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."