Fuck the engine, we gotta go. Shes tacing away, weak and thready." And here I am working a BLS bus.
We get to the first landing when Engine Five pulls up outside. Three guys come up and meet us. We were in such a hurry we didn't bother with a stair chair. "Hi guys" Tex is overly cheerful. "This is yours" we plop the woman in their arms and help guide them down. A fourth guy had the good sense to get the stretcher out so they just drop her in it secure her and I call out. "Hey, Cap, gimme one of your guys as a driver."
The son is trying to rub oil on his mother's face when Tex just pushes him to the front of the bus. "Not now, man, get in front." The kid takes the hint and climbs in as a Quincy Jake gets in the driver's seat.
More violent vommiting and her eyes roll back in her head. "No, no honey!" I yell. "Eyes open," nothing. "Hey open your eyes." Tex reaches over and flicks her nose, her eyes snap open and I take a quick set of vitals. 90/70, pulse 120, resperations at 36. When I check the eyes I find pupils fixed at one milimeter. My partner starts hooking her up to the oxygen as i check between her toes, fingers, up and down both arms and down by the groin for track marks. Nothing.
We make it to the Quincy as I'm going for another set of vitals, cursing BLS because I would have loved to pop in a line and get her on the monitor.
Once in the ED, I'm helping transfer her to a bed when Tex says. "Ah shit, do people with SARS vommit?" The nurse laughes and tells him not to worry. She starts to decomp really fast, bradying down to around fifty for a pulse. The physian and a few critical care nurses are already there so I ask, noone in particular.
"Somebody wanna tell me the score?"

Quincy

An engine crew is already on scene when I jump out the back of the truck with two medics I litterally just met. I've got the first in bag slung over my shoulder and the monitor in my right hand, mentally noting that I have two pairs of gloves in my rightside pocket.
As codes go, this one was easy. A 93 year old male with an unknown down time, litterally right in the front door as we walk in. Despite the two sets of winding staircases, his age emaciated 110 pound frame will pose no problem strapped to a backboard, especially with a group of eager engine boys to help us out.
Laurie, a thickly built bulldog of a woman drops to her knees at the now purpling man's head. Vommit chokes the man's airway so she passes off to Pete and notices me already setting up her IV bag and tubing.
"I'm bleeding it now," I tell her. "Get a venipuncture and gimme the sharp, I'll get ya a sugar. Op site's on my knee." I had stuck the side of a small clear occlusive dressing that old school guys refer to as "an opsite" on my knee for easy access, as she was on her knees it was right within reach.
"What's on ya knee?" She hasn't heard that term in years.
"An opsite....shit what do you Boston guys call em? A teg, I got a teg on my knee."
"O ok, are you a student or something?"
"Just waiting to test for medic and I been an RI intermediate for a while."
She nods, happy that I'm not some fresh out of school bumpkin like most of the other EMTs she needs to deal with.
The lieutenant of the engine company, a 5o something year old guy with a bushy white mustache has been pounding on the guy's chest for the fifteen or so minutes we've been there. "You guys gonna shock em?" He's got that almost childlike anticipation in his voice, clearly someone who loves his job. Laurie and Pete just smile and I get a blood sugar off the sharp she pulled out.
"Gluc's at 117. Sharp OUT! Sharp in the box." I gather up all of the wrappers, gauze and discarded non sharp refuse and stash it next to the O2 bottle. "All waste accounted for, next to the O2 bottle. No sharps."
The lieutnant is turning red, sweat soaking through his gray officer's polo shirt. "Hey Lou, " I ask. "You want me to spell ya over there?" He shakes his head but he's clearly beat. "Lou, I don't wanna be doin' that on you, how bout you let me take over?" He looks up, nods and says something about me being younger and gladly pushes aside.
As usual I feel the ribs breaking under my compressions, a weird kind of snapping and popping that feels almost like twigs breaking. The guy's wife, another 90 something is watching and sobbing so a female cop who showed up with us takes her in the other room. Another eager firefighter pushes in to take over compressions, fine by me.
"Pete, you want a board?"
"Yeah, lets blow this popsicle stand."
I jog down to the bus and grab a backboard in order to transport our guy down to the rig. Once we get him packaged we cart him down two windy sets of stairs two the street level and the stretcher, I'm bagging him and one of the Quincy Jakes is riding the rails like something out of ER while we hustle it to the truck.
Out of the corner of my eye I see a red car slowing down, rubbernecking at what's going on. The woman driving has her windows rolled down and I see her carseated daughter in the back, wide eyed at what we are doing.
I'm about to tell her to get out of here when the sweat soaked liutenant snarls. "You enjoyin' the show? Piss off, ya want ya kid to see this?"
In the back of the truck its me and Laurie, I'm bagging and compressing, one with each hand while she starts pushing more of her meds. She maxed out on Atropine in the house so now it's just epi until we hit the QMC.
"Tube's dislodged." I'm watching the belly blow up with air so I hand off the bag to the medic and fish out my stethoscope. I listen as she pumps in breaths and I listen for breath sounds and hear nothing over the lungs. Whoshing greets me in the stomach.
She turns to tell Pete to pull the bus over but I've already weasled the tube back into place by pulling it up a bit. Again we have breath sounds and I ask if she wants to decompress the belly, an old school procedure thats hardly ever done anymore but still, it makes bagging even with a tube a helluva lot easier.
Laurie laughes, "Who are you?"
When we get to the QMC, we bring our guy in and the doc calls it after a mere minute or two of CPR. The poor old man was practically in rigor when we got there and he's ice cold now. His confused ancient wife said she had talked to him fifteen minutes earlier but unfournatley who knows how long her age addled brain had taken to process the fact that her husband was down.
Overall as codes go, it was easy to work but wondering how long she puttered around the house with her dead husband lying there kinda gives me the shivers.
The rest of the evening went by uneventfully enough. I had been stuck on a transfer truck all day and after my crew left, I saw the medics leaving for this call. Not even knowing what it was I asked if they needed a third and managed to get a bit of excitement to start an otherwise uneventful evening.