agnes rocks

I was just reading a colleague's posting on nursing homes, and figured I'd add my two cents here. I dredged this posting up from the archives. . . I've worked in 4 different ASAs, and, I'm sorry to say, have found with few exceptions that care in nursing homes is substandard. Notice I did say "with few exceptions." But thank god some of the patients are able to maintain a bit of spunk, eh?

Note: All names and identifying features have been changed so I don't get sued.

I tried writing this blog last night when I got home from work, and kept falling asleep in front of the computer. . .I'd wake up just a little bit and notice weird words up on the screen scattered throughout my sentences. The words looked vaguely like "HEENT" and "NEUROS INTACT" and "MAEW" and "BILAT" and I started realizing that I've been writing so many charts that I'm now literally doing it in my sleep. But. . .again. . .I digress.
So, yesterday, our first call of the day is to a nursing home for a 90 year old patient with respiratory distress and an altered level of consciousness (LOC) with bouts of self-harm.

Huh?

We get to this place I'll call Hopeful Heights or Whispering Willows or Shady Pines or whatever stupid name I can come up with to hide the fact that this is a place where people come to die when their families can't or won't take care of them. This is the place where the male nurse resembles a serial killer or a child molester, take your pick, and the head nurse has track marks and a seriously high tattoo to teeth ratio. Hopeful Heights is not really a happy place. Did I mention it smells like poop?
I should mention that we do have a somewhat jaded view of some of the lesser quality nursing homes. We frequently get called to them in the middle of the night by alarmist nurses and CNAs who insist their patients are in a "coma" and we get there and scare them out of a nice sound sleep and everybody's pissed but the nurse, who claims she just "couldn't wake them up." (Geez, Nurse Ratched, why were you trying to wake them up in the middle of the night, anyway?) Either that or the patient has been sick for five days, complaining of nausea, hasn't eaten, raging fever, and when you get there you don't even ask if they've given anything for the nausea, because you'll get a blank stare, and nobody can tell you anything because "it's not my patient" or "we just had a shift change, so I wasn't here." It's load and go, and you try to figure out on the way why a patient has Tegretol and Ativan on their med list if they've never had a seizure.
Anyway, this little old lady is lying flat on her back under a thin sheet in a room so cold that I'm shivering. I can hear her chatting away with a companion at bedside, but as soon as she catches sight of me and the gurney, she clams up and goes "unconscious." Fairly convincingly, I might add. I say her name, introduce myself, let her know we're taking her to the hospital. Her eyes snap open-- there's a twinkle in there, but I'm not getting all of it just yet-- and she asks, "why?" And I say, "you've been sick." Her hand slowly raises from the bed and (I'm ashamed to say) my first thought is that this little old lady is going to hit me. . .but she points right at me and smiles a little bit and winks. . .and then boops me on the nose. Hmmm. All is not quite as it seems, methinks.
We get her packaged on the gurney, head elevated so she can breathe, under several blankets to warm her up a bit. We get her outside, she looks straight at me, smiles again, and says, "I hate that fucking Hopeful Heights."

Yes, she did too say that.

We go enroute code 1, turn up the heater, get an IV. I start a head to toe and when I check her pupil response I notice that twinkle. I shake my head and can't help but say, "Agnes, you're a rascal, aren't you? A real troublemaker." And she smiles hugely and points at me and says, "no, YOU are." And boops me on the nose again.

When I get old, I wanna be just like Agnes.

NyQuil Hallucinations

Thought I'd gotten things all taken care of with that job up north. Good people, good organization. I spent a lot of time trying to convince myself that the opportunities far outweighed the fact that I'd be miles from emergency medicine. . .(well. . .not literally, since this place was just down the hill from the hospital. . .but you know what I mean).

So last Thursday I'm minding my own business, buying gummy bears in the grocery store, trying to keep my daughter from filching out of the bulk bins, and my phone rings. It's a friend from the hospital I did all my clinicals at during school. Turns out, they need a paramedic tech in the ER, and they need to know today if it's something I'm interested in.

Well, duh.

So I head in there for an application, and it's like I'm the prodigal daughter returned. It was good to see all the nurses and techs, all the physicians I'd gotten to know so well. I even got hugs, which, really, you can never have too many of. We got all the particulars sorted out, and the head RN said he'd give me a call Monday. Which happened to be the day I was supposed to start up north.

Hmmm. Conundrum. Luckily, the EMS god Tai-ming stepped in. Saturday, I woke up feeling weird-fuzzy-lumpy. A little glazed. Thought it might have been from the illicit pizza I shared with A the night before (he keeps exposing me to gluten, on purpose, I think. I'm pretty sure he just wants the chance to use the Epi 1:1000 he carries in his med bag. But this allergy isn't quite there yet- yeah, my throat gets a little tight, my nose gets all phluggy, but mostly I just get rashy and gassy.) Anyway, Saturday. Did some laundry, but spent most of the time under a blanket, feeling cold. Went home early, went to bed post haste.

Sunday, I woke up. If you can call it that. I wasn't even feeling like death warmed over; I was feeling like death. My cheap digital thermometer, which usually reads me at around 96 degrees, had me at a temp of 104. My arm hair ached, for godsakes! I vaguely remember a friend coming over with meds, Jello, and chicken broth, but mostly I just slept. For 48 hours straight. I actually considered calling 911 because I really, really wanted an IV, but that's generally not a good idea when you know most of the responders. One of my friends from the department called to check on me, said he knew how lousy I was feeling; told me, "agree to an IO and that fluid's yours!" Which I politely declined, thank you very much.

I made it down the stairs yesterday; only had to stop twice to rest. Apparently the job up north is still mine if I want it, but I'm going to have to let them down. I've been wanting this ER tech position for a long time, now. I let it slip away once, and I'm not going to do that again. Great hours, great pay, no need to relocate. It's a beautiful thing.

just another day in the life of. . .

The call came in yesterday, 1600. An official job offer that originally was contingent on me passing the pee test and the background check. I don't have anything to worry about on either count, but I still get nervous. . .what if somebody screws up on the testing? But no, I passed with flying colors, of course, and I'm offered a job that begins in two weeks, full benefits, insurance within the month. Starting wage is $1 more than I was making doing overtime for the ambulance, and it's an 8-5 M-F kind of gig. The potential for learning is absolutely incredible: I'll be adding to my knowledge every day I go to work, because I will be working in different places every day- urgent care one day, for a neurologist or cardiologist or internist or pediatrician, etc. the next. . .the possibilities are limitless. It's as close as I can come to working in an ambulance, except that, you know, I won't be going into people's houses, and I won't get to drive code-3, and my office won't be this cramped little space (well, maybe it will. . .), and I won't have interfacility transports or emergent MI's or traumas. . . But I will have almost full scope of practice- reading ECGs, injections, IVs. And the whole sleep thing will be nice. Several different fire departments to volunteer for up there, too. I'll be moving that general direction as soon as I can get some money together.
My son's hearing has been steadily declining for the past year, and his speech, once fairly clear, is now muffled and slurred. His autism spectrum disorder is also emerging more and more, and the school district is taking its own sweet time in their evaluation. Over a year, now, and we've seen no results. He's scheduled for a CT scan in the next month or so; who knows where that will lead us?
I woke up early this morning to the sound of my daughter sobbing and the distinctive rattle of the front doorknob jiggling. I couldn't tell where my daughter was- sound carries in this house- and my heart started pounding. I've had two attempted break ins in the last four months (what they want to steal, I have no clue), my car's been broken into twice, gunshots are commonplace (our neighbors rang in the new year with a drive by shooting), and I've had my share of peeping toms. I was afraid to call my daughter's name, so I snuck down the stairs and found her scrabbling at the front door, trying to get out. She was carrying one of her little pink 2 1/2 lb weights, god knows why, and had managed to undo one of the locks. . .thank goodness I had that deadbolt fixed after the last attempted break in, or she would have made it outside. She tells me at breakfast that she dreamed there was a fire in our house. Hazards of having a firefighter for a parent, I suppose- a hyperawareness of burning buildings. My relief was palpable. . .
I wonder sometimes if I will ever find a man strong enough to be my partner. . .I am not the easiest person to get to know, and I don't trust many people. My kids are my first priority, and anyone who can't handle my son's issues is rapidly dismissed from my life. Perhaps that's setting me up for failure, and maybe that's a defense mechanism. Do those of us with all these emotional walls find our way to EMS for a reason? I'm not the only one in this profession with boundaries etched in stone. Is it the hours, really, that prevent us from maintaining close personal relationships, or is that just an excuse? How long has it been since I've been with someone who truly knows me? Depressing to think that it's been years. . .

star spangled blinders and distracting injuries, part 1

my daughter asked me this morning if I was going to have to go to work on the coast tomorrow or ever again. Her obvious, unadulterated joy at my answer- no- hit me like a punch in the stomach. How much have I missed in the lives of my children in the last 4 months, not to mention the 2 years I was in school? How much have they grown, learned, and learned to live without? A month ago, my boss informed me that my children would just have to suffer while I established a career as a medic, and it was that conversation that led me to give my notice. . .I pray for resiliency in my babies, and desperately hope that somehow, I can be both a good parent and pursue this calling. . .

New Years Day, and my roommate informs me that a) she got my car impounded and b) she will not be able to pay rent for January. At all. Thank goodness that interview went so well yesterday. . .

I've been thinking about some of my most spectacularly failed calls over the course of my internship and FTO time. These are the ones that end up being witchcraft and voodoo, the calls where I've been led down a not-so-rosy path, hook line and sinker. The first, during my internship, went like this:

76 yo female lift assist. Fire department on scene, all EMT-I or higher, calls for medic assistance and transport. They found this african-american woman sitting on the floor of her apartment, right in front of her easy chair. She denies pain, but every so often sighs and grunts. No SOB, pt looks a bit sweaty; my first impression is possibly flu. She says she's been a little sick today. FD states they eased her into a chair and she threw up; they think she might be a bit dehydrated and so they're trying to start a line. She should probably go in to the hospital for a work-up, just in case. They tell me she's remarkably healthy, otherwise; no significant medical hx. While FD keeps poking at her right arm, I slide a quick 20 into her left AC. We get the FD VS- all within normal limits- lower the gurney, and as we stand her up, she leans into me and vomits a tiny bit. She apologizes. We get her in the ambulance, she's still denying pn, denying any significant medical hx. We specify: heart? no. Diabetes? no. Stroke, seizure, lungs, recent illness? no, no, no, no. She's a bit more diaphoretic now, but smiling; still denying pn. Then she tells us she was fine yesterday, but is feeling soooooo weak today; she'd tried to stand up to go to the bathroom and her legs were too wobbly. I glance at my preceptor. We attach the 12-lead; unremarkable. SAO2 93%; lungs clear, no SOB, HR 100, BP 110/75, CBG a bit low at 90. IV established, bag of fluid hung TKO, 2 L O2 via NC. She still grunts occasionally, but we talk about how she's hoping for a sweetheart, someone who knows how to dance and can make her smile, how those two things are all that matters when you get to be her age. C-1 to the hospital, even then only 4 minutes away. We get her in the room, I give my report; the ER doc and all the techs are giving me the "why is she here?" look. I emphasize the sudden onset weakness, look to the pt for confirmation. She suddenly doesn't look so good, and is, in fact, getting more pale by the second. The doc calls for the cardiologist, the imager, everything STAT goddammit now! I grasp the pt's hand, nod briefly at her daughter, who looks familiar. . . leave to go write my chart. I come back for a signature, and I have never seen a black person that pale. . .her face is a gray, ghostly shade, and she looks frightened beyond belief. Her daughter watches, anxious.
Next transport in to the hospital less than 20 minutes later, and she is gone. The tech shrugs, says she coded as we were leaving; nothing they could do, really, with a PE, and her heart twice the size of normal. Her meds list, on file at the hospital, is proof of a dizzying array of conditions: asthma, diabetes, HTN, TIA, arthritis- the list goes on. She's had her flu shot, though, just last week. And I think to myself, as I'm back in quarters, the firefighters teasing me about this first notch in my belt, first patient lost, I think: pulmonary embolism? It was just a lift assist! And I run through all the things I know about PEs-- decreasing SATs in spite of high flow O2, SOB, possible JVD, possible cx pn, possible tachycardia, tachypnea, so many possibles. . .I search frantically through all my books for the golden nugget, the one thing I missed, the one thing I should have seen. I should have known, I should have known. . . I shouldn't have trusted the FD, even though they all are experienced medics, and me just a lowly intern. . .I should have known. . . I should have done a bilateral BP (but you got the IV in the left arm, I think to myself, and they were still poking her right arm. . .), I should have looked in her apartment for meds, I should have asked about recent surgeries, and smoking hx, I shouldn't have trusted the FD's standard RR16. I should have known to ask.
And I find it, the little nugget. . .12% of PE pts will show s1q3t3 on their 12-lead: a small s in lead I, small q in lead III, a flipped t wave in lead III. Did she have it? I don't know, I don't know. I didn't know to look.
Later that night, midnight, I'm off shift, picking up my son from his father's house. I look up as I get out of the car, and I see the daughter sitting on the stoop across the way. That's why she looked so familiar. I don't know what to say to her. I don't know that I can say anything except "I'm sorry. I'm so sorry I couldn't save your mother."