Wednesday, August 29, 2007

Rapid Sequence Immobilization

Aided with adrenaline and substances yet unknown to us, the man flexed his substantial muscles and screamed against his bounds. He let out anguished yells, cursing at all of us as we worked to hold him down. He was a big man, and we were all sweating.

My partner and I found him semi-conscious in the grass of a local park about a half hour before. He was lethargic when we walked up to him, his eyes distant and glazed over in some kind of dreamy confusion. He lay about 10 feet away from a twisted-up bicycle from which witnesses said he fell while riding through the park. They said that they knew him personally, that he is a "great guy who is always here with his family." Someone said that he had a history of seizures.

My partner glanced in my direction, and we agreed without words. I put both of my hands up towards my neck and he nodded, heading towards the ambulance for c-spine equipment and the stretcher. I did a quick assessment while I waited for the rest of the gear. No visible traumatic injuries, lung sounds clear, strong radial pulse at about 100, PEARRL. Blood sugar is 200. When my partner came back with the equipment we worked together with firefighters to roll the large man onto the board, securing his head, torso, and legs with snug straps. My partner and I bent our legs and then straightened, grunting as we lifted the massive package up to the stretcher.

In the ambulance the man began to come around. He was confused still, asking repetitive questions and often making statements that made no sense. I did my best to get a history and some background information, but the man was a poor historian at best. I got a full set of vitals, plugged in the EKG, started an IV, and told my partner we could go. The man remained confused the whole way, and despite my reassessments and double checking, I found very little that swayed me from a routine clinical impression of postictal-related altered mental status.

The man began to get a little more agitated as we rolled down the ED hallways towards the triage desk. He lifted his hands up towards the c-collar, but I was able to gently guide his hands away and talk him down. He listened to my words, agreeing momentarily but again reaching towards his restrictions a minute later. I told the triage nurse that it was probably only a matter of time before the patient lost control and ripped himself off of the board. He had that look that we have all seen before: chaos about to happen.

It did happen. About 5 minutes after getting him over the hospital bed, the patient began to lose control. Quiet requests turned into agitated demands, and then into senseless screaming. He pulled his head out of the blocks, the tape snapping and velcro ripping, all the while pulling at the backboard straps and rolling from side to side. The nurses and techs tried to calm him down, offer comforting advice through smooth tones, but the patient would hear none of it. He was on a one-way path, and would not come back. My partner and I jumped in to help, and even with our numbers, we struggled.

The doc strolled in casually, his white jacket crisp and clean, separate from the mess that was rapidly overtaking the small ED room. He asked for the story, and I told him while holding the patient down: a few brief details and a couple questions answered. He tried a round of Haldol and Ativan but it was without effect, and after another 10 minutes of fighting, the doctor casually waved his hand towards the intubation tray. The nurses, anticipating this decision, already had everything ready.

Rocuronium was sent through my IV, and within seconds, the patient was flaccid and docile. It was as if someone had found the patient's OFF button and finally decided to throw the switch, ending almost instantaneously the aggression we had been fighting for the past 20 minutes. Easy as pie, the doctor slid a miller blade into the open mouth, lifted, and passed the tube. It was good, of course. Everything was good.

I met up with the doctor later. The toxicology reports had come back, which indicated that the patient had extremely high levels of PCP in his system. It looked like the patient had smoked some of the drug before his bike ride through the park, and collapsed when the effects hit their peak. The potential trauma was still an issue, but the patient was not. He lay across the hall, silent except for the sound of the mechanical respirator performing it's windy functions.

The doctor and I discussed the drug a little bit when I made a remark about RSI. I admitted that I was glad the patient was calm with me, because I wouldn't have been able to restrain him in the ambulance if he had lost control then. The doctor was shocked to hear that we didn't have the capability to RSI patients. He stared at me, as if I were joking.

"So basically," he said, "either the patient is dead, or you are not going to get the tube?"

I admitted that this was probably the case for much of the time.

The doc sat back in his seat, thinking for a second.

"Jeez. You're right. Good thing he didn't come 'round till you got him here."

Thursday, August 23, 2007

Biggest Drill Ever

People who have done this before at Katrina, and others who have had experience with the military all admit that this is the way things tend to go. It was new for me, though.

Nine of us received phone calls at about 0730 on Sunday morning, just five hours after many of us got home after a long shift at the concert venue. The message was direct, but hollowed out and filled with mystery: get up, get packed, expect to leave within the next couple hours. It was chaos from the get-go, as most of us had no idea what to pack, how to pack it, and what might lie ahead. Groggily we all asked whatever questions we could muster when the phone calls came, but the supervisors calling didn't know the answers. All we know is that you are heading out today, probably soon, they said. Plan for seventeen days.

I got up and packed whatever I could think of, wondering if this was a good idea. I had already said that I would go, but this morning I wasn't quite so sure. I packed seven pairs of EMS pants with matching uniform shirts, loads of underwear, socks and various t-shirts. I remembered a rain suit and my MP3 player, a camera and the cell phone. I ran to the store quickly and bought granola bars and travel-size toiletries. When we finally got the call to go, I almost walked out of the door without my boots.

It is a scary thing to respond to a call like this. The storm had not yet hit, and none of us had any idea when, where, or how hard it would. On the TV they were showing frightening looking images of circular swirling clouds in the Atlantic ocean, arrows of potential paths swinging westward and slightly to the north, fading out in uncertainty around landfall. At the airport we huddled around together and nervously chatted about what may lay ahead. There were a few with us who had done this before, and we relied on them for whatever information we could get a hold of. As we sat and waited for our flights a few people told stories of their time at Katrina, horrible and haunting. Some of their experiences made my bones chill.

Through a layover we ended up in San Antonio Texas at about 0100, where a bus driver waited for us with a sign that read FEMA EMS DISASTER RELIEF. Stepping out of the airport was like walking into a sauna. We all staggered a bit at the heat, even at this early hour the air was saturated with thick humidity and almost hot to the touch. We weren't used to this at all.

The driver took us to a base of operations about 20 minutes away. It was obvious when we had arrived at our destination: idling ambulances lined the streets for blocks surrounding the building, which sat aglow from generator-powered overhead lights. There were hundreds of cardboard boxes filled with supplies in neat stacks at various locations outside of the building, and workers walked quickly from pile to pile with clipboards and packages like worker ants sprawling the terrain. The place was alive, and everyone was busy.

We got a quick briefing from one of our administrators, who had taken an earlier flight down. He was sweaty and looked tired already, having spent a number of hours preparing hundreds of brand new Nextel phones. Sitting back from his work for a moment, he informed us that we didn't know when we would be moving out, but it would probably be in a few hours. The main base of operations was at Kelly Air Force base, an hour away, where we would receive further instructions. Until then, he said, we should grab a spot on the floor and try and get some sleep. On the floor? It was concrete with a thin carpet, but we were exhausted. I bunched up a sweatshirt for a pillow and was asleep within minutes.

It was a consistent theme throughout our deployment that information would be
both set at a premium and low in supply. From nights on the floor to travel arrangements that changed as sure as hours passed, it seemed rare that our group heard about plans that would actually occur, reliable news about the hurricane's path, or informed truth about large-scale decisions. We were all used to working small-scale: champions of the backs of our ambulances and the source of decisions to be made on scenes. The patient laid out before us in clear presentation of the problem at hand. It was strikingly clear on our first night of this deployment, though, that we would not be experiencing the familiar. Our view was instead from the bottom-up, clouded by rumor and indirect contact with the management, and while we listened and obeyed, the decisions brought down made little sense to us other than that they came from authority who presumably knew better. Uninformed, we entrusted ourselves to the greater machine and blindly did as we were told.

We were awoken twice in the middle of the night from our snoring slumber, asked to perform a few minor tasks, and then let back to bed. Later in the day we were brought to the air force base, packed 6 deep in the back of a modular ambulance along with piles of suitcases. It was sweltering hot, and we sat quietly as the loaded ambulance labored through unfamiliar streets. We all remained in good spirits though, uncomfortable but inspired by the magnitude and meaning of our presence.

We arrived on the outskirts of the base, greeted by an incredible view of ambulances that had already arrived. They stretched off in the distance to vanish points, row after row. I have never seen so many ambulances together in once place. It was difficult to appreciate the view through my camera lens, but I made an effort:

After a brief wait at the staging point, we were brought by bus to another section at the base where we were to stay. It was an extremely large multi-purpose building, expansive on the inside with carpeted concrete floors and pillars spread out in grid fashion. We were given fold-out cots and a blanket, and told to settle down where we liked. Our group picked a spot in the corner, adding a margin of privacy by stacking the cardboard cot boxes in a makeshift wall in front of us. Many others followed suit as they arrived, and in a number of hours the building was a maze of sleeping EMS workers, cots, boxes, and tables.

It was here where we spent the rest of our deployment. We were there for two days, waiting on instructions to move south that never came. FEMA supplied the some 700 EMS workers who responded with ample sleeping supplies, hygiene kits, and food. Information remained spotty and often incorrect, while rumors were constantly passed from camp to camp about what our fates might be. At night when the lights were turned down, flipped-open cell phones were visible across the room like stars as workers searched the internet and friends for updates on the storm's path. We played cards, watched DVDs on laptops, and slept as much as possible.

While we waited, the storm crept onward towards Mexico, never swinging north as so many had feared. Word was passed around about the diminishing storm categories, from five to four to three to one.

On Wednesday a large group circled around the center of the room to hear news of our dismissal. Representatives from FEMA and Texas thanked us for our response and apologized for our inconvenience, giving the official word that we could all go home. Everyone clapped, a bit disappointed for the lack of action but ready to leave.

Our group left in a caravan of ambulances at 0500, ready for the 15 hour trip from San Antonio to Gulfport MS. It must have been a sight to see our 18 ambulances rolling down the road, filled with EMTs and Paramedics unshaven and exhausted looking. We emptied our fuel tanks twice, each time gathering at truck stops and joking around, taking photos of our group in front of ambulances that used to be part of our own divisions. Some people were extremely frustrated with the situation, becoming loudly vocal about their discontent from time to time. One group from another division taped signs to the back of their ambulances reading "Lied 2" and "Corporate Puppet" in lieu of our missing license plates. Most of us rolled our eyes at the complaints, though, and the experienced members of our group commented that such frustrations were absolutely typical of large operations like this one. The time-honored military motto of "hurry up and wait" was mentioned often, and despite the frequent frustrations, most of us remained in good spirits.

Towards the end of the drive we crossed through New Orleans and the surrounding areas affected by hurricane Katrina. I had never been there before, but was shocked to see how much of the damage still lingered even as viewed from the highway. We passed countless homes that remained crushed and broken, roofs folded in and windows smashed. I rode with a medic who was in this area for the storm, and he pointed to the left and right as we drove through, talking about where the water was and what the terrain looked like then. We drove over a large overpass which he said was almost taken over completely by the onrushing waters. Looking over the now dry and damaged terrain, it was difficult to imagine the forces that caused so much wreckage.

Many of us, myself included, were at least in some small way disappointed that Hurricane Dean stayed so far south. We wanted at least a little bit of "action," and wanted to charge into broken areas and work. Seeing this destruction, though, firmly grounded us. The extent of what a hurricane can do was never palpably clear to us, and realizing what disaster was avoided, all we could do was thank god nothing like this happened again.

We took flights the next morning out of the south and back home. On the way we discussed FEMA and the response, whether we would come back on the next deployment. Just about all of us said we would. Though the hurricane did not hit US land, this was in effect the largest drill FEMA has ever conducted, and with the experience under our collective belts, we each look forward to coming back and doing it better- next time.

Sunday, August 19, 2007


Hey folks, sorry its been a while since I've posted, but it is going to be even longer now. I got word last night several people from my company including myself are getting deployed to Texas to help out with the potential aftermath of hurricane Dean. It is still unknown whether it will actually hit Texas, or what kind of damage it will cause if it does, but FEMA is trying to get us down there ahead of time, and my flight leaves today at 3:00 for Atlanta.

I'll return with lots of photos and stories.