A middle aged man dressed in painting gear was standing in the hallway when we reached the apartment door.
"It don't smell so good in there," he said.
It didnt. It was awful, actually. The apartment was littered with trash all over the place, stacks of empty liquor bottles, fast food containers, and halfway crushed cigarette boxes covered the floor to the point where we couldn't see the carpet. A thick stench immersed the whole area like fog, sticking to our clothes and clogging our nostrils. We couldn't find a light switch that would work, but the dingy light filtering though milky windowpanes told us more than we needed to know.
There was dark, coffee-ground looking blood everywhere. It was piled in neat circles at various points around the apartment. On the floor next to the couch, in the toilet, over the side of the bed. A firefighter warned me just as I was about to step in some that I had missed. This man had been sick - horribly, violently sick - for some time before we arrived.
We found him in the kitchen. He was on the floor, crumpled forward against the lower cabinets in a semi-crouching position, frozen there. His arms were limp at his sides, awkwardly positioned in an unnatural angle. His head was down, but tilted to the right just enough so that I could see that the entire face had turned a dark blackish blue color. His skin was a sickly greenish hue and had a puffy, wax-like appearance. The same firefighter who had warned me about the blood covered his mouth and nose, recoiling in disgust.
Our patient was dead, plainly so and had been for some time. I held my breath as I leaned in to attach the ECG stickers, pressed the power button and let the flat lines roll.
He was 46 years old.
Wednesday, January 30, 2008
Tuesday, January 22, 2008
Proof in the Pudding
It was our third dispatch for chest pain that morning, and when I heard the call I rolled my eyes anticipating more of the same. The first two were "nothing" chest pains, pleuritic at best and nonexistent at worst, my partner and I were both sick of carrying these people from their third floor apartments without elevators, huffing and puffing as our visible, exasperated breaths lingered in the winter air.
It made it worse to find that the 12 lead ECGs read normal, that the chest pains were reproducible on palpation and respiration, and that there has been a productive cough for a week and a half. Still, these people insisted that they could not walk. They complained of shortness of breath, that they felt nauseous and weakened to the point of exhaustion. They were sick, probably, but not as sick as they (or I) seemed to hope. Sometimes I wonder if these patient's wouldn't share a high five with me if the ECG paper would spit out a few millimeters of ST elevations for once. ...Throw us both a bone, make it all worth it.
Walking into this patient's apartment to find him writhing in bed and clutching his chest did nothing for our attitudes. This was a common presentation, learned perhaps from a cheesy medical soap opera or dramatized movie scene, the complaints of pain were over the top in almost comical fashion, unreal in both magnitude and character. Real heart attacks don't look like this.
Usually, anyways.
Keeping that caveat in mind as we are supposed to, we asked the routine questions in a routinely respectful and interested manner. Tell us the story, what the pain feels like and where it goes. Tell us if you have ever felt this before, when it started and what you were doing at the time. The questions flowed in an almost mindless manner, automatic in their practiced repetition. I listened as the answers tumbled down and collected into their respective categories, and the "not a heart attack" bin was getting full.
There was time to do an ECG while the firefighters helped set up the stair chair (it was the third floor again), so I started to attach the stickers. On the man's chest was a CABG scar, which raised an eyebrow, but we carried on:
I let out a groan. My least favorite kind of ECG: just inconclusive enough that it probably means nothing, just abnormal enough that it can't be ignored. The 12 lead ECG is one of the most objective examinations we can perform, purported to be the gold standard in isolation of cardiac injury. Still, this one waffled.
I gave the guy oxygen, nitro, and asprin, then carried him down the 2 flights of stairs with the help of fire and police officers. The trip to the hospital was uneventful as the patient described to me the remainder of his story. The nitro hadn't changed his pain at all. I performed a more detailed assessment without significant finding, started an IV, and noted stable vital signs in my chart. Routine as can be, I had a good portion of my run-form written before we arrived at the hospital.
**
The doctor looked at my pink ECG strip carefully, and then back at the patient, to the monitor, and again to my ECG strip. He looked VERY interested. Concerned, even.
I watched him with interest and a bit of fear. I wonder what it was that he saw, whether I missed something or perhaps there was a change. I followed his eyes from the strip to the monitor and to the patient, looking for something. ...I couldn't pick it out.
He dropped the paper to the floor and asked the nurse what we had for IV access, his white coat flowing back in the wind as he walked briskly to the medication cabinet. He handed to the vials to the nurse, designating dosages of each. When they changed hands I got a glimpse of their labels: Lopressor and Cardizem. He wanted them both pushed, and right away.
Hushed silence as the nurse drew up the medications.
The nurse pinched my line and pressed the drugs into the IV. The doctor nodded when it was done, staring at the ECG monitor. Still confused, I bent over to pick up my dropped ECG strip.
The man let out a weird sounding grunt, and I could see from my bent position his legs jolt upwards from their rest on the hospital bed. I stood up to see the man with a funny look on his face, at the same time intrigued and releived. The monitor was moving much more slowly now, capturing a normal sinus rhythm at 70. The doctor was smiling.
"What the...?" I started to mumble under my breath, not fully understanding what happened exactly. The doctor heard me as he walked around the stretcher, and pointed at my strip.
"It was two to one AV-flutter," he said. "Look at the rate. Do you see any P waves?"
Still off balance, I stammered about the first-degree block, and that I thought the P waves were buried because the interval was so long.
"It's a tricky one," he said, "but the proof is in the pudding. Look at him now!"
He smiled and left the room.
I stood in the same spot for a moment, staring intently at the ECG strip. It still didn't look like a flutter to me, it wasn't even that fast, I thought I could pick out some (not fluttering) atrial activity, and anyways the patient was stable...
I take pride and special interest in ECGs, but this time I just didn't see it. I tried to look harder, but was interrupted.
"Hey man."
It was the patient from his bed.
"You did a good job."
It made it worse to find that the 12 lead ECGs read normal, that the chest pains were reproducible on palpation and respiration, and that there has been a productive cough for a week and a half. Still, these people insisted that they could not walk. They complained of shortness of breath, that they felt nauseous and weakened to the point of exhaustion. They were sick, probably, but not as sick as they (or I) seemed to hope. Sometimes I wonder if these patient's wouldn't share a high five with me if the ECG paper would spit out a few millimeters of ST elevations for once. ...Throw us both a bone, make it all worth it.
Walking into this patient's apartment to find him writhing in bed and clutching his chest did nothing for our attitudes. This was a common presentation, learned perhaps from a cheesy medical soap opera or dramatized movie scene, the complaints of pain were over the top in almost comical fashion, unreal in both magnitude and character. Real heart attacks don't look like this.
Usually, anyways.
Keeping that caveat in mind as we are supposed to, we asked the routine questions in a routinely respectful and interested manner. Tell us the story, what the pain feels like and where it goes. Tell us if you have ever felt this before, when it started and what you were doing at the time. The questions flowed in an almost mindless manner, automatic in their practiced repetition. I listened as the answers tumbled down and collected into their respective categories, and the "not a heart attack" bin was getting full.
There was time to do an ECG while the firefighters helped set up the stair chair (it was the third floor again), so I started to attach the stickers. On the man's chest was a CABG scar, which raised an eyebrow, but we carried on:
I let out a groan. My least favorite kind of ECG: just inconclusive enough that it probably means nothing, just abnormal enough that it can't be ignored. The 12 lead ECG is one of the most objective examinations we can perform, purported to be the gold standard in isolation of cardiac injury. Still, this one waffled.
I gave the guy oxygen, nitro, and asprin, then carried him down the 2 flights of stairs with the help of fire and police officers. The trip to the hospital was uneventful as the patient described to me the remainder of his story. The nitro hadn't changed his pain at all. I performed a more detailed assessment without significant finding, started an IV, and noted stable vital signs in my chart. Routine as can be, I had a good portion of my run-form written before we arrived at the hospital.
**
The doctor looked at my pink ECG strip carefully, and then back at the patient, to the monitor, and again to my ECG strip. He looked VERY interested. Concerned, even.
I watched him with interest and a bit of fear. I wonder what it was that he saw, whether I missed something or perhaps there was a change. I followed his eyes from the strip to the monitor and to the patient, looking for something. ...I couldn't pick it out.
He dropped the paper to the floor and asked the nurse what we had for IV access, his white coat flowing back in the wind as he walked briskly to the medication cabinet. He handed to the vials to the nurse, designating dosages of each. When they changed hands I got a glimpse of their labels: Lopressor and Cardizem. He wanted them both pushed, and right away.
Hushed silence as the nurse drew up the medications.
The nurse pinched my line and pressed the drugs into the IV. The doctor nodded when it was done, staring at the ECG monitor. Still confused, I bent over to pick up my dropped ECG strip.
The man let out a weird sounding grunt, and I could see from my bent position his legs jolt upwards from their rest on the hospital bed. I stood up to see the man with a funny look on his face, at the same time intrigued and releived. The monitor was moving much more slowly now, capturing a normal sinus rhythm at 70. The doctor was smiling.
"What the...?" I started to mumble under my breath, not fully understanding what happened exactly. The doctor heard me as he walked around the stretcher, and pointed at my strip.
"It was two to one AV-flutter," he said. "Look at the rate. Do you see any P waves?"
Still off balance, I stammered about the first-degree block, and that I thought the P waves were buried because the interval was so long.
"It's a tricky one," he said, "but the proof is in the pudding. Look at him now!"
He smiled and left the room.
I stood in the same spot for a moment, staring intently at the ECG strip. It still didn't look like a flutter to me, it wasn't even that fast, I thought I could pick out some (not fluttering) atrial activity, and anyways the patient was stable...
I take pride and special interest in ECGs, but this time I just didn't see it. I tried to look harder, but was interrupted.
"Hey man."
It was the patient from his bed.
"You did a good job."
Thursday, January 3, 2008
Thanks
We were at the hospital finishing up with a routine patient when I felt a tap on my shoulder. It was a large man, dressed in the yellow and black of the hospital security uniform. He towered over me, huge but in a quiet and almost meek way.
"Excuse me I'm sorry to bother you," he said, "but do you work on Saturdays?"
I was a bit taken aback, wondering what this man wanted, but I answered. Sometimes I do work on Saturdays for overtime. Not all that often, but on occasion.
The man smiled at me, genuinely happy to hear the answer. He reached behind him and pulled out a large wallet, stuffed to capacity with photos arranged in cloudy laminate organizers. Flipping through them, he came to a picture of a young man dressed in a police uniform. The face in the picture could not have been older than 25 years, but it was firm and determined, proud and focused. The man scratched at the photo with his thumb.
"Do you recognize this boy?"
I didn't know the face, but I knew immediately who it was. A few months ago there was a terrible car crash on the highway, I remember hearing the story. A car was broken down late in the night, and officers stopped to see if they could assist. It was wet outside as it had just started raining, the roads had turned slick and drivers had not yet noticed the difference in traction. As the officers walked towards the broken down vehicle, another car came around a bend and struck this young man, throwing him a long distance up and off of the highway. He was later found by some of my coworkers, too far gone to even transport to the hospital.
I heard about it the next morning, and remember finding the story particularly haunting. Out of the blue on a normal day of work a car comes out of nowhere and that is it. Bang. He probably never even saw it coming.
The big man looked at me as I studied the photo. I wasn't sure what to say. I wasn't on the call but I knew what had happened, and it was difficult to come with the appropriate words.
"Is that the officer from the highway?" I asked.
He nodded.
"He was my son. I just wanted to find the paramedics who were there that night. I never got a chance to shake their hands, thank them and tell them that they did a good job."
His eyes were wet as he talked, holding everything back to the best of his ability as he attempted to maintain a casual conversation. He forced another smile.
"It's the two month anniversary."
I looked at the floor, sheepish and not wanting to look at the man who carried so much weight. I told him that I was sorry, that I wasn't there but I had heard about it and I could pass on the word. Again I told him I was sorry.... "for everything."
He righted himself as he tucked the large billfold into his pocket.
"Yeah...." he said, trailing off. "Thanks."
I shook his hand and he continued on his way, down the hallway to complete his work.
"Excuse me I'm sorry to bother you," he said, "but do you work on Saturdays?"
I was a bit taken aback, wondering what this man wanted, but I answered. Sometimes I do work on Saturdays for overtime. Not all that often, but on occasion.
The man smiled at me, genuinely happy to hear the answer. He reached behind him and pulled out a large wallet, stuffed to capacity with photos arranged in cloudy laminate organizers. Flipping through them, he came to a picture of a young man dressed in a police uniform. The face in the picture could not have been older than 25 years, but it was firm and determined, proud and focused. The man scratched at the photo with his thumb.
"Do you recognize this boy?"
I didn't know the face, but I knew immediately who it was. A few months ago there was a terrible car crash on the highway, I remember hearing the story. A car was broken down late in the night, and officers stopped to see if they could assist. It was wet outside as it had just started raining, the roads had turned slick and drivers had not yet noticed the difference in traction. As the officers walked towards the broken down vehicle, another car came around a bend and struck this young man, throwing him a long distance up and off of the highway. He was later found by some of my coworkers, too far gone to even transport to the hospital.
I heard about it the next morning, and remember finding the story particularly haunting. Out of the blue on a normal day of work a car comes out of nowhere and that is it. Bang. He probably never even saw it coming.
The big man looked at me as I studied the photo. I wasn't sure what to say. I wasn't on the call but I knew what had happened, and it was difficult to come with the appropriate words.
"Is that the officer from the highway?" I asked.
He nodded.
"He was my son. I just wanted to find the paramedics who were there that night. I never got a chance to shake their hands, thank them and tell them that they did a good job."
His eyes were wet as he talked, holding everything back to the best of his ability as he attempted to maintain a casual conversation. He forced another smile.
"It's the two month anniversary."
I looked at the floor, sheepish and not wanting to look at the man who carried so much weight. I told him that I was sorry, that I wasn't there but I had heard about it and I could pass on the word. Again I told him I was sorry.... "for everything."
He righted himself as he tucked the large billfold into his pocket.
"Yeah...." he said, trailing off. "Thanks."
I shook his hand and he continued on his way, down the hallway to complete his work.
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