Monday, January 07, 2008


I wonder what it's like to wake up on a normal, beautiful, sunny and crisp winter day, go to a restaurant with friends for a bit of lunch, step outside, trip on a grating on the street, then fall into a coma and die?

As a paramedic student, I've been spending an awful long time in the Emergency Room lately. Mostly I'm there to help out -- you know, start IVs, do EKGs, take vital signs, etc., but also to observe. Thus I find myself observing a late-afternoon scamper as a notification from an ambulance comes in for a person falling from standing height, unconscious, being manually ventilated.

Doctors are literally pouring out of the woodwork. "Notify the trauma team!" screeches one MD, "Call neurosurgery!" yells another, "Does respiratory know?" asks a third. These people haven't even seen the patient yet, but already beepers and pagers are going off all over that block in Greenwich Village.

Finally, red and yellow flickering lights can be seen through the opaque doors of the ER as we all watch from the trauma room down the hall. Thirty seconds passes, then a minute. A doctor starts to walk towards the entrance, when... swoosh!... it slides open. Two medics are calmly and carefully pulling their stretcher towards the sea of green scrubs. The one at the head gently squeezing the bag at the patient's head every few seconds. They wheel him into the room and transfer this man onto on the hospital bed. A whirl of activity ensues.

Clothes are cut off. The medics are grilled by one doctor. Another nurse starts an IV and draws blood. Another doctor makes the decision to RSI (Rapid Sequence Intubation) the patient, a portable X-ray machine is suddenly in view. One doctor gets a brainwave: "This doesn't look like a trauma! There's no sign of external injury! Someone call the stroke team!" Ten doctors all working on one patient. Some independently of the others. How they know what another is doing, I don't know. Maybe they don't....

The decision is made to transfer the patient off the longboard and take off the collar protecting his cervical spine. I've moved outside the trauma room to talk to one of the medics who brought this unfortunate soul in. He asks me, "What do you think?" I shrug. The he asks me the question that's really bugging him: "Do you know why they're taking him off the board?" Again, I shrug -- they don't think it's a trauma I tell him; but I agree with him, if this were my patient I would leave him on the backboard. Both of us are powerless to stop the mass of doctors.

The process has finally reached an end. The patient is carted out for a CT of his head and any other body area they can think to irradiate. The show is over.

About an hour later I notice that the patient has returned. He's now in the main treating area, lying in bed, next to another patient, looking just like the rest of them, only this patient is on a ventilator. I ask the attending physician if I could look at his imaging. The CT isn't good. I massive bleed on the left side of his brain with midline shifting. On of the ventricles on the right side is empty. Essentially his whole brain is being squeesed through the only place where it can go: down through the hole which the spinal cord passes. I start to form a question, but the attending already knows what I'm going to ask.

"This was probably caused by his fall," he says, "There's nothing we can do. It's only a matter of time."

68 years old on a beautiful, sunny, crisp winter day.

Thursday, January 03, 2008

New Year's Eve on 7W

After completing the first phase of our clinical time December 1st, I took a few weeks off to rest and prepare for the Holidays. Unfortunately, when I looked more carefully at the work I need to finish by April 1st for the second phase, I realized I was starting to fall behind. Thus finds our brave hero walking into the Medic room at ten minutes to 4PM on December 31st for the eight hour tour leading into 2008.

I would have preferred not to be working, but this is medic school after all, and sacrifices have to be made. I should be counting my blessings since I was able to at least get up to see my grandparents and family over Christmas. I know at least one person who was doing tours over that holiday.

Prepared for the worst, I knew an ALS tour in Greenwich Village on New Year's Eve could turn into hours of responding to the "Unconscious," aka people who indulged on too much Champagne. Also, the possibility existed that we would spend the entire tour in the throng of partygoers chasing ghosts in the crowds at Times Square, a mere 30 blocks north from our assigned station.

Lady Luck seemed to be with us however and by 7PM, we were just starting to head to our first job for the "Internal Bleeding" of a 95 y/o women. Pretty uneventful call. It wasn't even too stinky considering her chief complaint was a GI bleed. I couldn't get the IV on my one attempt (also my first attempt in the field), but I think that was more luck (and not so great veins) than lack of skill on my part. In fact, after doing about fifty or so in the ER, I'm starting to feel more confident with sticking people. Her B.P. was pretty low and one of my preceptors got the line in the pt's other hand to start administering fluids on the way to the hospital.

Hours passed until we got our second job. This one was for the unconscious, but on arrival, the pt has already disappeared. Seems like there were some ghosts haunting the City after all. I actually don't mind chasing after phantom patients. I prefer to be working than idle (or as it was, studying my trauma textbook in the back of the rig), but it amazes me how many resources go into this one 911 call. For example, this was a street job, and more than likely, someone walked passed someone lying on the sidewalk. They then flipped out their cell phone, hit the magic buttons, and next thing you know, I'm on my way, along with another BLS ambulance, a FDNY engine company, and a police car going to another scene where everyone is gone by the time we get there. Oh well, this is the age we live in. Cell phones are everywhere and people have just enough scruples to call this an emergency, but not enough to walk over the person lying on the concrete, shake their shoulder, and find out if their alright.

Returning to the medic station, we find the street we're traveling down blocked by a fire engine. We weren't assigned to this job, but the firefighters wave us in. We call ourselves flagged down to dispatch and enter the nice, quiet restaurant. At least it was quiet until six firefighters, two Paramedics, one medic student, and two cops barge in.

The patient is a middle aged women. Cool, pale, diaphoretic. History of MIs and COPD. Appears weak, and slightly AMS. Bystanders report a near syncope as she was eating her dinner. FD has her on O2, so we make our quick, ninja-like exit with the stairchair to the back of our bus. I've noticed that the medics are staring to trust us students a little more, so I have the responsibility of hooking her up to the 12-Lead, and getting IV access. Both completed successfully (22-guage in the right AC! -- Woo hoo -- first line in the field!). Her rhythms look good and the field diagnosis is vasovagal near-syncope. we dish her off to the hospital without any problems and it's 11:00 PM.

No more jobs for the rest of the night, but a couple minutes to midnight we all start to gather on the sidewalk outside the ER. Nurses, doctors, staff, medics, and students stand at 7th Ave and 11th St. in Manhattan. We can just barely see the ball, but when the fireworks go off, we all cheer and hug each other. A few quick minutes of celebration and everyone soon returns to care for their patients.

What a great way to bring in 2008!