Track Marks

Do drug abusers ever get sick?

There is a particular posture that can be attributed to healthcare providers of any level when confronted with these types of patients. Maybe it is anger, or disgust. Perhaps it is mistrust or simply exhaustion from all of the shit that smells the same way coming through our doors. Signs and symptoms aside, if you, your chart, or your mannerism stipulates that you are a drug abuser: you will be mistreated.

This week, I watched an ER physician withhold ventilations from an opiate overdose with a respiratory rate of six. "He shouldn't have shot up" was the justification. The kid was cyanotic and looked like shit. When the narcan went in, they slapped him in the face in order to help revive their still unresponsive patient, and when he woke up denying drugs, the doctors told him that the narcan would kill him if he wasn't honest about his drug usage.

Same day, same hospital, I brought in a patient with profound right sided weakness, obvious right side facial droop, and a blood pressure of 180/100- all an acute onset 30 minutes before our arrival at the hospital. The patient was obviously frightened, and perhaps by some lapse of judgment she let loose through her slurred speech that she had used cocaine the night before. Hearing this, the triage nurse rolled her eyes. She got a bed in the hallway and I had to make a scene at the hospital in order to get some attention for my patient.

Impose whatever judgment you will upon these ED providers, but I have personally seen these same people provide absolutely top notch care. I've witnessed them go above and beyond to provide emotional support, and I've watched as their expertise illuminated acute pathologies that only great experience and skill could have possibly recognized. I've seen these people as shining stars within their departments, and even thought to myself that if I were ever injured on the job, these are the people I would like in charge of my care.

But then again, I don't do drugs.

Let the ECGs do the Blogging

Cardiology is one of my favorite aspects of this job. I find electrophysiology fascinating, and I relish every opportunity I get to look over an interesting ECG strip. I know some of my readers share some of the same interests, so I thought I'd post some strips from the past few weeks. I'll let the printouts do most of the talking:

80 year old male found seated in his recliner watching TV:




40 year old female feeling "weak" at Wal-Mart:



The nurses said this patient looked "restless." (This is the patient from Points of View):

Their Emergencies

I met a man and had a short conversation with him. He had a headache, ten out of ten, and couldn't talk about anything else but the pain. We were less than a mile from the hospital when he started mumbling incoherently and then went unresponsive. I found out a few hours later he had an acute subarachnoid hemorrhage, so massive that even the neurology folks stepped back in awe. He was forty years old, and alone in this country without family. For the rest of the day I brought patients into that same ER, placing far less sick people into their cots just a few doors down where this man lay, intubated and alone.

***

I transferred a lady out of the hospital a few days ago after a ten day admission for a swollen foot. She was pretty old and had a complicated medical history but was cheerful nonetheless. She laughed at some of my jokes and rested while I finished up the transfer paperwork. We fluffed her pillow at the nursing home before we left. Today I passed a number 8 endotracheal tube through her vocal cords and directed CPR even as her ribs cracked under the pressure. I couldn't get an IV and had to drill an IO into her tibia. Futile, though, as despite our sweat and effort the flat lines prevailed. She looked like a different lady than I had seen just a few days prior.

***

Raise your eyebrows if you like, but it makes me somewhat uncomfortable when through their stories, patients become people. A symptomatic tachycardia does not demand empathy. A clonic seizure can't crush a provider's spirit. Only people can do that. Only stories with which we can identify, only smiles and conversations can have that effect.

Prudence demands that we separate the disease from the person. Insult hits much harder than injury, and I think anyone who sees these kinds of things on a daily basis needs to put barriers between these patients and themselves. My paramedic instructor had a mantra that we were advised to live by, that these are "not our emergencies." I remember feeling that the concept was somewhat cold, uncaring, and against the grain of this medical field that I saw as powered through compassion.

Today, I understand its utility.

Points of View

We did a really good job, I'm not afraid to say it.

The guy was having a MI and we caught it on the ECG despite a baseline altered mental status and no clear chief complaint. We treated appropriately and gave a report on the way to the hospital that got the cath lab open and waiting for us. Door to balloon time was under 15 minutes, a lifesaving success for which my partner and I proudly accept our portion of the credit.

We followed the patient right up to the cath lab and bore witness as our inferior/lateral/posterior ST segment elevations gave way to a serious occlusion of the proximal circumflex artery. It was exactly where we thought it might be, and in the darkened surgery suite, my partner and I beamed.

We got some handshakes and genuine praise from the ED doctors. They said we did an excellent job, that they wished every call went this way, and that we should keep up the good work. It was only a few kind words but it meant the world to us.

Our supervisor was waiting for us when we returned to the ambulance. He was there when we arrived with the patient, and it seems he noticed in our haste we had forgotten to secure one of the four straps that hold our patient to the stretcher. The other three where in place, but I had removed the top strap because it was causing artifact on the twelve-lead ECG.

Pulling the yellow carbon copy from his stack of citations, he handed me my notice. "You should have put the straps back together before taking the patient out of the ambulance." A written warning. Next offense I'll get suspended.


Out of the clouds, Baby Medic. Back to reality.