On the Way to Paramedic in Northern VA
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Sunday, April 30 2006
Treat the Patient

"DTs," you fume. "Where have you been?"

Flat on my back lo these many days. My partner and I were lifting a 260 pound patient from our cot to his powered chair. Rather than grab the patient directly, a most undignified method, we were lifting the sheet on which the patient reposed - my partner had the shoulders and I below the knees.

Would that we had the same sheet, but alas we found that the patient had two sheets beneath him, which tried to separate while the patient was a-swing between cot and chair. A flashy dive-and-grab maneuver by Our Hero saved the patient from falling into the cot-chair chasm, but at what cost?

None, it seemed.

Our next call required someone to Press A Button to raise the bed. DTs did so, and somehow the combination of 1) Lean slightly, 2) Extend Index Finger, and 3) Press Button resulted in a snapping/cracking sound. DTs' spine separated at around L3, the ends protruding through his back and tenting out his uniform in a decidedly disturbing fashion.

The Shift, it would seem, was over.

And so, arriving home, Florence N. (not her real name) turned our modest quarters into Rehab Central. Heating pads, cold pads, and vibrating pads dominated, with TWO types of massage machine thrown into the decor whose central piece was Flexible Straws, those tiny tubes with bendy bits, so that DTs could self-medicate with Merlot and Burgundy while flat on his back. And Vicodin, but never (of course, smirk) in conjunction with alcohol. Let the healing begin.

And so time passed, until at last DTs felt able to attempt the tricky business of patient care.

Now, one of the coolest toys we get to play with is the Lifepak. Heart monitor, defibrillator (shocky-thingy where everyone goes "Clear!"), blood-pressure-taker and pulse-oximeter, the Lifepak Does It All. Heck, the thing is much like a car in that it can be fitted with Packages and Options - for instance, the Arterial Line Monitor Package, the 12-Lead Package, and the Expiratory CO2 Measurement Package.

Your EMT-B's eyes light up when learning to use this wonderful little toy, and it often seems they're not listening as the instructors chant, in forlorn tones, the mantra "Treat the PATIENT, not the MONITOR." Yeah, sure Bruce. Hey look! I made it beep all the time!

Our patient was a middle-aged woman with a decades-long history of imbibing ONE GALLON of hard liquor each and every day, washed down with a case of beer. Then she stopped, presenting the ED with classic symptoms of withdrawal - delirium tremors, hallucinations (both tactile and visual), and a general anxiety about this giving-up-the-booze idea. In the few hours it took the ED to "stabilize" the patient she received massive doses (massive!) of valium, ativan, thiamine, electrolytes and phenobarbital. Her tremors had subsided to the point of resembling extreme Parkinson's, sort of "Wow!" on our part and "You should have seen her earlier" on the nurses's.

The patient is conscious and I'm in the box with her as we transport to another hospital. She points out small, furry creatures in my ambulance.

"You don't see that little thing?" she asks. "It's right there, coming out of the wall! You don't believe me!"

"Well," I reply, "I don't see it - but I believe you do. Maybe it is there and I'm just not in the right frame of mind to see it." Deep philosophy but we're pals now.

Beep! Beep! Beep! says the Lifepak. A quick check shows that one of the wires has come off the patient - the little stickum is not sticky any more. I replace the stickum and wire, and all is well.

The patient is deep into a story, and chuckling.

Beep! Beep! Beep! says the Lifepak. And then, "Check Patient!" and a two-tone wail. I think, "Another wire, possibly, but why the urgent whooping noise?" and notice the waveform on the monitor. My patient is in VFib. Oh shit oh dear.

VFib, or ventricular fibrillation, is one of those rhythms we get to shock you back to life, because you mostly be dead.

"What's that thing doing?" asks the patient.

DTs' eyebrow rises. Fascinating.

The wailing stops. A quick look at the monitor and the patient is, in fact, back in a sinus rhythm. This is a good rhythm, thinks he to himself.

The patient, having paused ever so briefly because of the noisy interruption, resumes and finishes her story.

Hmmm, thinks DTs. A fluke. Possibly a malfunction in the-

Beep! Beep! Beep! "Check Patient!" Bee-doo bee-doo bee-doo bee-doo...

Again with the VFib. Again, also, the patient is breathing, awake, alert, oriented, non-diaphoretic, good skin tone, and asking about "that darned noise".

Again, after 30 seconds, the noise stops.

Maybe it's the tremors plus the drugs somehow, somehow fooling the machine into-

Bee-doo, bee-doo, bee-doo...

Enough! DTs presses the "Print" button on the Lifepak. There. Hands-free shock pads are right there but let's not worry the patient by applying them yet, they take two seconds to slap on. Airway stuff is out and ready. Wondering about our protocols, which follow the ACLS standard. Shock, yes, but does this patient really need epinephrine on board? With those tremors? Hmmm...

Of course, with the printer recording the waveform, the patient's heart refuses to enter VFib again. We deliver an alert patient to the ICU, and DTs does not disconnect the Lifepak until the ICU staff is ready to place the patient on their monitor. I give report, stating that the patient has done the VFib dance three times.

The RN is skeptical. "Well," says DTs, "I'm going to check out our Lifepak..."

Bee-doo, bee-doo, bee-doo - from the ICU monitor. The nurses spring into action, but stop, staring.

"Damn," says the patient. "That noise is in here, too!"

I resist the urge to ask, "What noise?" for DTs is not a cruel fellow.


Tuesday, April 04 2006
Patient Provider Education

Hanging on the wall, in most hospitals, is a Patient's Rights notice. There's some sort of acronym (I forget what it spells). The gist of the thing is that the patient is encouraged to ask questions of the health providers, educate themselves to both diagnoses and treatments, become active in the management of their illness, etc.

Some Bambulance Folk have been doing this since Day 1, in their small way, and DTs is of that ilk. We sharing types will take a blood pressure, heart rate, look at their rhythms, all that jazz. While we don't necessarily volunteer the information - some patients find it boring, or just don't want to know - we will if asked cheerfully tell them what we've found. Hey, it's their blood pressure after all, we simply measured it.

Some folk do ask, but one can tell they're too anxious. "What was my blood pressure? Was it good? Is it high?"

"What, did I frown or something?" asks DTs with a laugh. "Sorry! Well, it was 120 over 80, which is very, very good. Now that I foolishly worried you, though..."

It is in that vein of Educating Patients that I had a somewhat bizarre encounter.

Our patient was a middle-aged man with a non-tumorous growth near the brain. Our transport was taking him to the neuro center for the operation to remove it.

"They said it's over here, somewhere" said the patient, pointing at his head. "They said it's not cancerous." The patient seemed calm, unafraid, but something in the voice indicated he was frustrated with his own lack of knowledge about what was going on three centimeters from his index finger.

Somewhere?

"They, uh, didn't show you the CT or MRI?" asks DTs in all innocence.

"No," said the patient.

Hmmm. Decisions, decisions. I had a big packet of CT and MRI films which was going with the patient. On the one hand, there might be a very good reason why they didn't want to show them to the patient. On the other hand, this wasn't like a BP - I did not produce these films. Gripping hand, however, they are pics of this guy's skull, and the hospital has these neat little posters on the wall practically begging patients to show an interest in their treatments. Okay then.

"You know," says DTs, "They sent the films. If you want, we can take a look at them, but I have to tell you, I am in no way, shape or form a radiologist. I can't tell if anything's normal or abnormal and I probably can't answer any questions. But it's your head, you know, if you want to take a peek."

"Sure!" says the patient.

Folks, I am seriously rethinking this "share information" thing, and I'll tell you why.

DTs randomly selected a sheet from a folder of forty or more films. Each film had about twenty shots of the guy's head on it. Starting at the top, left to right, we're looking at the thing. Yep, it is pretty cryptic.

"See," said DTs. "I mean, you can see the brain and all, and here obviously is the skull, but dark patches? Light patches? I can't tell you anything. It is interesting, though, yes?"

"Yes," said the patient. "'Specially that nail."

Nail?

About the second to last frame on that sheet showed a 10-penny nail, suitable for building decks, smack dab in the middle of this guy's head. Point-up, meaning it was driven in somewhere below the jaw.

Wow.

"Uh, they didn't say you had a nail in there, did they?"

"No!" says the patient.

"Not re-enacting scenes from Lethal Weapon 2 at home, I take it?"

"Not recently," the patient laughed.

"Well, hell," says DTs, unprofessionally. "That ain't right. But it is non-cancerous, if you want to be nit-picky."

Quite understandably, more sheets are reviewed. None other shows a nail. Now, radiologists do sometimes use markers, kind of like "See here?" arrows, on the films, but this is definitely a nail, folks. Pointy end, three inches long, flat surface for hammering. Only on the one frame. If it was an arrow, it was the dumbest arrow design I have ever heard of. Why not put a ring of bullet-shaped objects around what you wanted to highlight, too? Or use a steel dagger to point out broken bones? And, if it was an arrow, why wasn't it outside the skull pointing in, rather than in the center of the brain?

"You know what I think?" says DTs. "I think this is some kind of gotcha, one radiologist to another. Kind of an in-joke or something."

"That's what I think, too," said the patient.

"Cuz, I mean, if you had a nail in your head, I should think they'd mention it."

"Yeah, you'd think so."

"And you'd probably remember getting it - somehow - in there," DTs continues.

"Unless having a nail in your head would make you forget the event," the patient pointed out.

"Pretty damned good aim for a nail, though," said DTs. "Why don't we let's put this all back and enjoy the ride. I'll take your blood pressure..."



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Posted Friday, May 12 2006 12:57  Site Meter