A Break in the Action

Nice to be able to sit down and write - I don't have to be to work until 6:00 tonight. Yesterday's 24 was actually closer to 27 by the time I got out. My supervisor needed coverage until 8:00 last night because he had a commitment of some sort. So I sort of drew the short straw. It wasn't a big deal, though; the sun hadn't set when I left Manchester, so that was okay. It was a long, long day, and I so needed a shower by the time I left.....

I actually got to do something with a patient that I hadn't done yet: CPAP. Okay - what is it? CPAP stands for "Continuous Positive Air Pressure", and the common application is for a person with Obstructive Sleep Apnea (someone like myself, in fact). In the instance of OSA it forces the airway to stay open with high-pressure air being forced into the lungs. Initially it was uncomfortable to use, but once I got used to it, I've had no problems and I've been using it since 2002. Works for me - I actually dream when I sleep, and I'm mostly rested when I wake up.

The emergency use for CPAP is for a person having a breathing emergency due to Congestive Heart Failure. In CHF, the pathophysiology is such that the right side of the heart is failing to move blood properly to the lungs due to decreased stroke volume. This can, and usually does, lead to an increase of fluid in tissues throughout the body, including the third space around the heart. It also leads to a backup of this said fluid into the alveolar spaces of the lungs, making it extremely difficult for a person to exchange Oxygen and Carbon Dioxide when they breathe. What the CPAP does is forces the fluids that are in the alveoli back into the tissue, and ultimately the bloodstream where with the creative use of medications, including Nitroglycerin and Lasix, the fluid can be led to the kidneys where it can be processed out of the body.

In our case, we didn't have the luxury of Lasix because the patient is in End Stage Renal Failure and goes to dialysis 3 times a week. However, I was able to give him Nitro so we could at least relax the smooth muscle and dilate his bronchial passages to give him the ability to move some air. It was absolutely amazing - from the time we started the CPAP to the time we got him to the Emergency Room at the Elliot, approximately 5-6 minutes, the change was quite noticeable. Our patient's mental status improved incredibly, as did his ability to move air and his level of Oxygen in his bloodstream. It made me a real believer in the application of CPAP in the field, especially if you can save the patient from having to be intubated.

If I had the ability to use Lasix, I wouldn't have cared if the patient peed all over my stretcher. As it was, the ED doc ordered it for him after we arrived, but he understood my point of view when I discussed it with him afterward. That was okay.

We had a call for a suicidal 26 year-old female earlier in the day. When we arrived, the police were already on scene, and when we got the patient, she was crying, very upset, said she'd gotten into a fight with her live-in boyfriend and wanted to kill herself. Said she had a history of asthma, also told us that some scratches she had on her right wrist were "cat scratches", although I didn't see (or smell) the presence of a cat in the apartment. She was cooperative with us on the ride to the hospital, but things changed when we got there - apparently the nurse who was going to be taking care of her pissed her off and she became rather violent. It took myself, two nurses, two security officers, and two Manchester police officers to hold her down so she could be restrained. I found out later that she's a regular at the city's Methadone clinic, and the scratches were most likely self-inflicted - big surprise there. Anyway, bizarre as that sounds, that was the entertainment for the shift, at least for me.

It's pretty bad when someone who is violent or combative for whatever reason can be viewed as entertaining. I suppose part of that is because those of us who have to deal with them are probably thanking God at some level that we aren't on the receiving end - "there but for the grace of God go I", or something like that. Now I realize many of the people I deal with have real problems that require real help. That said, I know that a fair number of these same folks bring their problems upon themselves. I see that often, and it's frustrating to not be able to do anything further, like impose a reality check on some of these same people. But that's extremely difficult to do because the problems like this that we see have to be rooted in some sort of real issue. However, it's not our job to get to the bottom of that; it's the responsibility of each of those people we deal with, and many of them are not equipped to do so. And that is sad.

"That's all I have to say about that." -- Forrest Gump