Blood has a very distinctive odor.

Blood has a very distinctive odor.

 Typically, “normal” blood has a metallic smell largely because of the iron. Iron is contained in hemoglobin which is a protein which carries oxygen to your entire body.

One of the things that is first learned when approaching a patient is that you MUST use all of your senses. Nose included, perhaps even (in my opinion) the most important. After seeing the various manifestation and appearance of blood, there are certain diagnoses that can be fairly accurately made just by having a whiff.  The blood I’m speaking of, of course, is blood that has already left the body. It’s either in the bed sheets, on the floor, in the toilet or spattered around the inside of someone’s car. Each of the aforementioned locations tends to bring with it, a different smell and a different diagnosis.

For example, if you respond to a car accident at 3am and the driver is dead but there are large amounts of blood on the seats or floor boards, the smell of the iron is nonexistent.  You can smell the alcohol in the blood on the seat.

Blood in the toilet or in other places on or around the patient that is dark and tarry is called melena. Melena is caused by a site in the (usually) lower intestines that is bleeding.  There is no mistaking the smell of Melena for anything other than what it is.

Ah, the nose.  We were dispatched to a “woman bleeding” in a very poor, very cold, 4^th floor walk up apartment. Women’s bodies are much more complicated than a man’s body. Their bodies have more sites to bleed from, and often, when they bleed, they BLEED! Any bleeding must be taken seriously. Any bleeding from a woman must be met with greater urgency.  I digress. On the 3^rd floor of this cockroach and bedbug infested home (no disrespect) our noses simultaneously did a quick sniff, smelled nastiness, and almost at the same time said “great”. Not in a good way.  Carrying our 50 or so pounds of gear another 13 stairs, already winded, breathing hard, made the aromatic and pungent air seem particularly unpleasant.

After knocking on the door and doing a quick assessment of our surroundings, we were introduced to our patient. I am a firm believer in the power of human touch and introduce myself each time, trying to get a handshake and touching the upper arm with my other hand. Touching is very important. It gives you an idea of the patients ability to follow commands, you get to feel their skin temperature to see if they are either hot, cold or normal and it creates a bond instantly that shows you care. Too many times I have seen EMS folks walk into a room, arms folded and simply begin firing questions at the patient. Who needs THAT! This patient no more wants you there to see her suffer in her embarrassment that you want to be there, trying to figure out how to effectively mouth breathe so your nose can take a break.

 Our lady today was a 50 year old woman with gastrointestinal (GI) bleeding as a result of years of drinking a fifth of vodka a day for more years than she can remember. Kids as young as 4 or 5 were trying to stay warm,   asking us for food, and begging us to help Nana so she wouldn’t die.

We were still holding our gear, with the help of the fire department, because one learns early that if you put your drug bag or airway bag or defibrillator on the floor, it goes without saying that a cockroach will wander into your gear, and you have now become a vector for disease.  According to the CDC  (http://www.cdc.gov/asthma/triggers.html) cockroach dropping are a trigger for asthma in kids and we don’t need to be introducing more distress into the community.

Nana was clearly sick. In fact she was probably hours away from stranding her grandchildren with only a memory and perhaps a few pictures.

Privacy is very important to patients. My partner took the kids into another room so I could get some concrete answers on the history and do a cursory physical exam. He kids don’t need to see or hear any of this. Nana is their link to the outside world and to diminish that by involving them, to me, is a sin.

She was frail, her eyes icteric (the yellow color of a yield sign), skin was cool and she was clearly dehydrated. The only medicine she took was for high blood pressure, which she should have flushed down the toilet, because she didn’t need them any more and you don’t want the children getting their mitts on them either.

This is not a complicated case, at least not any longer. Her blood pressure was terribly low, she had had melena on and off for a “couple years”, marked weight loss over the course of the past month, yet still kept drinking. Addiction can’t be fun. I’m not sure if the predisposition for some to become addicted to something, or anything, will be fully understood. At least in my lifetime.

Nana was in trouble, but we could stabilize her for the trip to the hospital where (I’m guessing) hospice and social services would get involved. Nana needed a few things. Oxygen, IV fluids to try to get her blood pressure to within reasonable numbers, Thiamine, and prayers. We tested her sugar and it was fine.  Her cardiogram was a mess and showed she had had heart attack in the past, but was way too fast. Not crazy fast, just a sign of her pain, stress and perhaps most importantly her illness and dehydration.

The oxygen was easy, and her oxygen saturation got better instantly. The EKG was easy, although on frail skin the adhesive can be tough but certainly not a contraindication. Accessing a vein would prove no easy feat. Earlier in Nana’s life she loved her heroin and lots of it. The access to her vasculature was impossible. My fear was that once we sat Nana up to move her, because her pressure was so low, she would pass out, which is exactly what happened. Eyeballs rolling back in the head, flaccid body except for the isolated focal seizure which happens and unconsciousness.  We laid her flat, feet elevated for a couple minutes while she came too. Last thing you want to do on a cold, poorly lit 4^th floor carry down is to do it with someone who is unconscious.

Typically we try to keep our “on scene” times to 20 minutes, but this took slightly longer. Nana needed fluid and the only place I could place an IV catheter was in her external jugular vein in her neck. I discussed it with her, told her the options and she said “Baby, if you can get a needle in my neck, you are a better junkie than I ever was”  Apparently she used her neck veins prior to using her arms, hands, feet and fingers. It was going to be uncomfortable for her for two reasons. This was going to be a big IV catheter and we had to really put her head down, as in almost upside down to get her neck veins to fill up with blood.  She tolerated it well, and I stuck the 14 gauge catheter in her neck without difficulty. We laid her flat again and started giving her some Saline. She was much tougher in body and soul than I.

You never want to take a 1000cc bag of saline in a patient with multi organ failure and give her all the fluid at once. Rather, we break it up into a smaller bolus to see how the tolerate it. After about 250cc, we sat her up. She stayed awake, but said the room was spinning. Progress. Reassessment of her lungs was fine. No gurgling. 250cc later she really perked up. I knew this was transient, but positive nonetheless. We sat Nana up and she stayed awake and was even laughing. Now don’t forget, my partner still has the kids in another room and she is still carrying her gear. I called for the kids so they could see Nana and give them some happiness and happy they were.

We got Nana to the hospital better than she was, and that’s the rewarding part.

To this day, I wonder what happened to those children. I know what happened to the late Nana.

Conservative medicine stinks

 Working in any aspect of emergency medicine takes its toll on ones soul. I don’t think it matters if you are a caregiver, work for food services, or are a registrar, once you are thrust, like it or not,  into the chaos that surrounds illness and injury, the only things that truly matter,  is that you truly love people and actually strive to be the best member of the health care team that you are a part of.

Being ill stinks. Most illnesses aren’t fatal. With the advent of really great antibiotics and advances in surgical techniques as well as a host of very efficacious and cool medicines, you stand a better than average chance of going home and hugging your loved ones.  As with everything in life (and death) there are inexplicable, mysterious and curious things that happen, without warning, without any sort of prodrome, or forewarning.

Pardon my unambiguous language, but being of Irish heritage we learn early on from the elders in our wacky overpopulated families that “shit happens”. Perhaps it is the only axiom from the Bible that was purposefully omitted. As my sons would say “back in the day” we had very little to work with, not because it wasn’t available, but because the politics of medicine got in the way. Case in point. The procedure we use to ventilate someone who cannot support breathing on their own is known as Endotrachael intubation (ET). The procedure is pretty simple. It involves hyperventilating the patient for a short period of time to bring up their blood oxygen levels for the relatively short time they have no ventilatory effort while we place the ET tube. Once the tube is placed through the vocal chords, we assess the placement in two ways. Bilateral chest rise and listening on several points across the chest to see that the tube is where it is supposed to be help confirm proper placement of the tube. Agreed, this is a pretty simplified explanation as there a variety of reasons why the tube could be correctly placed, yet the expected outcome may not show its head.

The Eastern Coast of the USA has been traditionally more conservative than the rest of the country. This was no different in most of CT, NY, NJ, VT, NH and Maine.

 

It was a very long time after I returned from Kansas after graduating from the EMICT program which is, without a doubt, the best Collegiate based Paramedic program in the country. My friends and colleagues Jody Gragg, Jeanette Hornung & I were ready to set the world on fire and to a large extent we did. They were fro KS and stayed in their home state with progressive prehospital care and the two of them have changed the face of EMS in Kansas. I came home to CT where I never experienced air rushing out of a young Paramedics balloon as I did in my home state. I went to work (as I have mentioned before) for New Haven Ambulance, thanks TOTALLY to Bobby Tarutis. I love that man for his faith and trust in me. There is a special place in heaven for him.

So here is the disparity in airway management between Kansas and conservative New England.  Short of breath or apenic in Kansas, you get an ET tube in 15 seconds or less, although jealously I must confess I saw Jeanette do it in 11 seconds and Jody in 9. Bastards! In CT, You are short of breath or apenic; you get either an Esophageal Obturator Airway (EOA) or an Esophageal Gastric Tube airway (EGTA). The both were terrible, were hard to use, depended on a good mask seal with the face and if the patient vomited, all of it was forced back into the lungs.

In New haven is the Ivy league school Yale. We did a great deal of calls out of there, especially when the new freshmen came to town. 3 am, Chris Dunne &B I get a call over the radio that in the men’s room, in one of the quads, was a young male “down”, bleeding to death from his mouth.

Yale was a 30 second ride from our station and our contact to the patient was perhaps 8 minutes after getting across the quad,  up the stairs, past a bunch of “Gee.. I don’t know man” crap where we found a 20 something, well dressed young man, lying on his back, covered in what was a bright red fluid. It wasn’t blood but two very bad things became obvious in less than 10 seconds. First, the fluid was alcohol. Sloe Gin Fizz to be precise and the second was that he was on his back. Fluid flows down hill and his lungs were full of booze. Had we had and ET tube, we could have aggressively suctioned his lungs in an attempt to free up some space for oxygen to communicate with hemoglobin and up his chances for survival. Would he have died from acute alcohol aspiration anyway. But we didn’t have an ET tube. The Docs at the two local hospitals didn’t feel we could handle the skill. Instead, we placed an esophageal obturator, which was useless. Sad to report this freshman died and whether it could have been avoided by a more aggressive and aggressively efficacious airway management technique, Mom & Dad still had to bury their son.­­_­­­­­­

Family sorrow

I haven’t written in a while, not because I haven’t had anything to say, it’s just that this is a particularly difficult time of year for me and for many friends, some still here and the families of some who have passed on.

Today, December 10th is the anniversary of my Mother’s death.  Even though it was in 1995, the pain and the emptiness are as fresh as the snow that is falling in many areas back home.

While this may not seem like an EMS story, it is. I’m not talking out of school, but my mother died way too young from emphysema. She LOVED (and I mean loved) smoking.

Many of you know this. I am the eldest of 7 kids (I know…good Irish Catholic family) and my youngest brother has Down syndrome. (Another story for another time). It stuck us all, around the same time, that as much as my mother loved her smoking, none of us smoked. Perhaps it was because we struggled so hard, countless times, to get her to quit, knowing full well the fateful outcome.  Please don’t misunderstand me, she was a wonderful, loving, sometimes harsh, funny mother & grandmother who loved to knit and watch the Mike Douglas show while, precisely at 5 pm, we ate dinner. Just the kids. My Father got home, depending on the day, anywhere between 6 & 7 and she always cooked a second meal for the two of them. My dad was a smoker too, but he went “cold turkey” (I’m guessing somewhere around 1970) and never smoked again. Perhaps he too saw the inevitability or perhaps he was trying to lead by example. I was and still am so proud of him for that leap of faith.

We lived on a small street in Westport, CT and at the end of the street, less than a 5 minute walk was Christies Country Store. It was run by the Masiello family and was the neighborhood “hot spot”. My mother used to send me up to Christies to buy her cigarettes. There was never a problem selling them to me. Christie new I didn’t smoke and knew they were for my mom. Frankly if Christie saw me smoking, she would have not hesitated to put me over her knee & let me have it. One day, after countless pleadings with my mom to stop smoking, I finally refused to go get her her cigs. Bold, perhaps. @5 days later, when I could finally sit again, I had held my ground. Ok, remember there are 7 of us. The memory is unclear after all these years, but I am sure she recruited another of my sibs to run up to Christies for her. Having 7 children makes you a master of logistics and she was pretty darn good.

Fast forward to 1995. Things started to go downhill rapidly. The coughing was relentless despite “puffers” & oxygen. She could no longer sleep flat, speak in full sentences, cook like she used to, gave up her passion of knitting and suffered as her body just broke down. Swollen legs, she had a special shower that my Brother Brian and my Dad but in for her so she could maintain some sort of dignity through her incontinence. I moved back with my parents for a few days prior to what I knew would be the end. I slept in one of the back bedrooms lying awake, listening to her die. Her shortness of breath was markedly worse, almost by the hour. Lying in bed, I thought about what I could, yet should not do based upon her wishes. She had a DNR and a health care proxy, so 911 was out of the question. I remember sitting at the kitchen table, just my Dad & I as he felt helpless and frustrated and I tried lovingly and with the utmost respect what the hospital was not an option. “Dad” I said “If we take her to the hospital, I guarantee thy will insert a breathing tube, put her on a ventilator and the likelihood of her ever having that tube taken out or breathing on her own again would be nil.”  He was so frustrated and sad and confused and I was helpless to make either one of them feel better.

It was about 3 am when I heard her call either “Joe” (my dad) or “Jeff”  We both went in to her and she needed to pee. My father lifted and carried her to the bathroom and when she was done, carried her back to bed. She was ashen, breathing shallowly, diaphoretic, and kind of staring off into space. I told her she was a good mother and did an amazing of a job raising 7 successful hell raisers, and that she should have no regrets. We all loved her for all that he was. She accomplished amazing things in her lifetime, not the least was going head to head with the Connecticut Governor Ella Grasso to get kids with Down Syndrome “main streamed” and not isolated in corners of schools, with no potential for growth.

My mother asked if we could say a prayer. She was laying on the bed, my father sitting on her left, me on her right and we prayed the Hail Mary. Just the three of us. 5 minutes later, she was gone.  My father, through his tears said “I can’t believe she is really gone”.  

First time I ever saw my Dad cry. 

Babies having babies

Babies having babies

Over the course of time, I have been blessed to have helped a variety of moms, in various socioeconomic settings deliver their babies. In 30 years I delivered 13 babies. Certainly not a world record by any stretch, but each delivery was not only exciting (for me anyway) but educationally challenging.

I was a brand new EMT in 76 or 77, riding with the Ossining Volunteer Ambulance Corps, and the sun had just come up in winter when we were dispatched for a woman in labor. “woman” was really a misnomer because she was 16. She was a girl.

A few facts that are important. Ossining is where Sing-Sing is located. It’s on the Hudson River, perhaps 20 miles north of the Bronx and if one were to try to count languages spoken, homeless people on the street living under bridges on route 9A, you would be hard pressed to find two people who agreed on the sum total of people. Ossining opened my eyes to how wonderful Physicians and Allied health professionals could be, taking care of the poor for FREE. Remember, I grew up in Westport CT where poor meant you couldn’t afford the blue Volvo you so desperately had to have. The clinic was / is  The Ossining Open Door (http://www.opendoormedical.org/)  Please find a few dollars and help them save lives.  

The estimated per capita income in 2011: $28,871 and the estimated rent is $1,303. That leaves my fellow New Yorkers less than 40 bucks per day for food, medicine, Daycare, and, the topic of this rant….birth control.

The mid 70’s, leave many holes in the memory. Explicitly, I remember on our crew was Toby Kress, who was very smart, very streetwise and by trade, an educator. Toby had (has) a daughter Ellen who, not only stunningly beautiful, but stunningly smart. Mom & daughter taught me much, They taught me about compassion, about being non-judgmental and about the fact that life deals us a hand of cards. Some of us are great card players and some can’t open the box that cards some in. Regardless, each of us has some skill that helps us survive.

So, as I have reluctantly, yet proudly related the humor in these situations…….Here is the synopsis of baby #1’s  entrance into the world.

Remember, mom was 16. Not streetwise,  not even sure how she got into this mess except that some horn dog teen ager took advantage of her.

Mom is on the stretcher. Contractions perhaps 3 minutes apart. Babies are typically born, at least vaginally, face down, then they turn, delivering a shoulder, then you better hang on. All bets are off, no turning back over the course of time, The finish line is in sight.

There are a few fits and starts as we move through this dance. Perhaps after 2 minutes, and the contractions had stopped (Don’t forget it’s early and I NEED COFFEE) I make a comment.  An innocent, not going for a laugh comment…..”Sure does have a lot of hair on it” I say. I SWEAR I was referencing the baby’s head. Mom says “Thank you”. I say..”No The baby”

After we both had a good chuckle, mom delivered a gift from God. She was so sweet, and amazingly quiet. Almost as if to say, “You guys have any idea what the heck you are doing?”

I spoke with my wonderful friend Diana Ferris Dimon today and shared this story. Diana has one of those brains that is so smart, so logical, so intuitive, so insightful, that anyone who she befriends automatically has a life that is markedly and profoundly improved forever.

Her observation of this event made me feel proud and our conversation made me feel loved.