A long walk

In less than a week I am traveling to my favorite empire and going for a little walk. And by little walk, I mean a 73 mile cross country hike which I think still falls into the British definition of "walk."
A few friends and I are literally going coast to coast in the Scottish Highlands. At the very least I hope to figure out the differences between single malt, double malt, and scotch whiskey, but it probably won't matter in the end when I hold a random glass up and say "What was this one again?! Oh, who cares, cheers!" It would also be great to practice throwing telephone poles, play some mournful tunes on the bagpipes, knit a tartan, and to have a chat with Nessie, but we'll see how that works out.

I will be checking out some fantastic paintings, learning about Scottish history, riding a bike on the wrong side of the road, and I hope to sneak in a visit to Kal, aka Traumaqueen. Then I can lust after Scottish ambulances as well as English ambulances.
I was also going to sit in pubs with a sign that said "Single American Anglophile" with an arrow towards me, in the hopes of attracting a young Scotsman with a proper accent, but the "single" part of that is becoming less and less true. Well, I already bought the sign, so maybe I'll try it anyway.
If I do find nessie, I'll be sure to capture it with my new camera.

...like a hole in the house

Yes, this is as awesome as it looks. This is the result of an unfotunate teenager learning that sometimes you can go too fast in a car. The driver lost control, drove through a yard, dodged a tree by some miracle and slammed into an unsuspecting house. The house lost. Well, so did the car.

This was one of those accidents where I was getting nervous going there because they had already called for one helicopter, and when I got on scene, they called for a second one. Oh crap. I was alone on the medic unit at part time work. I pulled up and saw three patients on backboards, all conscious with not a huge amount of blood on them. I was comforted. One EMT told me they had the worst one that they were loading into the ambulance. I took a minute to assess the other two patients and found their injuries unimpressive. They didn't need a helicopter or a paramedic. It was at that point I realized that I hadn't seen any of the car or cars involved. I gave a quick look around, and found the car smashed into the house about 300 feet from the road. Wow. I was impressed and my concern for the 'worst' patient grew.

I stepped into the ambulance; my patient had a bump on the head and some hand injuries, probably from holding the wheel while the windshield was smashed in. From what I could see, luck was a serious factor. Given the mechanism of injury and the fact that the bird was already on the ground at that point, I flew the patient to the trauma center.

The ambulance dropped me back at the scene and I took a few minutes to take some pics. The homeowner invited me to go through the cellar door to the basement. Holy crap, this was the coolest thing in the history of cool things. The front half of the car was suspended in their basement. Cement blocks and whole bricks had exploded all over the floor. I mean there was debris more than 30 feet away from the car. It was brilliant. The car was leaking all kinds of fluid, but except for the obvious hole in the house, not too much else was damaged beyond repair. Thankfully no one was doing laundry down there when it happened.
More or less the same pictures are in the paper so I figured it wasn't a violation of anything to show them here.

Therapeutic Punching

The call went out for seizures. I made my way there and the ambulance crew was walking out to meet me in the hallway. The patient looked fine. We got in the ambulance and I got the story straight from him. Apparently he had been experiencing "seizures" throughout yesterday and today. The last one was right as they called 911. The patient though, was totally coherent now, felt a little tired, and could suspiciously remember all of theses 'seizures' (which just doesn't happen to seizure patients.) He said that suddenly he would get a really hot feeling and then would have a seizure.

Mere minutes into describing these events to me, as I put him on the monitor he said, "I think I feel one coming on!" He then went stiff and unresponsive, and the monitor showed ventricular tachycardia, basically a lethal heart rhythm. Before I could even change my pants, he converted back to a sinus rhythm. "Are you okay?" I asked. "Yeah, I'm okay." he answered weakly as if he was trying to convince himself.
Holy hell! I turned to the driver and calmly said "We can go now." as I twirled my finger in the air like a helicopter blade. He got my drift and I asked the EMT to cut the guys clothes off as I got the defib pads out. I quickly explained to the patient what was happening and warned him that he may need a shock. Good God, I can't believe the things I say to people. Basically "If you die again, I am going to shock you. Should work. Should be fun."

Before I got the line in, the patient did it again. I gave the monitor one look and then gave the patient what is known as a precordial thump. A nice therapeutic punch in the chest. In theory, this produces a couple of Joules and can interrupt the VT. I am pretty sure that the EMT thought that I was crazy at that point. The patient converted and I apologized for having to hit him. From there I had about three minutes to the hospital and I got a line started and told the ER what we were coming in with, knowing that if I didn't, they would kill me when I came in the door.

My partner heard my report and came out to greet us in the ambulance bay. The patient went into v-tach again and converted in just a few seconds. I was more than happy to hand him over to the ER. Within five minutes while we were still in the room when he did it again. This time it lasted a little longer than we were comfortable with and we shocked him. Yay, converted again. He was on an amiodarone drip pretty quickly and eventually transferred to a cardiac specialty hospital.

I'm not going to lie, this patient made me the most nervous ever. But it was also pretty awesome!

Here are a few EKG tracings for you.

Why Zoll is inferior

Photographic evidence of the insanity that is telemetry with zoll monitors. Here, in a tangled jumble are the parts required to send a 12 lead using a zoll.
This is what greeted me in the back of the monitor when I checked the truck this morning. I almost took it all out and threw it in the trash. It was literally exploding out of the monior, impeding access to things that are slightly more important including the cord to the defib pads. To send 12 leads with zoll, it is a multi step process requiring the white box shown, and the mini portable radio shown to the left of it. All those wires move between those two items and the monitor. You can also see where some kind soul used IV tape to secure them together. Thanks. Now it's sticky. One has to take the EKG tracing, plug all this stuff in, establish a med patch with the receiving hospital, turn everything on, give your report, have only a little bit of fun saying "Stand by for 12 lead!", then key the mike, and in theory it will be sent. In theory. As far as I've heard, we haven't had a huge success rate. And I think that most people, like me, are avoiding having to do it altogether.
I made it slightly more organized but cannot eliminate all the silliness that is involved in completing the actual telemetry. Johnny and Roy had an easier time of it!
So, whoever reads this from my old work (who is considering switching), please take note. LP 12s are great monitors!

Early morning complaints

It was 3 am we were called for a lady who thought she was having a stroke. She had no signs or symptoms that would indicate that she had anything wrong with her. Except that she called 911 in the middle of the night, which is a disorder that should be in the DSM IV. She certainly didn't have a reasonable answer to my favorite 3am question of "What changed that made you call us now?"
I was riding the actual ambulance, so when my BLS partner took the call, I was super excited to be driving an ambulance again. It's kind of disturbing how long a chase car medic can go without actually driving an ambulance. But I digress.

We dropped her off and the nurse asked her all the same questions that we had. She then asked the patient why she thought she was having a stroke. The patient paused in thought and said, "Well, right now I feel really tired....Like I really want to sleep." I had to leave at that point to stop myself from shouting. "You feel tired because it's 3am and you are awake and in the ER!"
Good Lord, I can't stand time wasters.

Wedding Hair

Another wedding, another seemingly large amount of bobby pins in my hair. For those that care, all maybe one of you, I had 31 pins in the last picture.

This past weekend one of my best friends got married. It was pretty much exhausting, but went really well, and everyone had a good time. Most importantly, they got married. I was surprisingly stressed for a while there, but in the end I had fun. I got to road trip with my college roommate, get my hair done like a southern bell, found a river, and reconnected with friends I hadn't seen in a long time. I am super happy to have done that. And I was generally feeling some huge relief and happiness by the end of the week!
For those that care, all, well potentially more than one of you, there are more pictures here. Yes, we started the week with the bride in a box of packing peanuts and several adult women chasing after an 18 month old to strip him of his ring bearer tux. He really likes to dress up. The week progressed and the same adults stayed up way too late feverishly and obsessively making wedding favors and doing various other pre wedding crafts and activities. We also ate cookie cake, real southern BBQ, and drank way more southern sweet tea than is recommended by the American Dental Association.

I could probably say more, but for now, I'd rather be taking a nap.

Here is our 'mail order bride.'

15 Lead (reprise)

I didn't fully explain, I'm afraid. V4 is used as V4R. V5 is moved and used as V8 and V6 is moved and used as V9. Try it sometime. Impress your friends and colleagues! Don't forget to mark the 12 lead when it's printed out. That is all.

PS Tracy: 80-120 mg/dl is normal. 180ish is generally considered high. My concern is piqued if the patient is over 200 without a reasonable explanation. Sometimes the gloucometer says "HI" which is, of course, very bad (I'm good at pointing out the obvious). On most meters (that I know of) a reading of HI is > 600 mg/dl.
For the brits, if you divide the reading in mg/dl by 18 you get your reading in mmol/L. 600/18 = 33 mmol/L.

Thanks for the questions!

How to worry your colleagues

It's 102 degrees Fahrenheit. It's sunny. You get out of work at 3pm. Anyone normal would run to the nearest swimming pool or ice cream shop. You, on the other hand, decide to hike eight miles. Where you go is basically the same temperature as the surface of the sun. But you march on; pack fully loaded on your back, slathered in suntan lotion, sprayed with bug repellent, three liters of water in tow.
This will worry your colleagues. When I left, my boss asked me what size IV I'd like when I went unconscious and he responded to the call. A modest bilateral 18s would be fine, I replied. It actually would have been a good idea prophylactically, so maybe next time. It will also worry your parents, friends, siblings, and that guy you're dating.

Why would one do this? Training. It is the first time I have trained for a vacation. But more on that later.


It took a while for them to notice something was wrong. He had filled his gas tank and leaned into his car to get something. Nothing unusual there. A few minutes passed and they noticed that he hadn't stood back up. Someone curious approached the car. First off, his exposed hand was blue, this couldn't be right. He shouted for someone to call 911. He edged closer to the man and shook him. Nothing. Someone handed him a phone and he was asked if the man was breathing. He wasn't sure. Help was on the way, he was told. He didn't know what to do and was getting flustered by the dispatchers’ instructions. "No, I don't think I can get him onto the ground. He's in an awkward position." Thankfully, sirens approached. A paramedic arrived and asked what happened. He couldn't answer. She looked at the patient and attempted to pick him up. "Damn, I'm going to drop him." She turned to him and asked, "Can you lift?" He held out the phone to her, in shock over the situation. "You can hang that up now, thanks. Can you lift?" Before he could answer, her partner arrived and together they lowered the man to the ground.

It had been a boring day so far. The tones dropped for a possible cardiac arrest. They nearly ran to the truck, aching for something to do. The call was around the corner, at the gas station. "Must have been the price of gas." She joked to her partner. They got there first in their chase truck, a bystander pointed to the car where the patient was slumped over the front seat. "Sweet, this looks legit." Her partner put it in park and she hopped out. She approached the scene. "What happened?" she asked a bystander calmly. He didn't answer. She took one look at the patient and was worried. His face and hands were blue from lack of oxygen. She attempted to get him out. "Damn, I'm going to drop him." She turned to the bystander and asked him if he could lift. He was taller than she was and maybe could help. He wordlessly handed her the phone, still connected to the 911 operator. "You can hang that up now, thanks. Can you lift?" She repeated, hoping to hide the frustration she felt at his futile gesture. Her partner arrived and helped to lower the patient to the ground. They dragged him into a more open area. She started CPR and, her partner got the BVM out. The ambulance arrived and together they put the patient on the monitor and into the ambulance. She intubated him while her partner started a line, and declared the patient was in PEA. He gave some drugs as she secured her tube and listened to lung sounds. A few minutes of CPR, and she noticed a pulse in the patients neck. "Whoa, stop CPR for a sec, I think he has a pulse." He did, and in the same minute they were at the ER doors. She happily reported a strong pulse and blood pressure to the receiving nurse. "On his keyring it said to call a priest in an emergency." she added as she left the room. The nurse thanked her.

"This one must be serious," The CT tech said to his partner, "they've moved him to the front of the queue." They went together to help the nurse wheel the patient to the scanner. Their day had been typical so far. It took a few people to get him onto the narrow CT table, he had so many tangled IV lines and wires connected to him. The respiratory therapist bagged him throughout, as the techs started the scan and watched the computer screen carefully. And there it was, a subdural bleed, probably from a ruptured aneurysm in his brain. The CT tech showed the nurse the areas of white in the scan. Short of a miracle, this patient would not recover. He would be admitted to give the family time to decide what to do.

Another patient in another hospital had been waiting for a new kidney for a long time. Today she got it. She will get to see her grandchildren grow, get to travel the world, and soon appreciate even the most mundane tasks, including pumping her gas.

15 lead

Sorry Steven, it took me a few days to get your answer. Turns out I couldn't find pictures of a 15 lead, so I had to take a picture of the one out of my book. (credit to Bob Page.)

V4R goes where V4 goes only on the right side. Elevation in this lead alone is diagnostic of a right sided MI. (Occlusion of RCA)

V8 and V9 can show a posterior wall MI.

Ken- thankfully, my patient had a lot going on and his 3rd degree block sort of got better. Here we follow ACLS (advanced cardiac life support) from the American heart association (AHA) Probably the same protocols that you guys follow. Basically the only treatment for symptomatic and unstable 3rd degree block is pacing.


The other day I had one of those calls where I was on scene so long, I felt like exchanging Christmas cards with the patient and calling him on his birthday. It started out as a simple diabetic, but when we got there the patient was more or less awake and oriented. He had had a syncopal episode which led to our being called.
We checked his sugar and it was something like 42. Not good. So I looked around the room, and there were some muffins on the kitchen table. We had him eat one of those, and drink some OJ. Wanting to give those enough time to work, we waited a few minutes and checked his sugar again. 41. What?! So, to plan B. We had him eat a tube of glucose. And some more juice too. We waited a while in hopes that his sugar would be more normal. In this time, though, his wife said that he was acting more normally, which is always good. We were having a nice chat, I learned about all their children and grandchildren, what they both used to do for a living, and we all joked around like old friends. We took it again, 59. Not good enough for a refusal. We had certainly established by then that the patient had no interest in going to the hospital, and his wife was quite satisfied he had made a full recovery. Unfortunately, in the bizarre system I work in, we cannot "treat and street" without informing a doctor of what's going on. No doc is going to let a blood sugar of 59 refuse. So, to plan C. (or I could say plan D as in dextrose) We started a little line in him and gave half an amp. We waited a few, just to make sure it would take effect. I carefully took his sugar again. 181! Fantastic. Good enough for government work, good enough to refuse, good enough to satisfy my worries.
As we left, he was eating another muffin, and we gave the wife all of the standard post hypoglycemic care and advice. Our scene time was over 45 minutes! Finished in time to raise our own blood sugars with a now, late dinner.

The superior inferior

I would say that the most frightening, cluster inducing type of heart attack is the inferior MI, which is also the most deadly, 80% of patients with this condition die. The tricky part about them that instead of responding well to nitrates (the usual treatment for heart attacks), these patients drop their blood pressure precipitously instead. Potentially to the point of death.
We got called for chest pain and when we arrived we found a guy, laying in bed, so wet with sweat that it looked like he had stepped out of the rain, complaining of severe chest pain. From the start this call had potential. He had been outside mowing the grass, developed this pain and stopped, hoping it would go away. At this point he went upstairs. Why? I couldn't tell you. Then he took three of is prescription nitros. Hence the laying down and the blood pressure of 80 palp.

We immediately put him on the monitor which showed what is called a third degree atrio-ventricular heart block. Basically, this patients atria (the top of the heart) and his ventricles (the bottom of the heart) were pumping at different rates, totally independent of eachother. This is very unusual and very bad. We ran a 12 lead and found ST elevation (indicative of a heart attack) in the inferior leads. Oh crap. This is also very unusual and very bad. We started a line right there and began putting fluids in him. Getting down his narrow winding stairs was an experience in itself, and I think nearly killed at least one EMT. When we did successfully get him outside and in the ambo, I had to wipe the sweat off of him and got another 12 lead (pictured below) My partner started another line, gave him aspirin and I got a 15 lead (pictured below) which is a fun thing to do, and gives me even more areas of the heart to look at. That one didn't look too great either. The prehospital treatment for a heart attack like this is fluids, and I mean a lot of them. I called the doc and thankfully he took my word for it and was ready when we arrived at the hospital.

2nd 12 lead

15 lead

About two minutes after we got there, a helicopter was called to take the patient to an interventional cath lab. About three minutes after that the patient coded and went into ventricular fibrillation. Very bad. I was restocking when I head them call it in his room. I ran in in time to see them shock him once and he came back to life. Conscious and alert. "How do you feel?!" "Better." Better?! You just got shocked with 360 Jules, and you feel better?! That was freaking awesome. Thankfully someone was explaining all this to his wife, who, I'm afraid didn't get that we were in quite a hurry on scene. I always stop and talk to the family before we leave. "We may be in a hurry, but you don't need to be. Drive safely to the hospital, okay?" She calmly agreed.

Post resus 3 lead. Second degree heart block type 2...maybe.

Post resus 12 lead. Now with more elevation and reciprocal depression in leads I and aVL. (may have to click the picture for a clearer view)The helicopter picked him up shortly after, and as he was lead away, I wished him good luck and he thanked me. Amazing. I don't honestly know what happened then. I asked the doctor the next morning what he had heard. He was sorry, but no updates. "That's okay. If I don't know, I'll just write my own ending. It's usually better that way anyway."

June 1st

So, I didn't take a picture yesterday. I had a great day of dress fittings, civil war medicine, and family dinners with families that weren't mine before. Today, one of my best friends got married.

Mad props to whoever can guess how many bobby pins are holding my hair in place.

This marks the official end of the picture a day project, but I don't think this will stop me from trying to take my camera everywhere. A few actual written posts are in the works, and it's just a matter of taking the time to sit down and finish them. These especially include explanation of the 3rd degree block and the fly out of the same patient. And also, I hope a little 'getting fancy' about preserving lives and things that I've convinced myself that I didn't miss.
And oh yeah, that makes 45 posts in the month of May. That's a new record!