Wednesday, June 04, 2008

General Weirdness

The past two days have been, well, weird. I can think of no other way to describe them.

I gave my notice yesterday at The Rock, my full-time employer. I did request to be put on Per Diem status, and they assented to that. I'm happy - I can tell them "no" whenever I want after June 16th. And it's funny; word got out awfully fast after I did that deed. I've had so many people tell me either that I sucked or that they wanted my schedule. If they want it that bad, they can bid on it. And it's not all it's cracked up to be, either, which is one of the reasons I'm all done with it. My home life was starting to take a bit of a beating as I never got to see my wife or my kids in any sort of regular fashion. Hopefully that will change once the schedule I'll work is established. I have no idea what that will be as of yet, and I probably won't know until I've gotten through orientation. So there will be more to follow on that.

However, since I will continue to be an RRA employee in some way, I'll still have stories to tell about Manch. That won't change.

One of the medics I work with asked me to cover part of his shift last night as he had some personal business he needed to take care of. I agreed to help him out, and I have to say that I worked more between 5PM and 10PM than I did from 7AM to 5PM, which is my regular shift. But I had something strange happen in that short time: all but one of the calls we went on were patient refusals. The first was not; we were the second ambulance in on a 3-car MVC with entrapment. The jaws were working on an Infiniti SUV that had rolled due to being T-boned at an intersection. The driver was restrained and she had her side airbags deploy. Because of both of these things, she walked away from the accident with nothing but a scratch on her hand from glass, and she refused transport to the hospital. The five people in the other two cars either were transported or refused care and accompanied the family members that needed to be transported to the hospital. Everyone went to the same hospital - this caused a raging cluster-fuck as not only did our patients go there, but the other 3 city trucks brought patients in there within 15 or 20 minutes of our arrival. The last of them was a cardiac arrest that ALS-5, our 24-hour transfer truck, brought in as they got dragged into the city rotation. A 59 year-old male, really large, found down in his car. From what I was told by the medic on that truck, CPR was in progress on the street when they arrived. He had two IO's in place, one in each leg, and a combi-tube for an airway. Judging his size and weight (I'd estimate maybe 400 lbs. at about 6 feet) he wasn't getting an ET tube - probably really anterior, but since I wasn't there I don't know. Just the same, when they arrived at the hospital my partner and I helped them and the engine company unload. They had PEA on their monitor - I guess they shocked 3 times to get to that point - and got pulses back once before they lost them. I found out later on that this happened two more times in the Trauma room. But then they lost him.

I know how that goes; mine (in a previous post somewhere back in the archive) weighed in at over 600 lbs. and was witnessed by myself and three of my colleagues in the back of my truck. So I understand that this happens all too well.

Tuesday was equally strange albeit in a manner opposite of Monday. We did all of one call, and it was a BLS hospital discharge to rehab care at one of the nursing homes. Nothing too notable - an 84 year-old female post CHF episode going to work on strengthening herself. I don't know if she's going home, though, as some of her belongings were waiting for her when we arrived at the nursing home. Four large boxes. That makes me think that she'll be there for some time, if not for good.

Otherwise, we did a whole lot of nothing.

I'm working in Goffstown as I write this. It's 12:45AM and I haven't had a chance to settle down for some sleep yet. We did one call so far and it was a little bit atypical: 58 year-old male - a former Force Reconnaisance Marine - history of anemia and problems associated with cellulitis that somehow has affected his joints, complaining of flu-like symptoms and some shortness of breath. Symptoms onset at approximately noon Tuesday, and they include a temperature, generalized joint pain, and increased work of breathing that is out of character for him. He is a non-smoker, and his only other medical history is high cholesterol, which is being managed with Lipitor.

Exam shows flushed, warm, and slightly diaphoretic skin. Lung sounds clear in all fields. Patient has no abdominal pain, and all quadrants are soft and non-tender. Patient is able to move all extremities. Pupils are slightly dilated but do react to light down to about 2mm. Temperature is 102.6 degrees F. Pulse of 116 with sinus tachycardia on the monitor. SO2 of 92% on room air. Blood pressure of 106/64. Glucose of 173 mg/dl. He'd taken 650mg of aspirin approximately 1 hour prior to EMS arrival with no positive change in temperature or discomfort level. In fact, his wife reports that his temp rose a little over 1 degree since the aspirin.

Treatment included 4 L/min of Oxygen by nasal cannula - SO2 increased to 98% with treatment. Cardiac monitoring continued on patient. IV bolus of about 300ml of 0.9% Normal Saline during the trip into the hospital. No negative change in his condition, but no real positive one, either.

My own differential diagnoses with this are pretty clear-cut, I think: first, he may very simply have a flu-like virus of some sort. Second, because of the history of cellulitis, perhaps he is dealing with an infection of some sort relating to this originating from a possible flare-up. However, I saw no signs of the presence of cellulitis when we did our exam, so I would have to hold judgement on that. Third (and the one I suspect is most likely), because he is chronically anemic (for an unknown reason at that point; whatever the cause is, it is likely an iatrogenic one) he may be dealing with the beginning of some sort of systemic infection as his immune system could be compromised somehow. At least that is my best guess.

Feedback, as always, is welcome.

At this point I think I'll stop and try to sleep. It's time for that.


EE said... gut says something that I'm not even going to write. We had something similar to this the other day...

Did you ever get a follow up report on the dude?

max said...

blood cultures would be high on the list of stuff to get done.... some travel history is always nice too.

manchmedic said...

Interesting points all the way around... I haven't gotten any sort of follow-up as I haven't really had an opportunity to do that. It's on the list, however.

I'm pretty sure that they were going to draw blood cultures off of him. I'm thinking that with the other things he had going on they were probably going to get the normal lab work, i.e., a CBC, probably an INR, and I wouldn't be surprised if they were going to get a D-Dimer and a Sed rate as well.

I hadn't thought about the travel angle; if he's been out of the country he definitely could have picked up something... If I can get a follow-up on him I will pass it on.