Alive:Improved?????

We get ANOTHER call for trouble breathing. This one is to an apartment complex that caters to people who are just barely this side of needing "assisted living."

We've gone there so much that we have a key to the front door on the ambulance as our standard equipment.

We arrive to the 3rd floor apartment to find a woman who is 84 years old, up on her feet, agitated and talking like this:

"I"
GASP
"am"
GASP
"Having"
GASP
"trouble"
GASP
"catching"
GASP
"my"
GASP
"breath"
GASP, WHEEZE GASP

Get it?

I ask her about previous medical history (Heart disease, lung disease, diabetes, hypertension,etc.) and get a "no" at every single one.

She is house proud and wants to jump up out of her seat to open every door, move every piece of furniture, show us every thing every time we move. Over and over again, I ask her to, "Ma'am, PLEASE! Sit down and be still!!" after I've given her 15 liters per minute of oxygen.

Finally, while I'm struggling to fit our large cot into her tiny apartment, She jumps out of her seat! I have to use my 'Cop Voice',

"SIDDOWN! DO NOT MOVE STAY RIGHT THERE!!!" (I'm doing my best to scowl) "You! (I actually point at her) stay right there and let me do my work, OK??"

This earns me a meek nod from my patient as she hungrily sucks on the oxygen mask as if it were water and she was 5 days in the desert.

On the cot, out the door (keys, alarm, etc) into the elevator and into the back of the ambulance. Go, go, go!

I can't really figure out how an 84-year-old woman with NO previous medical history is having this problem just out of the blue at 3:00 am on a Saturday morning.

Until someone knocks on the door of my ambulance.

Now, you must understand that I get this all the time. Curious (Nosy) neighbors who are concerned for the welfare of their friends (Morbidly curious about who's dying before them) are always ready to ask me all kinds of impertinent questions.

I'm ready for this when I find my patient's daughter with a leather-bound book that contains all her mother's medications, medical history and allergies. It turns out our 84-year-old patient has had atrial fibrillation for the past 10 years, Hypertension (high blood pressure) and a whole bunch of other problems for just as long.

"Did you take all your pills today?" I later ask "Mom".

"Pills???" She replies.

Right! Ok! She gets the full work-up. Nowhere in the history I got from the daughter do I read anything about dementia or Alzheimer's disease but I'm trained to presume the worst.

Her Blood pressure is 200/104 (WOW!) and her 12-lead shows the early signs of an inferior MI (this means that the bottom part of the heart is sick and not getting enough blood/oxygen, etc and is not doing its job).

She's NOT complaining of any chest pain but the vague inferior MI signs lead a cautious medic to go above and beyond. We perform a 15-lead (for those of you who have been to a Bob Page seminar, it's V4R, V5-V8 and V6-V9) you all know that a right-sided MI (a sickness or oxygen/blood starvation of the RIGHT side of the heart) is a bad, bad thing. Even more so because we are not regularly taught to diagnose and treat this kind of sickness as a regular part of our training.

(Simply put, the right side of the heart takes blood from the body and pumps it to the lungs so it can dump all the Carbon Dioxide it acquired from the rest of you and trade it off for Oxygen the rest of you needs to keep doing whatever it is that you do!)

The 15-lead shows a very slight deficit (infarct) there. Cardiologists look for at least 2mm of S to T wave segment elevation to tell them that the patient is really sick. I only see 1mm of S-T elevation but she's not hurting yet.

*In my head to myself: "do we have to wait until it's a FULL-ON heart attack before we decide to transport/treat them for a heart attack??*

We give her oxygen, aspirin and not much else as she's not complaining of any pain. Her trouble breathing is still there but she can now talk to us 5-8 words at a time between breaths. When I listen to her lungs, I can hear nothing but good, clean air moving back and forth. If I heard the sound of crackling cellphane or the crinkling of fine paper, that would tell me that her lungs are filling up with fluid, most likely due to congestive heart failure.

I was somewhat disappointed to hear clean/clear lung sounds. A case of pulmonary edema with congestive heart failure is one of those things we can treat really quickly and effectively if we catch it in time. However, things are never this easy!

We decide to go to a cardiac center (clearly, it's a cardiac event!) and we call 'em up by radio.

I've been spoiled. I'm used to talking to Emergency Medicine doctors. They value the opinions and judgement of Paramedics. They know when we speak of a patient who is "combative," for example, we actually mean, "She's drunk, bashed-up, possibly brain-injured but DEFINITELY beating me up and I'm ALL BY MYSELF in the back of this ambulance for the next 10-20 minutes so, PLEASE, give me permission to sedate them to a state of mutual happiness right NOW!

This time, I spoke to a cardiologist.

No fault on them. None at all. However, I think this cardiologist has become too accustomed to working in a hospital or Emergency Department where she has an unlimited number of ER techs, Phlebotomitst, Respiratory Techs, Nurses, Radiologists, Interns and other help at a moment's notice.

In the back of the box? It's me, the scared paramedic intern and the confident, capable EMT-B. And, THAT'S IT!!!

"Give your patient 0.4 to 1.2 milligrams of nitroglycerine (NTG) and monitor vitals" says the cardiologist.

I know. I know that if my patient is truly having a failure of the right side of her heart, she's deader than a doornail not 20 seconds after I give her this medication.

"Roger, [Cardiac Center], I understand your orders per [Doctor So-and-so] for 0.4 to 1.2mg of NTG, however, I must impress upon you that this Medic believes the patient may be suffering an inferior/right sided Myocardial Infarction and NTG may be detrimental to the patient outcome." is what I say over the (recorded) radio.

"understood, Medic XXX. Please administer 0.4 to 1.2mg of NTG, Sub-lingual and report any changes."

"Roger, [Cardiac Center]. 0.4 to 1.2mg NTG as per [Doctor So-and-So], please confirm spelling of doctor's name. "

"Medic XXX, [Doctor So-and-so (spelled out)] authorizes 0.4mg of NTG. Please consult and advise if any changes or if you need orders for further administration."

OK! Now the Cardiologist has had time to refer to her (his?) drug reference and brush up on the concepts of 'Pre-load' and 'After-load'. I think I covered my butt by pinning this on the doctor in question ("Pls confirm spelling...."). I have to say, with a blood pressure of 200/104, I'm not as cautious about giving her a medication that will open all her small arterioles and allow her blood pressure to drop a lot.

I'm also not so cavalier that I don't start two intravenous lines (ways to inject a blood-like fluid or medications into her bloodstream) with 1000ml bags of fluid (one of the most important things we need to revive someone) connected to each one.

We give her ONE dose of Nitroglycerine (0.4mg)

Her blood pressure DROPS!! from 200/104 to 128/60.

OH MY!!!

However, she's still awake and talking to us. All this time I have my hand around her wrist. I'm feeling the pulse of blood through her wrist. At first it was "bounding" or hitting back against my fingers pretty hard.

Unlike my compatriot, I'm not so freaked out by her drop in blood pressure. I can still feel her pulse in her wrist. My thinking is, if her heart is strong enough to push blood all the way out to her wrist, it's strong enough to push blood to her brain, into her lungs and to back-flow into the arteries of her heart. Yeah, we dropped her pressure HUGE but she's still going.

In the ER, the Cardiologist asks me if we gave her ANOTHER nitroglycerine dose.

"Hell, No!" I reply

"Why not?" She asks me with a cross look on her face.

I put my hand on her arm, "Doc, have you ever worked alone?"

She looks puzzled. This is a foreign concept to her.

Alive: Improved.

--maddog

Alive:Improved

The call goes out as "Trouble Breathing"

CC-Rider and I are together again. Our driver, SmokeyJoe, is a recent Paramedic who's still getting his ride time in. He left the USMC and started paramedic school when he was 32. (Sound familiar?)

CC-Rider says to the both of us, "This is your call! I'm driving!" She clearly has much faith in us.

The "trouble breathing" is a woman sitting on the floor in the open front door of her house when we arrive. Her face, lips and neck are about twice the size they should be and she speaks to us in a pattern like this:

"I...GASP...ate...GASP...a...GASP...pistachio...GASP..." (you get the picture).

"Ma'am, are you allergic to anything?"

"Yes...GASP..nuts...GASP!"

I look at SmokeyJoe over the top of my glasses and see his eyebrows do their best to meet his hairline.

Ooooookay! it's GO TIME!

I don't need my stethoscope to tell me that she's closing up. From a foot away I can hear a noise like "HeeeeEEEEEEP!" every time she breathes in. My stethoscope does tell me that she's not moving any air in her lungs other than the very center of her chest. Basically, this means that her allergic reaction is causing the muscles around her bronchioles (the smaller pipes that lead from your windpipe, or bronchia, to the business parts of your lungs) have all squeezed down really hard and are blocking any air from getting to the parts of her lungs that will enable her to get oxygen into her body and carbon dioxide out.

This is what we call, "bad."

Her husband hovers nervously in the foyer. SmokeyJoe and I waste no time. We practically fling her onto our cot, dash the 10 yards to the medic unit and load her up. CC-Rider is already there and bobs her eyebrows at me, asking what to do.

"Epi, IM." I tell her, indicating her to inject 0.3mg of epinephrine into my patient's arm muscle. This is a pretty cool drug. The paramedics in the UK accurately call this drug adrenaline. That's what it is. It's the thing that makes your lungs open up, heart race, blood vessels constrict and dries up any secretions in your mucous membranes. (Pseudo-ephedrine, or sinus medications is a form of this). The dose we give people having allergic reactions (anaphylaxis) is, for the human body, HUGE!

It works quickly and very well, however, it just buys us time. It'll probably wear off before she's done having an allergic reaction. SmokeyJoe tries and fails to get an IV line on twice. I tell him to start a neb of albuterol. This is a drug that acts directly on the aforementioned bronchioles and cause them to open up. We deliver it by nebulizing it so the patient breathes it directly into the lungs (quickest way to get it where it's needed).

Meanwhile, I drop the IV perfectly into the patient's left arm. This is significant in that it's my first successful IV in over a year (not a lot of chances to start one when you're a teacher) and I was nervous that I had "lost" my skills. CC-Rider jumps in the driver's seat and we roll. Our patient is breathing easily and has the hyper, nervous laugh that comes with getting jacked up with more adrenaline than your body can make in an hour.

She's not the only one breathing easier. SmokeyJoe and I are already confident in the fact we had a "save."

What I mean is, had we not arrived (or arrived late) this one would have closed up and suffocated. She'd be dead at age 33 and her husband would be a lost and confused man, having watched his young wife die before his eyes.

We turn her over to the friendly staff at the local hospital and in the part of my paperwork that says, "Condition of Patient Upon Arrival at Destination:" I gladly choose "Alive:Improved."

Life? It's good.

--maddog

Epiloge: I saw her a few hours later when we brought another patient at the same hospital. The sight of her happy (normally sized) face made up for the "died-despite-all-we-did-and-we-did-it-right" condition of my current patient.