Tuesday, November 20, 2007

SICK

Ohhhhhhhhhhhhhhh, I am SO tired but I have to debrief what happened on last night's shift before I can sleep this morning. Remember my categories, SICK and not sick? Last night shortly after shift change we got called code 3 (lights and sirens) for a headache!?!?!? We had a really far run for this address, and we kept wondering why a headache would get a code 3 ambulance. We were met at this house in the woods by a frantic man waving and hollering...hmmmm, not a good sign, but we get a fair number of frantic family members for not sick patients, so we didn't get too excited. As a matter of fact, my partner was driving and he clunked the back fender into the low rock wall surrounding the garden next to the house and we both howled with laughter for a few seconds as I teased him about it.
We followed the frantic husband upstairs and were greeted by the cutest kids, 4.5 and 3 years old. I rounded the corner at the top of the stairs and knew immediately from my first glance that this was no minor call. Our patient was a 30 year old woman and at this point unconscious and alternately flushed hot, and pale cold. When I first touched her I thought she had a fever, and a few minutes later was shocked by how cold she was. When I dug my finger into the soft part between her jaw and her earlobe (a pain stimulus that rouses all but the unrousable) she opened her eyes and moaned, but quickly returned to unconsciousness and then began to vomit copious amounts of curried bile. Yum. Of COURSE we did not have our portable suction with us, as we had not thought it necessary for a headache call! And--this is the killer--of COURSE I did not have the rolled up plastic garbage bags I ALWAYS carry in my pocket for puke and bloody clothes so it got all over the couch, floor, pulse oximeter, jump bag, myself, and my partner. It took us 3-4 minutes of intense work just to manage her airway at that point.
Our medical assessments are broken down into sections. The first 2-3 minutes is what we call our primary survey: assess level of consciousness (there are many levels, not just 'awake' or 'unconscious'), whether there was trauma involved and the need for c-spine precautions (broken neck/back), check for a clear airway, adequate breathing, adequate circulation, and do a quick, hands on once-over of the whole body. In the primary survey if you find a problem with any of the above, you fix or maintain it, and your patient is considered unstable and gets one of two things: #1 a protocol with drugs/IV/in depth assessment and then rapidly put in the ambulance, or #2 get the hell out of there and into the ambulance as fast as possible.
If, by the end of your primary survey and a set of vital signs, you as a paramedic don't know with 90% certainty what is going on, it's time to get the hell out of there. I did a primary survey and a quick set of vitals and had no idea what I was dealing with so we rolled her in a blanket to protect us from the puke, which she promptly puked on again, and hauled her out to the ambulance.
We took off to the hospital code 3--a RARE occurrence, as we often arrive code 3 and then either stabilize or realize the patient is in the not sick category, and drive with no lights or sirens to the hospital. If you ever see an ambulance going code 3 with only one paramedic in the front seat, and/or lights on in the back of the ambulance and people back there, someone is pretty close to dying in the back. Or needs major surgery: ie, amputated part, limb threatening injury, or simply involved in an accident involving pretty significant deceleration or trauma and may need surgery for internal injuries and/or bleeding. The next part of our medical assessment is the secondary survey and is more involved. On my secondary survey I took a look at the medications she was on (which we threw in a bag and brought with us), considered her recent health problems or lack thereof, and did a detailed physical exam including pupils, pain response on all 4 limbs, listen to her chest and bowels, and check for injuries, abnormalities, and clues as to why she was in her current condition. And started an IV. I had to try twice because the first one made her yank her hand away from me and it blew and bled everywhere. Blood and puke together; awesome. My second try was a success. Pretty quickly into my secondary survey I shortlisted two probable causes: drug overdose or a stroke. When I got to her feet I heavily leaned towards a stroke because she had no response to pain in one leg, and no reflexes. Plus, she was on estrogen birth control, which can cause strokes, and naproxen, a painkiller that can cause brain bleeds. The only thing still dragging me towards the possibility of a drug overdose was a history of depression and the fact that she had 4 or 5 bottles of the naproxen in various stages of emptiness...later, a toxocology screen showed some opiates in her system and realistically my protocol includes a shot of narcan but I withheld it because I saw no evidence of narcotics...anyways, narcotics were not to blame for her condition.
We called ahead to warn the ER we were bringing in a SICK one and usually when that happens the trauma bay is cleared up and the staff ready to roll as soon as you walk in the door. We came in and I started, "This is the one we called about....." and my voice petered away as I looked around the Chilliwack ER at a frieking war zone; there were at least 4 patients in there as sick as mine, and one being actively resuscitated. There was plastic tubing, discarded plastic packaging, clothing, and bloody towels all over the floor, and people were literally RUNNING from place to place...the best I could do was wait for triage and the best she could do for me was to put my patient in the pediatric bed. Where my patient promptly vomited. Again. At this point, everywhere I go all I can smell is barf! Pretty quickly we had a team of people in the pediatric bay, all talking at once and everyone's questioning glance on me for answers...her nurse looked me in the eye and asked me, "Why is she sick?" a professional triumph for me, because that means she trusts me. She's seen me work for six weeks now and trusts my judgement. Very cool. "Either a CVA or a drug overdose," and I give her the rundown of my pertinent findings.
While actively suctioning to clear her airway of yet more vomit. How much food can one stomach HOLD for pete's sake? Then she blew a pupil and we all knew it wasn't a drug overdose. Her eyes started deviating up and towards the left, which is where her headache originated, and which signals swelling of the brain on the side the eyes are looking towards.
Sick, sick, sick.
My heart howled. She's only 30. Her kids are my kids' age.
Two hours later we took her code 3 with a nurse and respiratory therapist to Royal Columbian for neurosurgery for a brain aneurism. This time I was driving and we made it from Chilliwack hospital to the Royal Columbian, door to door, in 39 minutes. Whew, I'm fast! She was intubated, catheterized, IV drug administered, and on a cardiac monitor. Ready for brain surgery. One minute she was talking to her husband, the next she was overcome by a headache, and sixteen minutes later we arrived and encountered what I described, and a couple of hours later she is having brain surgery! Crazy. Sad. Random. Hug your kids, people. Life is short.

5 comments:

Dana said...

Wow. Your last two posts have made my heart ache. The impact on lives part is heartwrenching and sure hard to read. Your patients (and friend) are in my prayers.

The technical stuff is fascinating!! Keep it coming, I for one love hearing all the details.

Dawn and Dale said...

WOW! That is unbelievable!! Thank God her husband was home!! Could you imagine??!! Insane!!

Will you ever get to hear how she's doing now???!!

nancy said...

2 nurses I have worked with had husbands who died of ruptured brain aneurisms. Recognition and treatment of the condition has come a long way to the point people at least have a chance at survival. Every second counts and I'm really impressed with your diagnostic skills Melissa! As soon as you said code 3 for a headache I thought aneurism, only because of what this nurse told me about her husband - not from anything I learned in medicine!

Roboseyo said...

melly-cat, you're a flippin' badass!

"Hug your kids, people. Life is short."

tamie, the tamie said...

you rock. your job is crazy. i love reading your blog.