Cardiology: Back to Basics

AN EYE-OPENING EDUCATION

It was a quiet May afternoon working in an a high-volume EMS service. As I was finishing one chart, the tones drop yet again. “Medic 13, we have a priority one run for you on chest pain and shortness of breath.” Just like every other run in my career, I responded to the call without hesitation. Our unit arrived on scene with the local fire department and the patient who had made his way out to the end of the driveway. As I approached the patient, I introduced myself and my partner and I started our assessment. The patient was awake, alert, and oriented. He appeared to be in good health. His skin was pink, warm, and dry. The patient had no problem speaking in long winded sentences and did not have any signs of shortness of breath or difficulty breathing for that mater. I questioned the patient about his chest pain and any other related symptoms. At this time the patient was essentially pain free and looked be back to his normal pre-incident status. The local fire department was dismissed and the patient was assisted to the ambulance for further assessment and in my mind, a possible refusal of transport. At this time the patient was laughing and joking with us, “I think it’s just stress or it’s my way out of my honey do list for the day”. After a brief interview and with some additional encouragement the patient agreed to allow me to apply the heart monitor and check some baseline vitals. The patient’s vital signs were nearly the same as a world class athlete: BP 118/68, RR 12, lung sounds clear and equal bilaterally both anterior and posterior auscultation.  The monitor display showed a heart rate of 68 normal sinus and the 12-lead revealed a left bundle branch block (LBBB) with some slight ST-segment abnormalities.

sgarbossa1

I began to explore his medical history and any possible contributing factors. The patient denied any medical history, didn’t take any prescribed medications, and had no family or lifestyle risk factors for acute coronary syndrome (ACS). At this point, I was running out of ideas. I asked the patient to repeat his story one more time to make sure I had everything correct before allowing him to sign a refusal form. During the third and final question and answer session, the patient decided to mention the near syncope incident that preceded this entire episode. “Oh, I didn’t hear you mention the feeling of almost passing out” I said. With the near syncope, chest pain, and acute shortness of breath, the patient finally agreed to be treated and transported to the hospital. We ran through the standard treatment: aspirin, nitro, and oxygen. The patient continued to be pain free with no other symptoms present through transport. A repeat 12-lead was done en route, strictly due to my own curiosity. LBBB was noted with no additional changes from the first. “I told you, it’s just the stress.” said the patient. As we continued to joke back and forth, the patient appeared to be back to his normal. I told this patient its probably nothing serious. “I don’t believe you are having a heart attack from the 12-leads we have performed.” Pairing my assessment with the patients nonexistence for previous medical history, I truly believed this would be a simple in-and-out for the patient. We pulled in to the hospital and transferred the patient  to the ER cot with a bedside report to the receiving RN and attending ER physician. The ED staff started with all of the normal treatments: lab draws, monitor applied, and a 12-lead.

As I finished up with my signatures and shaking the hand of my patient, the ER physician requested a copy of my 12-leads for comparison. Crap. Did I miss something obvious? Returning to the ER with 12-leads in hand, I began to converse with the physician again. He interrupted our conversation to contact the cath lab and activate the system for emergent cath procedure. As the Physician hung up the phone, I hoped and prayed he would not walk into my patients room and tell him the bad news. I could feel the anxiety set in followed by the palpitations and nausea. The physician returned to the patient’s room with the news, “Sir, you’re having a heart attack”. I hung my head low and departed the emergency room and returned to the ambulance where my paramedic partner was restocking the ambulance. “What’s wrong with you?” he asked. “I somehow just missed a MI on that guy” I replied. A few minutes of silence went by and just as the nausea was letting up, someone tapped me on my shoulder. I turn around to see the ER physician. “Do you know why you missed that one” asked the physician. Before I could produce any response the physician said “it’s because you were never taught to look for those kinds of heart attacks”. The look of confusion and anger must have been plastered all over my face because just moments later the physician smiled, laughed, and said “Follow me, I’ll explain it to the both of you”.

After a brief field education and a new term I had never heard before, I returned to my ambulance more determined than ever.  Sgarbossa? WTF, I thought to myself.  As I look back, I can now answer that questions that I must have asked myself over a hundred times that day.  What just happened was that I had received an incredible education that I didn’t know I needed.  Along with that education, the physician ignited the desire for me to learn cardiology.  Over the next few years I would dive deep into cardiology books, attend multiple cardiology in-services, interview local cardiologists, and download, print, and review any online documents I could find.  What I discovered is that the subject of cardiology is much more complex than what was presented to me in paramedic class.  The purpose of this blog, and the next few blogs that follow, is to explain and expand on some of the information and education I have been able to gather over the past few years.  I want to provide the hard to find and even harder to interpret information along with some addition education of cardiology topics to you the reader.  The plan for this series of blogs is to start at the beginning with heart anatomy including the electrical pathways and the coronary arteries and progress all the way through each type of myocardial infarction (MI) and anything in between.  Along with the breakdown of each category of MI, case studies, actual 12-leads, and video imaging will be presented to help explain the topics from multiple angles.

Back to the Basics

Heart Anatomy

The heart is made up of four chambers, with each chamber completing a specific task each time the heart contracts.  The right side of the heart operates on a low pressure scale and contains the right atrium and right ventricle.  The primary function of the right side of the heart is to receive blood from the body and pump it to the lungs for oxygen and carbon dioxide exchange.  The left side of the heart operates on a high pressure scale and contains the right atrium and right ventricle.  The primary function of the left side of the heart is to receive oxygenated blood from the lungs and pump it throughout the body.

Right Side of the heart

Blood enters the heart through two large veins, the inferior and superior vena cava, emptying oxygen-poor blood from the body into the right atrium. As the atrium contracts, blood flows from your right atrium into your right ventricle through the open tricuspid valve. When the ventricle is full, the tricuspid valve shuts. This prevents blood from flowing backward into the right atrium while the ventricle contracts. As the ventricle contracts, blood leaves the heart through the pulmonic valve, into the pulmonary artery and to the lungs, where it is oxygenated. The oxygenated blood then returns to the heart through the pulmonary veins.

Left Side of the Heart

The pulmonary veins empty oxygen-rich blood fromheart the lungs into the left atrium.  As the atrium contracts, blood flows from your left atrium into your left ventricle through the open mitral valve.  When the ventricle is full, the mitral valve shuts. This prevents blood from flowing backward into the atrium while the ventricle contracts.  As the ventricle contracts, blood leaves the heart through the aortic valve, into the aorta and to the body.  During relaxation, blood flows into the right coronary artery (RCA) and left coronary artery (LCA) to provide blood flow to the heart.

Tracing the Hearts Electrical Pathways

The contraction of the muscle fibers in the heart is very organized and pathwayscontrolled. Rhythmic electrical impulses flow through the heart in a precise manner along distinct pathways and at a controlled speed. The sinoatrial node (1) initiates an electrical impulse that flows through the right and left atria (2), making them contract. When the electrical impulse reaches the atrioventricular node (3), it is delayed slightly. The impulse then travels down the bundle of His (4), which divides into the right bundle branch for the right ventricle (5) and the left bundle branch for the left ventricle (5). The impulse then spreads through the ventricles, making them contract.

The rate at which the pacemaker sends out its impulses, and thus governs the heart rate, is determined by two opposing systems—one to speed the heart rate up (the sympathetic division of the nervous system) and one to slow it down (the parasympathetic division). The sympathetic division works through a network of nerves called the sympathetic plexus and through the hormones epinephrine(adrenaline) and norepinephrine (noradrenaline), which are released by the adrenal glands and the nerve endings. The parasympathetic division works through a single nerve—the vagus nerve—which releases the neurotransmitter acetylcholine.

Coronary Artery Anatomy

Coronary arteries supply blood to the heart muscle and like all other tissues in the body, the heart muscle needs oxygen-rich blood to function.  The coronary arteries consist of two main arteries: the RCA and LCA.  The left coronary artery then splits into two additional main branches: the left anterior descending (LAD) and the circumflex artery (Cx).  To try and simplify the coronary anatomy lets isolate each artery and take an in-depth look.  For this blog we are going to assume normal cardiac anatomy and leave out any of the abnormal cardiac anatomy presentations.

Right Coronary Artery

The right coronary artery emerges from the aorta just a short distance from the heart.  The artery travels in the AV grove giving way to multiple branches until turning posteriorly to supply blood flow to the back side of the heart.  For purposes of simplicity this blog will focus on RCA and the two main branches:  the right marginal branch and the posterior descending artery.  Near the start of the RCA a small artery knows as the sinoatrial nodal artery to supply blood flow to the SA node.  Studies very slightly, but this appears true for approximatly 60% of the population.  In the remaining 40% the sinoatrial nodal branch comes from the LCA.   Continuing down the RCA the right marginal branches off and travels toward the apex and continues to supply blood flow to the right ventriclerca1 and inferior portion of the right and left ventricles.  Next the posterior descending artery wraps around to the back of the heart just after the marginal branch to provide blood supply to the posterior wall of the right ventricle and the posterior and inferior portion of the left ventricle along with the posterior septum wall.  This artery and its main branches will be shown in more detail in a following blog along with video imaging.

Left Coronary Artery

The left coronary artery is tasked with providing blood flow to a slightly larger area.  The left coronary artery emerges from the aorta, and passes between the pulmonary trunk and the left atrial appendage. Under the appendage, the artery divides into the anterior interventricular descending artery (LAD) and the left circumflex arteryreaper-heart-5-300x295-jpg1(LCx).  This division happens fairly anterior and results in a very small LCA compared to the RCA.  The short length of the LCA is actually beneficial in some ways because there is less room for occlusions to happen  resulting in the well known field term “the widow maker”.  The branches of the LCA are more complexed and will require some detailed explanations in an attempt to paint a clear picture.  The first branch of the left coronary artery is the LAD and it travels along the anterior portion of the heart through the anterior interventricular sulcus (AIVS), an anterior groove in between the right and left ventricles and toward the apex.  The branches off the LAD include: the diagonal artery branches and septal artery branches.  The diagonal branches course diagonally on the anterolateral portion of the left ventricle and provide blood flow to large portions of the anterior wall. The first diagonal branch is designated as D1; the second diagonal branch is designated as D2; and so on.  Again for simplicity the focus will be D1 and D2 only.  For anatomy purposes the portion of the LAD between D1 and the LCA split is refereed to as the proximal LAD.  The last 1/3 of the LAD is refereed to as the distal LAD.  The portion of the LAD that is between the proximal and distal LAD is refered to as?  Yep you guessed it, the mid-LAD.  As the LAD courses through the anterior interventricular sulcus it gives off several branches called septal perforators (SP), which supply blood to the interventricular septum.

The left circumflex artery(LCx) originates at the bifurcation of the LCA and passes down the left atrioventricular groove. The LCx branches into smaller branches called Obtuse marginal (OM) as it paslca1ses down the groove. It also gives rise to one or two left atrial circumflex branches that supply the lateral and posterior aspects of left atrium.  Finally the artery wraps around the lateral wall and travels down the posterior interventricular groove giving the posterior descending artery blood supply.

Wrapping it Up

Its obvious that there is a lot of information thrown at you in this blog. For most paramedics, this is probably just review, but we felt this was a great place to start.  The section on coronary arteries was a bit lengthy and detailed and it was planned that way.  To truly understand some of the cardiology topics and myocardial infarcts in the future blogs, a solid understanding of this anatomy will be crucial. We hope this blog was helpful, enjoyable, and beneficial for you, and we hope you stay tuned for our next cardiology blog on STEMI imitators.  As always, comments, questions, and academic feedback are welcome!

Episode 22: MAAAYYYBEEE We’re Not Great at Spotting Atypical Strokes

Listen here or download on iTunes, Podcast Addicts, or Podcast Republic.

An article from Frontline Medical News in 2014 was heavily critical of the amount of missed strokes by prehospital providers. A retrospective study that lasted from January 1st, 2010 to December 31st, 2011 reported that out of the 10,384 patients that were transported to an emergency department via EMS and that 41% of stroke positive patients were missed. To quote one of the reviewing physicians, “if a paramedic called us to say a stroke was going on, the likelihood was extremely high it was a true stroke. However, when they didn’t think it was a stroke, it didn’t mean much.” McStrokeOuch. We’ve all been taught about the Cincinnati Prehospital Stroke Scale. It works, and it’s a great assessment tool. But what about the patients that don’t present with limb ataxia, dysarthria, or facial drooping? Is there a stroke patient that might be having an atypical stroke? Well… yes, and we’re going to be getting into that now. What about the patients that we are convinced are having a stroke, but are actually experiencing something differently entirely. For today, the subject will be missed stroke activation.We’re going to be focusing on a very niche market of stroke patients today. These are the patients that don’t fit into the typical criteria that prehospital providers have pigeon-holed stroke victims in. The majority of the patients that stroke activation were missed on, were patients of atypical ages and symptoms. Well if they don’t have any traditional symptoms, do you just expect us to ask our Magic 8 Ball if they are having a stroke or not? Hold your horses… we’re getting there. Let’s start with a scenario. 

SCENARIO

You and your partner are called to the home of a mid-60s female with a report of dizziness and near syncope. As you know on the door, the patient calls out from the living room advising that the door is unlocked. She is lying on the floor complaining that “the room is spinning”. As you the story unravels, the patient tells you that she has been feeling this way for the last six hours. Your initial interview and assessment reveal no likely cause of hypovolemia, metabolic factors (i.e. hypoglycemia, diabetic/alcoholic ketoacidosis), or cardiac arrhythmias. The patient states that this is the first time that she has ever experienced symptoms like this before and denies any recent illnesses. Her blood pressure is 162/94, heart rate is 76, SpO2 is 96% on R/A with no obvious signs of distress and clear lung sounds. You assess her blood glucose and see that is 143mg/dl. She is afebrile and there are no orthostatic changes to her vital signs. The patient is A/O x4 with no limb ataxia, dysarthria, or unilateral facial drooping. She states that she has a history of hypertension and GERD, and that she is not compliant with her medications. She denies any recent trauma. As you sit her up, she cries out that her symptoms have worsened greatly and that her nausea turns to active vomiting. Sounds like it’s a just a case of vertigo, right? How do you know for sure? In the list of possible differential diagnoses, did you even consider that this could be a stroke?

WHY WE NEED TO START TAKING VERTIGO SERIOUSLY

  • A 2009 AHA article states that >25% of all patients that present with vertigo-like symptoms actually are found to have some element of posterior circulation infarcts, which is gravely concerning! How many of these patients are we not screening?!
  • A significant number of these patients did not present with limb ataxia, dysarthria, or other concerning neuro deficits (i.e. facial droop, etc). A common symptom of posterior stroke is acute dysphagia (inability or difficulty swallowing due to pharyngeal weakness)
  • A 2013 Lancet article tracked 1,141 patients and their preceding symptoms leading to posterior brain circulation infarct.Out of the studied patients, 54 of them had isolated vertigo symptoms. A statistically small percentage of around 0.05%, right? Yeah, that’s still 54 people that were either misidentified or told that nothing was wrong.

DIFFERENTIATING STROKE FROM ACUTE VESTIBULAR SYNDROME

Enter the HINTS exam.

  • Who do you perform the HINTS exam on?
    • Patients that have been experiencing hours/days of vertigo
    • Patients that are experiencing spontaneous nystagmus
    • Vertigo symptoms worsen going from lying to standing
  • Why perform the HINTS Exam?
    • Assists in differentiation between vertigo and posterior stroke
  • The Three Steps of the HINTS Exam
    • Nystagmus
      • Primary Gaze
        • Is there nystagmus at rest?
      • Lateral Gaze
        • Be careful while you are assessing for lateral nystagmus; having a singular object that you are looking at can reduce the severity of the nystagmus
        • Patients with vestibular neuritis (common cause of dizziness/vertigo symptoms) will typically experience unidirectional nystagmus… and that’s okay
        • Patients experiencing bidirectional nystagmus… not so good
      • Test of Skew
        • Covering/uncovering a patient’s eye(s)
          • Does the eye have any vertical movement when it is uncovered?
      • Head Impulse Test
        • Looking for catch-up saccade
          • Catch-up saccade is good!

  • HINTS Exam leading to probable vestibular neuritis
    • Must have ALL of the above
      • Unidirectional nystagmus
      • No vertical skew
      • Abnormal HIT
  • HINTS Exam leading to probable Posterior Circulation Infarct
    • Can have ANY of these three
      • Bidirectional nystagmus
      • Vertical Skew
      • Normal HIT
  • How sensitive is the HINTS exam in differentiating between vestibular neuritis and a stroke?
    • Same AHA article published in 2009 states that the HINTS exam was 100% sensitive and 96% for identifying stroke patients that were concurrently experiencing vertigo symptoms for several hours/days
    • Not only that, but a comprehensive HINTS exam proved to be sensitive for early detection of stroke patients that early MRI

**SOAPBOX MINUTE WITH MIKE**

So what are we driving at? Maybe the reason that we are missing so many stroke positive patients is that we aren’t considering possible life threats that don’t fit into our limited understanding. By not looking for atypical symptoms or considering textbook symptoms in patient demographics that aren’t typical, we are causing harm to our patients. It’s time to start doing more aggressive follow-up and research.

Episode 21: D.O.S.E. (Direct On-Scene Education) with Captain James Carroll

Let me start off by apologizing for the buzzing in the background of this recording. IF you can get past that, the content and ideas of this presentation are incredible. We would like to thank Capt. James Carroll of Broward CO, FL for taking the time to sit down with us and explain his passion for community outreach. 

EMS-IERC DOSE

Listen here or download or iTunes, Podcast Addicts, or Podcast Republic.

What is DOSE? DOSE is an innovative attempt at eliminating sleep related infant death due to suffocation, strangulation or positional asphyxia by using First Responders to identify and remove hazards while delivering education on-scene. First Responders are trained to identify and remove hazards from an infant’s sleep space while on scene during emergency and non-emergency 911 calls. DOSE was created and developed by Captain James Carroll and Jennifer Combs, MSN, ARNP.

If you or your department is interested in implementing a program like this, contact Capt. Carroll via the D.O.S.E. website.

Jayson McConnell


IMG_0300Jayson McConnell started his EMS career as an emergency critical care technician at Parkview North Hospital in Fort Wayne, IN.  As he continued to strive for education and experience Jayson continued up the ranks as an EMT-A with New Haven/Adams Township EMS.  Determined not to slow down, Jayson enrolled in and completed the accelerated paramedic program in Adams County.  Jayson currently serves as a Paramedic in Adams County, Allen County, and most recently as a paramedic on the mobile intensive care unit.  Jayson is also in the process of applying for a Primary Instructor license at the start of 2017 to increase his EMS education opportunities.

August 2016 Trauma Case Study

This case study was donated by a friend of the show that works in a large metropolitan area. Let us know what you think!

HPI

You and your partner work for an urban EMS system and are dispatched to a reported “jumper” from a bridge nearby. As you enter the scene, you and the responding fire crew are guided to the back of an industrial park with no obvious hazards noted. A few bystanders that are present inform you that the patient, an approximate 20yom, jumped off of a nearby bridge into a ditch. The bridge was estimated to be fifty feet high. You and your partner set up your stretcher at the nearest access point. After hiking down into the ditch with a few members of the fire crew, you note that the patient is lying supine on the ground and is only responsive to painful stimuli, occasionally opening his left eye and groaning. You rapidly immobilize the patient with a c-collar and extricate him out of the ditch on a scoop stretcher. Transferring him to the pram, you note the patient has an approximate baseball-sized indentation in the posterior region of the head, bilaterally deformity to the ankles, left-sided deformity to the lower leg, and right-sided depression to the chest with clear and equal lung sounds that are maintained throughout care. There is notable dilation in the left pupil and the right is constricted. Blood and clear fluid are noted from the left ear canal.

INITIAL ASSESSMENT

  • Patient remains only responsive to painful stimuli and is given a GCS of 9
  • Skin is profoundly pale, diaphoretic, and cool
  • Respirations appear shallow and irregular ranging from 10-28
  • Strong, regular radial pulses in the 70s

VITAL SIGNS

  • BP: 152/86
  • HR: 76
  • SpO2: 91% on room air
  • RR: Irregular; ranging from 10-28
  • EtCO2: 39mmHg
  • BGL: 157mg/dl

TRANSPORT AND TREATMENT

Patient transported to a local Level I trauma center that is approximately 15 minutes away from the scene. En route, patient mentation decreases to a GCS of 8 with markedly reduced respiratory rate at 6bpm. Nasal airway placed and BVM ventilation commenced with improved SpO2% to 98 and an EtCO2 maintaining between 36-39mmHg. Crew considered advanced airway placement, but withheld due to lack of paralytics and significant trismus noted. Two large bore IV lines established. Patient maintains clear and equal bilateral breath sounds. Pelvis is splinted prophylactically. Left lower leg, left ankle, and right ankle splinted.

VITAL SIGNS AT TRANSFER OF CARE

  • BP: 164/92
  • HR: 64
  • SpO2: 98% with BVM Ventilation
  • RR: Pt is now apneic and being ventilated at 20bpm
  • EtCO2: 38mmHg

FOLLOW UP

Patient is diagnosed with a subarachnoid hemorrhage, basilar skull fracture, three broken ribs on the right side and two on the left, bilateral ankle fractures, a left-sided tibia/fibula fracture, and an L4-L5 fracture. Patient rapidly transferred to the surgical department where he arrested and was later pronounced.

DISCUSSION

  • What would be your first priority for this patient?
  • How would your care change if you were a rural provider as opposed to an urban medic?
  • If you had access to paralytics or induction agents, would you have attempted to chemically facilitated intubation?
  • What would you have done differently?
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The Mute Medic Volume III

Stereotype -/ˈsterēəˌtīp/- a widely held but fixed and oversimplified image or idea of a particular type of person or thing

My eyelids felt like sandbags as I embraced the vibration of the high idle on the truck murmuring like grasshoppers on a summer evening. We had parked in an abandoned lot away from the streetlights, hoping that the unforgiving night would grant us some reprieve. Three hours left of our twelve hour night, and this was the first time we had made it to a post. After  a swig of lukewarm coffee, I folded my hands in my lap and attempted to drift away anywhere other than where I really was. The sibilating noises from the passenger seat unnerved me. Lucky bastard. I’ve done 90% of the work and he’s the one napping.  After several minutes of squirming and attempting to adjust the position of my incommodious seat, I decided that it was a lost cause and retreated to the patient compartment to stretch out. Throwing a blanket down over the bench seat, I was overwhelmed by the stench of booze, vomit, and coagulated blood from the last road scholar we had just transported. Fumbling around in the dark through my cargo pocket, I produced a jar of Vick’s. Finally, I could breathe again. With the exhaust fan humming in the background, I was able to pass into a light sleep that lasted for roughly ten tantalizing minutes. Static came over the radio, followed immediately by an unwelcome transmission.

“Ambulance 41.”

Ugh. Are we the only ones working tonight? “Go ahead,” I grumbled, making my annoyance apparent.

“Ambulance 41, assist police and fire on a shooting at a nightclub.”

“Cleeaaaaarrrr.”

To this day, I am still amazed at how fast utter exhaustion can lift after hearing those words. Swearing under my breath, I quickly tossed the blanket out of the back of the ambulance, launching myself into the driver’s seat. My somnolent counterpart didn’t stir. In a moment of testosterone overload, I punched him in the shoulder as hard as I could.

“Wake up, dude! We just got a shooting!”

“Are you serious?!” With the energy of a sloth on Ambien, he struggled to sit his seat upright, while wiping drool from the corner of his mouth. “Was I snoring?”

“Sounded like a freakin’ artillery barrage.”

As we neared the scene, the chaos was palpable. Teenagers running in every direction, and only three officers attempting to keep at least thirty unsettled bystanders back. Despite the excitement from the crowd there some optimistic statements from onlookers saying, “She’s gonna make it”.. There was a crater in the left side of her head with obvious brain matter and a pool of blood under her. Fighting the bounding of my own pulse, I reached under her jawline only to confirm that she did not have one. My partner went back to the ambulance to grab a sheet, when I began to hear murmurs from the crowd, inferring that our pronouncement was based on her ethnicity and that if she were Caucasian, then we would no doubt be working to try to save her. As the grumblings spread, drunken belligerence became the overall attitude. In the span of twenty seconds, we went from saviors to oppressors. My partner and I need not say anything to each other; our decision had been made for us. As he rapidly exchanged the sheet for the wheels, I ducked as a beer bottle grenade went soaring over my head and landed on the ground with a ferocious explosion. As did another. And another. A simple pronouncement had just became a public relations mission to avoid a riot. With stretcher now present, firefighters assisted my partner and I in hoisting the hefty young woman onto the pram as we darted for the ambulance. Gunfire erupted down the street as well more screaming and shouting. We locked ourselves inside and took off for the hospital, hearing projectiles ricocheting off of the bus.

“Ambulance 41 en route emergently to Memorial with one patient, condition Charlie minus.” My voice cracked and wavered. I tried to hide the excitement in my voice, but anybody that knows me knows that I speak a million miles a minute when I’m stressed. Immediately I called the receiving trauma center that we were about twenty minutes away from and explained the circumstances of why we were transporting a traumatic arrest to begin with. I knew that this was against our policy, but frankly I couldn’t care less at the time. As we progressed closer to the hospital, I could see the half-assed nature of work the other crew members were doing. Lazy, sporadic CPR with long intermissions between crew members as well lackluster ventilations.

“We all know what the outcome is going to be, guys, but could we at least make it look like we care and we tried?” I suggested. “There’s a reason everyone was upset back there, and it’s because they expected us to not care.”

“No. It’s because they’re all a bunch of animals. Those friggin’ monkeys belong in a zoo. Sick of dealing with their n****r bullshit.” The lieutenant fired back at me.

“Excuse me?” I retorted noticing the Confederate flag tattoo he  sported proudly on his right arm.

“You heard me. I’m just saying what we’re all thinking.”

“Don’t give yourself that much credit.”

“If you ask me, we should throw ‘em all in a stadium, load ‘em up with a bunch of guns, and watch ‘em all take each other out. Might even pop some popcorn and make a night of it.” He sneered.

“Why don’t you shut up before you become the second unresponsive person back here.” I could feel my blood boiling.  Our eyes locked, and in a moment of clarity I saw the real enemy in this situation. The bus slowed rolling unsteadily over a few speed bumps and came to a halt. We unloaded the pram continuing CPR on the way into the trauma bay. After a short handoff report and fifteen minutes of mopping the blood out of the back of the rig, I noticed my crimson footprints leading back out to the truck. I walked through the grass hoping that the early morning dew would clean them up. Trotting through the lawn, I recalled an excerpt from The Merchant of Venice.

“If you prick us, do we not bleed? if you tickle us, do we not laugh? if you poison us, do we not die? and if you wrong us, shall we not revenge?”

The engine crew had departed and only my partner and I were left. I could hear the squawking of my radio in the background. The impatient dispatch crew was harassing us to get back in service to take a non-emergent abdominal pain call around the corner. After a less than gracious reminder that we needed to return the scene to sign the crime log, we bought a few extra minutes before heading back.

0402. A gentle breeze started to blow and a soft rain began to fall. In a few minutes, it progressed into a full-fledged storm that sounded like pebbles bouncing off of a tin can. Our wipers couldn’t keep pace with the droplets that struck the glass. As we approached the area, fluorescent yellow tape and psychedelic flashes of blue and red filled the night sky. Sauntering over to the crime scene station, we ran into our esteemed colleagues from the fire station holding the metal clipboard, begrudgingly adding their names to the list. Slamming the notepad into my chest, the lieutenant grumbled, “Here you go Mr. Bleeding Heart.” I suggested he attempt an anatomically impossible procedure as we parted ways. Watching the ink run off of the paper, I handed the crime log back to the attending officer.

Maybe I’m different than most medics, or maybe I’m just more vocal about how I feel after difficult situations. I spent the entire drive home sitting in disbelief. I just couldn’t accept that in the 21st century someone could be so calloused about another human’s death. Not only that, but attributing ill motives and wishing harm to an entire group of people. Working in an urban setting, I will admit that I was surprised at first to hear someone attribute ulterior motives to me claiming that my performance could ever be based on racial stereotyping, but now I feel differently. Having not grown up as an African-American in Midwestern America, I admit that I was skeptical when I first heard cries of racism and bigotry in the workplace. It had never really affected me personally, and the obvious human response is to believe that movements that we aren’t invested in lack legitimacy. That night changed my mind forever. When I hear people in the field rush to denounce things like Black Lives Matter or immediately claim there is no such thing as systemic racism within our society, I shake my head and only think about how much further we have to progress. If we are honest with ourselves, we all have our stereotypes. Even if it’s not about race, it could just as easily be about socioeconomic classes, genders, or geographic regions. I can’t imagine what it must be like to wake up every day expecting to be treated in an inferior manner just because of the color of my skin. Empathy requires us to move past our own realities and embrace what someone else’s is. Just a thought…

There is no reconciliation until you recognize the dignity of the other, until you see their view- you have to enter into the pain of the people. You’ve got to feel their need.”- John Perkins

Why Your Patient Isn’t Just Drunk

Beer BottlesLet’s start off with a scenario that I am sure all of us are familiar with. You and your partner are dispatched to a reported fall outside of a bar at 0100. As you arrive to the scene, you see an approximate 35 year old staggering around with blood noted on his forehead. The patient tells you that he “only had a couple of beers” and “just lost [his] footing”. He denies any loss of consciousness or neck/back pain. The only visible trauma is a 2” laceration on the right-side of the forehead and you have controlled the bleeding. As you begin to assess the patient’s mentation, he is answering all of your questions appropriately, his vital signs are stable, and he denies any medical hx, current medications, or allergies. You and your partner attempt to coax the patient into moving into the back of the ambulance for further examination. The patient repeatedly tells you “I’m fine” and is refusing further examination and transport to the hospital. Do you allow this patient to refuse?

SOBRIETY V. INTOXICATION

BreathalyzerSo is merely drinking “a few beers” grounds for calling someone intoxicated? At what point can we call someone intoxicated and use the rules of implied consent in treating patients even against their expressed wishes? After scanning several different definitions of intoxication, there are a few disparities. Definitions like this: “a state in which a person’s normal capacity to act or reason is inhibited by alcohol or drugs” (Encyclopedia of American Law) are widely accepted, but where does that leave us? Obviously, these situations are handled differently depending on your medical direction, but here are some things to consider. Sure, your patient may be able to answer all of your questions appropriately, but what is their environment like? What are the chances that if you leave this patient exactly where you found them, that the patient or someone around them will be harmed? What is your patient’s speech like? Are they slurring or able to speak without difficulty? What is their motor function? Are they able to walk with steady gait? Are they aware of their surroundings, or are they going to wander off into traffic without intervention? Is there a chance that maybe their alcohol consumption could be masking other problems?

ALCOHOL, BLOOD, AND HYPOVOLEMIA

Alcohol does two different things to the cardiovascular system. It inhibits platelet aggregation as well promotes platelet aggregation. Yes, you just read that correctly. Alcohol accomplishes two polar opposite things within the blood stream. A way of looking at it is that platelets stick together in the bloodstream from consistent alcohol consumption leaving the chronic alcohol drinker with a higher risk of stroke, MI, PE, etc. The problem from platelet aggregation inhibition comes when there is a source of bleeding within the body whether due to a traumatic or a medical cause. A study linked here, shows that alcohol can actually “inhibits platelet adhesion to fibrinogen-coated surface under flow”. symptoms-blood-clot-knee_d9b3c4b45c84d7f1

So once your chronic alcohol drinker starts to bleed, it is very difficult to get said bleeding under control, BUT that’s assuming that you have discovered the bleeding to begin with. Anyone that has been in the field for any length of time should have a healthy fear and reverence for the intoxicated patient that has fallen and struck their heads. Even if not recently, immediate signs of brain hemorrhage can lie dormant, and for the patient that is potentially already altered, the subtle changes could easily be masked. Due to the corrosive nature of alcohol, chronic drinkers are much more likely to develop intestinal bleeding. There is a communal eyeroll anytime someone complains of hematemesis or melena, but for alcoholics, this is a potentially life-threatening problem that is often blown off in the emergency department and in the prehospital world. Hypovolemia whether due to blood loss or sheer volume depletion because of vomiting from conditions like pancreatitis or being on diuretics like lactulose (commonly prescribed for patients with cirrhosis to assist in filtering out toxins within the body) is a common problem that needs to be addressed. Was that a long enough run-on sentence for you? I promise I can do better. subarach ct

ALCOHOL: THE GREAT DECEIVER

Let’s roll with another scenario here. You and your partner are dispatched to a report of an unconscious party at a private residence. A landlord went over to check in on a tenant and found him “unresponsive” on the ground. The patient is bradypneic and is unable to awake with painful stimuli. The patient wreaks of ETOH, but can you definitely say that this patient is just intoxicated? Can you as a prehospital provider state that the patient did not suffer a cardiac, neurologic, or diabetic event? Can you definitively say that there are no other intoxicating agents onboard; i.e. barbiturates, opiates, etc? Obviously, being unable to prove a life-threatening problem is not a reason to suspect that every intoxicated patient is suffering from one, but as critical thinkers prehospital providers have to be on the lookout for deterioration. We are not advocating for cookbook medicine or performing innumerable diagnostic tests for the sake of doing them, but when clinical and vital signs are not adding up, maybe it’s time to stop assuming that our patient is just intoxicated.

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The Mute Medic Volume II

Fatigue -/fəˈtēɡ/- extreme tiredness, typically resulting from mental or physical exertion or illness

I, like many others before me, looked in the mirror today and said “to hell with this life”. It wasn’t the pay. It wasn’t the hours. It wasn’t the autonomy. Maybe it was the fact that I had to strip my uniform off in the laundry room before heading upstairs because I was afraid of tracking in the last drunk’s vomit or having my kids see blood on my uniform from the 19 year-old that was shot in the head in a drive by…

As much as you try to turn off the camera in your mind, the internal hard drive can’t be erased. Why didn’t anyone warn me about this before I became a paramedic? I almost gave it up today. I was teetering on the precipice of futility and purpose. That makes it sound like I emerged victorious. I didn’t, but I came away reminding myself that I can get through one more day. Maybe help one more person. The truth is, every shift is a choice.

I guess you could say that this inner monologue started a few months ago. It was 0300. I woke up, drenched in sweat. Hyperventilating. I was there again. Like it just happened. She was 25. I remember standing over her flaccid body, staring at the tube in her mouth wondering what I could have done differently. The monitor illuminated the room, the apnea alarm shrieked like an animal caught in a trap. Nothing. No pulse. No breathing. No soul. Her eyes were wide and pupils dilated, like she could see everything we did. Everything we tried to do.

As the wind drifted through the cracked window, I could almost hear her whisper, “Why couldn’t you save me?”

A disheveled shadow came out from another room. His burnt fingertips continued to feed through his hair as his eyes darted back and forth. The Pink Floyd shirt he wore was tattered and had numerous stains on it. The stench that followed him around was a mixture of bleach and tobacco. With tremulous hands he reached for his pockets, and then continued to fidget with his hair.

“Any of you have a light?”

My partner and I shook our heads and continued about our business. The lanky man stepped over the fluorescent red bio-hazard bag and reached into the lifeless woman’s pocket.

“Hey, what the hell are you doing?!” I yelled.

Retrieving a pack of cigarettes and tie-dyed lighter, the man turned and winked at me. “These will do.” The hairs on the back of my head stood up straight like soldiers waiting at attention. A few officers stopped him and began to question the sordid figure about his involvement with the girl. My partner was speaking with the coroner on the phone, while I went back to picking up the Epi vials and wiping the emesis off of the defibrillator cords. I heard two small voices downstairs. A younger officer came up to me.

“They want to see their mother.”

Two unkempt children climbed the narrow staircase. The boy was maybe five and the girl around seven. Their hair oily and teeth crooked and yellow. It was 1230 in the afternoon, and they were getting hungry for lunch. Mom hadn’t fed them all day long, probably because there was no food in the house. The children’s grandparents had dropped the kids off that morning at the dilapidated residence. What we found out later was that the children’s grandparents were actually their legal guardians. After several heroin related arrests, their mother had her parenting privileges revoked. She pleaded with the grandparents to let her see her children. After months of begging, they agreed to let her have a “trial day”. Instead of buying food for her children, a “friend” came over and the mother disappeared. As the children’s stomachs grumbled, they went in search of their mother, and they found her…

“Is she going to wake up?” the boy asked.

I fought back the tears trying as hard as I could and tried to cushion the truth. “No… She’s not going to wake up…” I didn’t know what else to say. Never in my absurdly short training period did anyone ever cover explaining death and grief to school-aged children to me. I escorted them back downstairs and sat them on the couch. Clicking on the remote, Dora the Explorer emerged on to the t.v. screen. Both of them sat their. Silently. I rummaged through the cabinets and the refrigerator only to add to my disappointment. Running out to the bus, I grabbed my lunch box and came back in with a cheese stick, apple slices, and half a sandwich. Before the next commercial break, all that remained were plastic baggies that the kids had wadded up and thrown on the couch.

A green station wagon pulled up to the front of the house and both of the kids bolted out the door. An officer and I followed them out, as they piled into their grandparent’s vehicle. A few minutes later, they turned off down the street and on their way back to what I can only pray was a reprieve from the insanity that they had just experienced.

A few minutes later, our equipment was organized and thrown back into the ambulance. Maybe it was a blessing in disguise that we worked for a high-volume urban service and didn’t have time to think about what we just witnessed. Maybe that’s why I’m thinking about it now. For the rest of the shift, my partner and I played the nursing home shuffle and ran a few other minor medical calls. It was quiet, though. None of the normal chatter that we bandied about most days.

I find it odd that three years after this call happened, I can still remember every detail. I remember the rank smell of cat urine and the tobacco stains on the rug. I remember the holes in the planks going up the stairs and the obscenely dark room with no functional lights. The overflowing toilet that sat there stagnantly for God only knows how long. I’ve had calls like this before, but this is the one I remember. This is the one that wakes me up in the middle of the night. The one that I think about on Father’s day, wondering if those kids will ever have a steady figure in their lives to help them sort out the hell they’ve lived through.

0315.

I went out to the couch and sat down. Hunched over the coffee table, a bowl of Frosted Flakes in tow, I needed an escape. The television flickered in the background as I turned down the volume hoping to not wake anyone up. There had to be something on this late to take my mind off of my dreams. I stumbled upon an older episode from Batman: The Animated Series. Perfect. Childhood nostalgia was what I needed, but I got more than what I bargained for. What I had hoped for was that Batman would swoop in and save someone in distress while simultaneously pounding his adversary into oblivion. Because that’s how the real world works. In this episode, however, Batman was struggling with his sense of efficacy. In a rare moment of utter humanity, he sat dejected in a chair by himself in the Batcave. As his butler, Alfred, approached they had this conversation:

Alfred: Master Bruce, are you alright, sir?

Batman: I’m tired, Alfred.

Alfred: Well I shouldn’t wonder, you’ve taken no meals today, and I can’t recall when you last slept.

Batman: A weary body can be dealt with, but a weary spirit, that’s something else. Sometimes, old friend, I wonder if I’m really doing any good out there.

Alfred: How can you doubt it? The lives you’ve saved, the criminals you’ve brought to justice.

Batman: I’ve put out a few fires yes, won a few battles, but the war goes on Alfred, on and on…

The rest of the episode went on to validate Batman’s calling to protect those around, and to the seven year old me, I’m sure it would’ve been awe-inspiring. This time it was different. This time I sat alone in the dark just like my childhood idol wondering what fires I was going to try to put out…

Pediatric Tachyarrhythmias

You are dispatched to a residence on a report of a child with an altered mental status. Upon arrival, you find an 8 year old boy lying on the couch responsive to verbal stimuli. His mother states he had been playing outside today when he came inside and complained of extreme weakness. He laid on the couch to rest and the mother was unable to rouse him.

HISTORY

  • WPW syndrome

MEDICATIONS

  • None

ALLERGIES

  • Penicillin

VITALS

  • BP -90/58
  • HR -190
  • BSL- 98
  • O2 sats – 95% with clear lung sounds

BROSELOW

  • 50 inches tall, 57 lbs (25.9kg)

INTERVENTIONS

  • Monitor applied showing a rapid, narrow complex tachycardia.
  • Oxygen via NC at 2lpm
  • Vagal maneuvers

Attempts to slow heart rate by vagal maneuvers prove inadequate. The pt is seemingly becoming more lethargic. IV 22g is established in the right AC.

  • Adenosine
    • 0.1 mg/kg = 2.6 mg
      • IV
      • Rapid flush with 20 ml saline
    • repeat double the original dose x1 = 5.2 mg

Adenosine proves ineffective in reducing heart rate and child continues to deteriorate in condition.

  • Medical control contacted for Synchronized cardioversion
    • 1 J/kg = 26 j
    • Repeat to 2 J/kg = 52 j

Patient is successfully converted to a normal sinus rhythm. He becomes alert and is able to answer questions appropriately,  though he complains of some weakness and tiredness.

  • Causes of SVT in children

    • Wolff-Parkinson-White syndrome
      • Most common type of SVT in children
      • Extra pathway within the heart’s electrical system that connects the atria to the ventricles
        • Typically only AV node is the connection (causing a short circuit)
      • Most of the time this doesn’t affect the rhythm
        • Early beat (PAC,PVC) will cause the impulse to travel through AV node and back through extra circuit
            • “Dog chasing its tail”
      • Be conscientious of using AV blocking medications (i.e. Adenosine, diltiazem, verapamil, etc.) in A-fib with accompanying WPW; can result in V-Fib; cardioversion is the gold standard for unstable A-Fib with WPW patients

A-Fib wWPW

Atrial Fibrillation with WPW

    • Atrioventricular Reentrant tachycardia
      • 10% of cases of SVT in children
      • “Pacemaker” or extra focus that is located above the SA node and beats faster.
      • Diagnosis and treatment of both are similar to all forms of SVT

pediatric svt

Pediatric SVT

    • Almost all SVT cases have excellent outcomes and quality of life
      • Avoid caffeine
      • Certain medications
    • Generally, no restrictions are necessary unless extenuating circumstances. Activities involving climbing or heights are discouraged due to dizziness/fainting associated with episodes, resulting in a fall.
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The Mute Medic Volume I

Hero -/ˈhirō/- a person, typically a man, who is admired or idealized for courage, outstanding achievements, or noble qualities

She walked up to me and gave me one of the hardest hugs I have ever gotten from someone. Her husband patted me on the back with tears welling in his eyes. “You saved her life; I don’t know what I would have done without her.” Their daughter was in that awkward pre-teen phase with multi-colored hair trying to emulate the hipster movement with her thick-rimmed glasses and ironic mismatched clothing. Her son brought his toy ambulance with him and continued to blare the siren while crashing it into my foot. I didn’t know what to say. When you become a paramedic, there is this twisted fantasy you have about doing something daring and risky and receiving praise when it’s over. Today was different, though. My partner and I had quite literally saved this woman’s life, but I felt numb to the adoration. This woman continued to hug me while crying, expressing her heartfelt gratitude over and over again, but the only thing I could muster was, “glad everything worked out, okay.”

Who the fuck says that?

My chief came into the room, camera in hand, and asked if he could get a group picture. After several minutes of arranging and rearranging, he seemed content with the set up, and snapped a few photos. My mind continued to wander off to that fateful day. I tried not to come off as a deer in the headlights, but I am confident my acting skills were not up to snuff that day, as the woman continued to try to engage me in conversation. In the background, I listened to my partner over-dramatize his involvement in the run and make it sound like he was a stunt car driver in a chase scene instead of just transporting a patient in the back of the bus. Inwardly I rolled my eyes; four months of exaggerated war stories were taking its toll on my stomach, adding to the ulcer that was already there.

*Click*

As the room was buzzing with the chatter of awkward strangers, my chief meandered around the room snapping pictures. There was a natural decline in conversation, and as the topics grew stale, the woman handed my partner and I two boxes and a couple of thank you cards. Inside, were baked treats; everything from chocolate-covered strawberries to cookies to cannolis. The selection was overwhelming, and you could tell that the family spent a pretty penny on all of the bakery options that were presented to us. The supervisors were in the middle of shift change, and kept filing in and out of the room. There were big smiles and attaboys flying around the room at unprecedented rates. It was nauseating. After three years of hard work, bad hours, and poor sleep, I was being recognized by a patient for a job well done. This was the first time I had heard a word from my management team, though. The woman gave me one last hug and a quick kiss on the cheek thanking me for my 45 minute contribution to her life.

“I owe my life to you.”

Those words reverberated off of the walls in my head, and I knew that I couldn’t live with them. My mind continued to drift elsewhere; mainly the day that I met this woman.

It was late March. There was dew on the grass and still had that spring nip in the air. I knew it was going to be a bad day at work. For the last two weeks, my partner and I had been attempting to bridge up an EMT trying to become a paramedic. It had been very painful, and I could feel my patience becoming increasingly thinner. As we were finishing our truck check that morning, I heard dispatch come over the air.

“Medic 23.”

“Go ahead for Medic 23.”

“For your information, the paging and mapping system are down today. You’ll have to use your mapbooks and call into dispatch for your call times.”

Could we have one fucking day where something actually works?

“Medic 23 is clear, thank you.”

I was driving while my partner was taking his morning nap on the bench seat and the EMT we were cross-training rode shotgun. This was the fourth time this EMT was attempting to become a paramedic; she had failed every other time, and this time wasn’t going much better than the previous ones. Her phone rang once, and she proceeded to let it ring.

That has got to be the most annoying ringtone I have ever heard.

“You going to answer that?”

“It’s my daughter.”

“You going to answer that?”

I think she finally got the hint that she either needed to answer the phone call or shut her ringer off. I am not a morning person, but still, there wasn’t enough coffee in this world to make that bearable. After five minutes of bickering and occasional yelling, she hung up and there was a long pause.

“Trouble in paradise?”

“I need to go home.”

“What’s going on?”

“My daughter just got into a wreck and my son’s about to get arrested.”

Ladies and gentlemen, I present another episode of Young and the Restless.

“Mmmmkay. I’ll let the supervisor know.”

I called my supervisor and informed dispatch over the radio that we needed to turn back around to the base. After dropping her off, I yelled back to the patient compartment to see if my partner was still alive. I saw the lights flicker on while my partner stumbled around as if he were reenacting Frankenstein. He sulked in the front seat.

“I’m tired, and I don’t feel like doing anything.”

“Join the club.”

“No… I’m really, tired.”

“I have two kids, a full-time job, and I’m going to school. Sympathy is in short supply today.”

I felt like an asshole responding like that, but I had already filled my complaint quota for the day and we hadn’t even made it to our first post. My stomach was growling, and all I could hear was coffee and a breakfast burrito calling my name. Wrong again.

“Medic 23.”

“23, go ahead.”

“We’ve got an emergency call on a pregnancy just around the corner from you.”

Dispatch gave us the address as well as some additional directions into the subdivision.

Too fucking early for babies…

I flipped on the lights and sped up to the house. It was a well-kept subdivision; a pleasant break from the dilapidation we normally worked in. My partner and I unloaded our gear and strolled up to the house. We knocked on the door with no answer.

“EMS. Paramedics.”

I knocked one more time, and then turned the door handle. The door wasn’t locked and opened into a full living room. There was hardwood everywhere as well as modern art and sculptures. The house was clean and free of the normal debris that we normally had to navigate through. As I cleared the door and turned to my right, my stomach sank.

Shit.

There she was. Lying on the floor with her pants around her ankles in a puddle of blood. Sweeney Todd kept a cleaner barber shop. Blood covered the floor and had saturated her pants. Her skin was a translucent gray and her voice quivered.

“I think I waited too long to call.”

I grabbed for a radial pulse and felt nothing. My partner and I quickly exchanged looks and came to the same conclusion. We were behind the eight ball. The woman whispered to me that she had had a miscarriage days ago and hadn’t gone to the doctor for follow up care. I had to take my ear piece out to hear her as her faint voice said that she had soaked five pads and passed five large clots. I fumbled with the automatic blood pressure cuff.

58/20.

Goddammit.

My partner grabbed the EKG cables and place them on the patient’s arms and legs. She was bradycardic and profoundly hypotensive. We both reached for the tourniquets trying to find a place with a palpable vein. I knew I was only prolonging the inevitable. I scanned her neck for an EJ and saw nothing. I didn’t have a choice. I rummaged through the first-in bag and took out the IO kit. I depressed the trigger for a second and heard the whirl of the drill. As I prepped my needle and saline lock set, I reached for the lidocaine.

Why the fuck isn’t there any Lidocaine in my IO kit? You’ve got to be fucking kidding me… Could resupply for one fucking day do their jobs!?

I thought I was going to have an aneurysm, but I couldn’t convey that. My partner at the time, God love him, fed off of every bit of chaos and uncertainty that he saw and heard. I so much as said the word “problem” and there was instant panic. As calmly as I could, I asked him to check the drug bag for Lidocaine. Goose egg. Despite my deeply pessimistic tone, I do believe in divine intervention. Our supervisor was making his round that morning and just so happened to be heading to that very same run. With Lidocaine. Simultaneously, our supervisor and the woman’s husband walked in the door.

No pressure.

I explained to the patient and her husband what I had to do. I was going to have to place an IO in her tibia because she had no veins that I could start an IV on. I prepped the site and said the infamous line.

“You’re going to feel a little pressure.”

I could feel the grinding of the needle into her bone. Her screams reached near animalistic tones as I had to repetitively coach her to lie flat on the ground until I was done. I pulled back on the syringe and saw bone marrow. I was in. With every milliliter of Lidocaine and saline that I pushed in came more screaming until she was hoarse. I couldn’t sedate her because of how unstable her vital signs were. My partner got up front and drove. Correction. He flew. Like a bat out of hell. It was as if I was auditioning for a program at NASA trying to construct something in an anti-gravity simulator. The OB/GYN specialty center was at least twenty minutes away and I was alone for all of them. For 19 minutes I worked my ass off. I was a sweaty mess at the end of them. From hanging saline and TXA to running 12-leads to calling the hospital…I felt drained. There was one minute though, where I stopped and recollected my thoughts. She reached out her hand and asked if she could hold mine.

“I’m scared.”

So am I. “I’m not going to let anything bad happen to you back here.”

It was a promise said with utmost confidence. One I knew that I couldn’t keep. Despite hawk-like vigilance, there was no guarantee I could make to her or her family that everything was going to be okay, and I knew it. All of us want to be in control, and loathe the times that we feel we can’t be. I felt out of control, though. We rolled into the emergency department and while passing off report to the nurses there, they treated my report with zero sobriety.

“Thank God for ambulance drivers,” one of the nurses echoed.

Thank God for doctor helpers.

*Click*

She took one more photo with me before the clan climbed into their SUV and drove off. She rolled down her window and signaled for me to come closer.

“You were my hero that day.”

She teared up, put on her seatbelt and their vehicle backed out of the lot and faded away down the street. I felt the pain in my stomach sharpen…

Hero. Not by a damn shot…

Growing up, I idolized Atticus Finch, Bruce Wayne, and Matt Murdock. They were my heroes. While all fictional, they never compromised their values and continued to fight social injustice and human suffering. I can honestly tell you I don’t feel like I fit the bill and will continue to feel that way. For all of the successes in my career, I feel like there are just as many, no, more failures. If we are honest with ourselves, none of us are heroes. Heroes don’t have to go home and drink just to feel normal. My heroes never screamed at drunks or practiced punitive medicine… Compassion fatigue and cynicism were never traits of my heroes, but if I am truly introspective, they are qualities that I possess. Maybe one day, my sons will hear the stories I have lived through and think I am a hero. I hope they don’t. I hope they never have to witness or imagine the things I see daily. Maybe one day there won’t be a need for heroes…