Attempt

ALS 4 from 5 p to 7 am on overtime. It had been one of those horrendous nights where we left at around five pm and didnt make it back until about 4 am. Almost every patient was an ALS call. But the one that came in at quarter of five in the morning was the worst. I had been asleep for a little over forty five minutes when the tones dropped for an overdose on the other end of town.
"Engine Five, ALS 4 respond to XXXX for an overdose."
Groggily, realizing I still have to work a transfer truck for 12 hours, begining in less than six hours, I key the mike. "Four's responding. Is PD enroute?" Overdoses, especially ones that come in at this early in the morning usually end up being Code 10s, dead on arrival with obvious signs of being dead for several hours. In other words, long gone.
"Negative, patient is a 48 year old woman, shallow respirations. Shes known to us, possible suicide attempt."
Maggie, my chaufer for the shift gets in the driver's seat and states. "I know right where this is." She hits the lights and I drift back to sleep on the ride over to the apartment complex.
I wake up from my little nap when the radio chirps. "ALS 4 from Engine 5, just back right in up to the steps and bring in all of your stuff. We'll get the stair chair but bring in all of your stuff." I sigh and reply that we will, when they say that, the patient is usually very critical.
And she was.
Forty eight years old, snoring respirations at four to five times a minute. Her right eye is pinpoint and her left one totally blown. One of the firefighters gives me a quick report. "Breathing like four times a minute, pressure is at 70/palp. Pulse around 110. Jaw is wicked clenched, I can't even get an OPA in." The small piece of plastic used to hold open an airway when a tube is not possible.
We bundle her into the chair, take her down the stairs and drop her on the cot. Once in the back of the truck I cut off her nightgown and throw on cardiac leads. Shes in a sinus tach with occasional PVCs. We drop a nasal trumpet and I steal a firefighter to bag. The lieutenant hands me an empty bottle of psych meds. It was filled with 60 pills two days ago and now its empty.
We try for two IVs and get little more than flash before the lines blow. Her sugar comes back at 102, normal and not the problem. I pop an IO into her right leg and it flows fine. We transport, a quick little jog down to the Elliot. My patch was simple but it got the job done.
"Elliot Hospital, Elliot Hospital. Status One traffic, five minutes out on Med 1"
"Elliot, go ahead and please identify."
"Good morning, ALS4. I'm about five from your facility with a forty something year old female. Took a full bottle of at least 60 psych pills. Vitals unstable full report on arrival, I'm busy now. Have a team standing by."
I push 2mg of Narcan and nothing happens. Big shock, I didn't expect it to but on the off chance there's narcs in there I wanted to try. Her teeth are still clenched but we're pulling into the Elliot.
Once inside I help them work her up, I bag her while they push RSI meds to parlyze her and then help the doc get the tube. She was really anterior and I had to force her trachea down for him to see it.
They bring in a ventilator as the cops show up and tell us the rest of the story.
Apparently the woman is very well known, numerous suicide attempts with an extensive depression and bi polar history. Her husband had come home at around seven the night before and found her sitting in the chair much like we did in the morning and thought she was sleeping so he left her alone. When he woke up to take a piss int he morning he found her still sitting there and tried to wake her up, then he found the bottle of pills with nothing but dust in it and called 911.
Manchester is one of those typical New England urban centers, the largest city north of Boston. As such it attracts the typical urban problems of drug abuse, assaults, homeless people and the mentally ill who gravitate toward large urban areas. The over taxed healthcare system tries to do a treat and release that relies on people who want to kill themselves being trusted to take home quantities of meds capable of producing that goal and then following the propper dosage plan.
The city has four ALS trucks in 911 rotation. We basically serve as the reset button for a population that bounces in and out of care facilities. When the inevitable happens, we are there to pick up the pieces.

Long Shift

When I got on at 7 I knew it was going to be a long day. It was chilly and raining which in my experience usually ends up leading to a lot of bullshit.
Our first call comes in as difficulty breathing way out on the Londonderry line. When we get there, a little old lady is wearing a fishing style boonie cap and complaining that her abdomen hurts. The firefighters are grinning and I know this isn't a good sign.
"Ma'am whats going on?" I ask in a normal tone of voice.
"You need to talk softer, my sense of hearing is very acute."
I lower my voice and ask. "Why'd we call 911 today?"
"I'm sorry you'll have to speak up."
Without further questions I tell Josh to go get the stair chair and once we put her on it she tells us she hasn't pooped in a week and now her stomach hurts.
We ride to Elliot with lights and sirens because she complains about everything.
Once we finish up some paperwork and get back in service I grab a muffin and a coffee. Pulling out of the Dunkin Doughnuts parking lot we get banged out for another difficulty breathing, this one around the corner from CMC. As we're responding the fire alarm dispatcher comes over the radio with one simple transmission.
"Fire Alarm to ALS 3, be advised 911 states bystander is performing CPR."
The engine is on scene about a minute before us and all they have managed to do is find the apartment. A large black man is laying on his back between the bed and the wall with his eyes open, his fiance is running around crying as I feel for a pulse.
"No pulse, get on compressions." I cut off the guy's shirt as one of the firefighter places his AED next to me. "Wanna put that on him?" Josh comes running in with the drug box and the monitor. The AED tells us not to shock him and on our monitor I see he's in total aystole. "Okay, continue compressions." We pop an oral airway in as Josh runs out to get a board, in a few minutes we have him on the board and the engine crew and I muscle him out the door, Josh grabbing all of our shit and hustling it out to the truck. Once in the back we get him back on the monitor and see he's still in asystole. I consider a standard IV.
" O fuck it, I'm doin' an IO." The intraoseous needle, a drill that basically places a 15 gauge needle dirrectly into the bone marrow for drug and IV fluid administration. I pop it in and it flows great, two rounds of Epi and atropine and he's on the table at CMC.
Forty minutes later he's officially dead.
We're dispatched from CMC to a "sick person", Manchester Fire Alarm's ubiquitious definition of anyone who can't figgure out why they need an ambulance. When we arrive on scene, a little old man is outside waving franticly. Josh jumps outs and I grab the bag, when we get to the old man he tells us his wife cannot stop going to the bathroom. We find her inside sitting on a hospital chux on the couch wearing a fishing hat. She has the air of someone who will make my life difficult.
"Hi, hon, I'm Nick, I'm a paramedic. What'd we call 911 for today?" I ask in a normal speaking tone.
"Theres no need to shout, infact, talk softly, my hearing is very acute." Her nasally voice commands and I drop mine a few decibles.
"So what can we do for you today?"
"What? I can't hear you."
We transport her to Elliot with no icident.
Another sick person, this one on the North Side. We go lights and siren through traffic that would prefer not to move.
On the way Fire Alarm updates us again. "ALS 3 be advised on scene nurse states possible stroke. Engine 8 will meet you there." They tone the engine and we pull into the parking lot of a moderate income apartment complex. A morbidly obese man sits on the steps with a crowd of onlookers tending to him.
"Gentlemen," He addresses us in a slightly effiminate tone that I know all to well. "I am not going to the hospital. The only problem is that my right hand doesn't work correctly." Strokes make guys sound like they are a bit light in the loafers, the slurring of the speach and the overly cautious word choice indicative of a brain event.
"Did your right hand work before?" I ask as the "nurse" on scene begins to describe how the patient needs a swallow evaluation. Josh tells her that they will take care of all of that as he scoots her out of the way. The egine pulls in and four firefighters join us.
"Well I was having trouble writing, you know, words?"
"Yeah, I'm familar with language," I reply and ask him to give me a nice big smile and squeeze my hands with both of his. The right side of his face droops, his right grip is weak. "Sir, you gotta go to the hospital."
"No, I'm going inside to take a nap." He tries to get up and finds his right leg isn't working. "What the fuck is wrong with my leg?"
The captain from Engine 8 says, "Why don't you let them take you to the hospital and they can find out there." The patient complains and protests as soon as we stair chair him to the truck and plop him on the stretcher. Once in the truck he gets even more nervous. He's tachy on the monitor with a pressure in the 90s, we pop a sixteen in his left wrist and I run a 12 lead. By the time we get to the hospital his tongue is hanging out of the left side of his mouth and he can't speak. I have the BVM ready as we wheel him into the Trauma Room.
After grabbing some ice water and attempting to write up my report the tones go off and we respond from Elliot to a psych problem in the South Side of the city. Lonely, bored and mentally ill people have found that when their prescribitions run out, 911 will send a truck to pick them up and take them into the hospital. Since they don't have insurance or have some form of state provided insurance they don't pay a co pay so its cheaper to dial 911 than to call MTDS cab.
Fire Alarm states simply "ALS3, respond to XXXX street for a psych problem. New England Fire Alarm for details." New England refers to the now defunct phone company that used to service Manchester. It's slang for call on a landline.
When I call FA on my cellphone the dispatcher starts by saying. "I'm sorry." Never a good sign. She proceeds to say. "These are two regulars, 58 year old female and her 35 year old son both have BiPolar with psychotic tendancies. PD should be enroute but they have a suspect with a gun in the West Side so you might be on your own." I thank her, hang up the phone and swear.
When we get on scene, a home oxygen delivery guy is sitting out front looking at the open front door of the house.
"You call 911?" Josh asks him.
"Yeah, they're pretty bad off in there."
"How?" I ask as I pull the large MagLite I keep in my door out and slip it into my belt at the rear for a quick draw, usually the sight of a large pipe type object is enough to calm down assholes.
"Man, they're just screaming and sitting around, its weird."
"Lovely,"I mutter and we walk up the steps.
Each of us stand to the sides of the door to avoid any gunfire and I yell out. "EMS, can we come in?"
A voice calls back that we can and we walk in to find a woman with a nasal canula and thousands of feet of tubing smoking cigarettes at the bar with a half empty bottle of bourbon. Her son sits in an easy chair rocking back and forth.
Josh goes and talks to the woman and I talk to the son. He tells me that hes in a lot of mental pain and he needs morphine. He goes on and on about how hard it is to be in this much pain and he needs pain meds because he is having an anxiety attack. His vitals disagree with his complaint and he denies physical pain but tells me I don't know what its like. "My mind hurts, I need narcotics." He snarls.
I ask one question, perhaps the most important question. "Can you walk?" He walks with me out to the truck, sits on the bench seat and continues to half heartedly request morphine as Josh carries his 98 pound mother out and plops her unceromoniously on the cot. Vitals on both of them are fine as we drive into CMC. The mother tells me her son could use some morphine.
We clear CMC and head back to the station for shift change. I bounce a few more psychs and then my night partner Rob and I head to an address around the block from where I live. A 10 month old baby fell on a concrete floor and is not acting right. We get there and he's lethargic with his pupils sluggish. I scoop him up and we run out to the truck, lights and sirens to Elliot, the Trauma Center. Two blocks from the hospital he starts to wretch and almost loses conciousness.
The night goes on with us getting dispatched to a sick person at the bus station. A little Indian guy with vomit all over his shirt and hospital ID bracelets from Los Angeles County General Hospital sits barely responsive on the bench near an idling bus.
The bus driver says "He's sick, dude, I got him off the bus and called you guys. I gotta get to New Haven by 8 am , can I leave now?"
I tell him to take off and we pull the guy onto our stretcher. He stinks of booze as we wheel him into the truck. We're down the street from CMC. I throw him on the monitor to find a Sinus Arrest rthym at about 75, not to concerning. An 18 goes in his left AC and we find his sugar is reading as Low on the glucometer, once it stops giving numbers thats a bad thing. His pupils are equal and reactive so I push D50 and watch him go from low blood sugar and drunk to just plain drunk. He tells me he loves me and I reply. "I know."
At CMC we are finishing paper work up when Fire Alarm comes through. "ALS3, are you in service for a call at CMC?"
"ALS 3 to Fire Alarm, we're sitting at CMC now, what do you need?"
"Phone-A-Nurse states you have a suicidal patient in front of the emergency room."
Phone-A-Nurse is basically a line that people call when they have medical problems but don't want to go to the hospital. Nine times out of ten, phone a nurse sends an ambulance anyway.
"ALS3 responding and on scene, show us out and investigating." We find a 30 something year old male walking around and ask him whats going on. He states he was on the phone telling them that his wife, a woman in the Cardiac Room was trying to kill herself with sleeping pills and he wants to know if she will be okay. Hospital security had kicked him out when he asked a nurse for fentanyl because of a car accident injury. The police show up, find he has a warrant for unpaid something or other in Northern Bumfuck County and arrest him.
When we finally get back to the station the tones go off yet again. "ALS 2, 3, Engines Six and 8 respond to XXXX Street Apartment XXX for a stabbing. Stage for police, be advised multiple calls and victims."
The apartment is two doors down on the same floor as my own and when we get there I see ten marked police cars and a three or four unmarked, a few police mountain bikes an unmarked van that usually carries the SWAT team.
Walt and Maggie, the ALS 2 crew are grabbed by a cop who blurts out, "The guy upstairs is fucked up. I think he's dead." He's not but close to it, a pneumo thorax and a punctured lung will do that. The guy that stabbed him is on the pavement covered in blood with a nasty laceration to his head. I get to work on him, patching him up with 4x4s and cling wrap, mvoing his clothes and asking if his neck hurts.
He looks at me blankly after denying pain and says. "Man, don't I know you? You look familar."
"People tell me I look like Russel Crowe and George Clooney only better looking. Thats probably it."
"No, I've seen you before."
I shake my head. "No you haven't. Can you walk?"
He shuffles over to the truck wrapped in one of our blankets as ALS 4 is dispatched to check on the pregnant woman they were fighting over.
Once we drop him off at CMC I write my report and fall asleep in the truck on the way back to quarters for shift changes. When I hand Eric the radio for ALS3 and thus pass the torch he says. "You look like shit, go home."
I reply, "Dude I was just there, I wanna go somewhere else."