"You wanna just head in?" Kyle asked me.
"Sure. Pick up is in 10 minutes but she's probably ready."
We're lead into the house by the home caretaker through the garage. As I approached our patient Mary, I heard her whimpering softly. She was lying in her bed which is set up in the middle of her large, ranch-style home. Her husband turned away from the TV only to greet us with a nod.
"Hi Mary. How ya feeling today?" I asked.
"Ooooh.. Ohhh owww.. My legs hurt... And my arms...Owwww ooohhh..." she moaned. I looked up at my partner and cocked my head to the side, giving him the 'this-don't-look-right' expression. We've been partners for awhile, so he understood immediately and held out his hand for the BP cuff and stethescope. I tried talking to her caretaker quickly to see if there was something else going on.
"No blood presha. Hard to get on her." she said in a thick accent.
"No blood pressure? Since when?"
"Tursday. Been seeek. No good."
"Ok. When was she dialyzed last?"
"MMmm... Friday. No, Saturday..ya."
"Hmm.. Ok so that's 2 days."
My partner looked up at me with obvious concern in his face. "Nothing. Can't hear a thing."
"Really? Let me see."
He handed the cuff and stethescope over and I wrapped the cuff around her arm and pumped it up to 180. I released the knob to allow the air to flow out, listening desperately for a heartbeat under her bicep. The needle jumped faintly around 60 but continued to fall rapidly. I heard nothing. I tried again, but this time the needle fell without a single twitch. I took the scope off and tried to palpate a pulse. No radial, no brachial, no carotid.
"Mary? Sweetie, you with me?"
"Ya honey. I'm ok. Just hurtin'. Owwww."
I looked over again at Kyle and shrugged. "She's alert and oriented. She probably just needs dialysis. Maybe she's just got too much fluid, causing the edema so it hurts and makes it hard to hear a pulse." I said.
He nodded again. "Should we go to the ER?"
I looked down at Mary. Since she's a regular patient, I know her well. She looked a little pale, but not bad. No trouble breathing, lungs sounded clear, but she definitely seemed ill.
"Her dialysis center is just next to the hospital. Let's head over and see how she does. If anything we can bring her into the ER if she gets worse."
He nodded again and we loaded her onto the gurney. As we walked out, I repeat to him what my paramedic instructor has drilled into my head; 'is it working for your patient?' Normally, a patient with no blood pressure and no pulse would be, well, very bad. In this case, my patient had what we call co-morbidity; a laundry list of medical problems that might contribute to her symptoms. She was awake and oriented, but in pain. There was obviously something wrong, but not necessarily life threatening. So, is it working for my patient? She was alive, and seemed basically okay.
We loaded her into the rig and I sat down beside her on the bench to do paperwork. I looked at her closely after a couple of minutes had passed. She looked strange, different than just a few minutes before.
"Mary? Mary, how are you doing?"
"Aw hun. Can you let the kitty in? She's crying. Oooohowww ohhh.."
"Mary, sweetie, do you know where you are?"
"Yea but my kitty is cryin'."
I frantically searched her again for a pulse, looking for anything that may have caused her sudden drop in mentation. I gingerly placed a finger on her neck and drowned out the diesel. I felt it. Very faint, and very fast, but it was there and it didn't feel too good. I poked my head through to the cab.
"Hey, divert to the ER. I'll call and update dispatch and have them notify. She's not okay. Don't turn on the siren just yet." I said softly. He nodded again in understanding and turned his worried face from the rearview back towards the road, focused on getting us there. When I sat back down and looked at her again, I realized what was making her look so strange. Her color had gone from slightly pale to downright gray. Almost jaundiced looking, her skin now held a yellow-green-gray color and her eyes looked sunken in and clouded. I kept talking to her, but she still wasn't making any sense, even though she had been just a few minutes prior. I called my dispatcher to update them on the situation, letting them know we would be taking her to the ER across the parking lot from the dialysis center. One of our newer dispatchers answered the phone.
"Sure. Pick up is in 10 minutes but she's probably ready."
We're lead into the house by the home caretaker through the garage. As I approached our patient Mary, I heard her whimpering softly. She was lying in her bed which is set up in the middle of her large, ranch-style home. Her husband turned away from the TV only to greet us with a nod.
"Hi Mary. How ya feeling today?" I asked.
"Ooooh.. Ohhh owww.. My legs hurt... And my arms...Owwww ooohhh..." she moaned. I looked up at my partner and cocked my head to the side, giving him the 'this-don't-look-right' expression. We've been partners for awhile, so he understood immediately and held out his hand for the BP cuff and stethescope. I tried talking to her caretaker quickly to see if there was something else going on.
"No blood presha. Hard to get on her." she said in a thick accent.
"No blood pressure? Since when?"
"Tursday. Been seeek. No good."
"Ok. When was she dialyzed last?"
"MMmm... Friday. No, Saturday..ya."
"Hmm.. Ok so that's 2 days."
My partner looked up at me with obvious concern in his face. "Nothing. Can't hear a thing."
"Really? Let me see."
He handed the cuff and stethescope over and I wrapped the cuff around her arm and pumped it up to 180. I released the knob to allow the air to flow out, listening desperately for a heartbeat under her bicep. The needle jumped faintly around 60 but continued to fall rapidly. I heard nothing. I tried again, but this time the needle fell without a single twitch. I took the scope off and tried to palpate a pulse. No radial, no brachial, no carotid.
"Mary? Sweetie, you with me?"
"Ya honey. I'm ok. Just hurtin'. Owwww."
I looked over again at Kyle and shrugged. "She's alert and oriented. She probably just needs dialysis. Maybe she's just got too much fluid, causing the edema so it hurts and makes it hard to hear a pulse." I said.
He nodded again. "Should we go to the ER?"
I looked down at Mary. Since she's a regular patient, I know her well. She looked a little pale, but not bad. No trouble breathing, lungs sounded clear, but she definitely seemed ill.
"Her dialysis center is just next to the hospital. Let's head over and see how she does. If anything we can bring her into the ER if she gets worse."
He nodded again and we loaded her onto the gurney. As we walked out, I repeat to him what my paramedic instructor has drilled into my head; 'is it working for your patient?' Normally, a patient with no blood pressure and no pulse would be, well, very bad. In this case, my patient had what we call co-morbidity; a laundry list of medical problems that might contribute to her symptoms. She was awake and oriented, but in pain. There was obviously something wrong, but not necessarily life threatening. So, is it working for my patient? She was alive, and seemed basically okay.
We loaded her into the rig and I sat down beside her on the bench to do paperwork. I looked at her closely after a couple of minutes had passed. She looked strange, different than just a few minutes before.
"Mary? Mary, how are you doing?"
"Aw hun. Can you let the kitty in? She's crying. Oooohowww ohhh.."
"Mary, sweetie, do you know where you are?"
"Yea but my kitty is cryin'."
I frantically searched her again for a pulse, looking for anything that may have caused her sudden drop in mentation. I gingerly placed a finger on her neck and drowned out the diesel. I felt it. Very faint, and very fast, but it was there and it didn't feel too good. I poked my head through to the cab.
"Hey, divert to the ER. I'll call and update dispatch and have them notify. She's not okay. Don't turn on the siren just yet." I said softly. He nodded again in understanding and turned his worried face from the rearview back towards the road, focused on getting us there. When I sat back down and looked at her again, I realized what was making her look so strange. Her color had gone from slightly pale to downright gray. Almost jaundiced looking, her skin now held a yellow-green-gray color and her eyes looked sunken in and clouded. I kept talking to her, but she still wasn't making any sense, even though she had been just a few minutes prior. I called my dispatcher to update them on the situation, letting them know we would be taking her to the ER across the parking lot from the dialysis center. One of our newer dispatchers answered the phone.
"Hey Mark. We're diverting to the ER, she's not looking good." I said quickly, almost whispering.
"Okay. Give me some vitals so I can let them know."
"Uh, that's the problem. I can't get any BP or pulse on her really. I can feel a weak, rapid carotid but nothing else. Sorry. Respirations are 24, unlabored and slightly shallow on 6 liters of oxygen, but her mentation just dropped and her color is all wrong."
"Uh, that's the problem. I can't get any BP or pulse on her really. I can feel a weak, rapid carotid but nothing else. Sorry. Respirations are 24, unlabored and slightly shallow on 6 liters of oxygen, but her mentation just dropped and her color is all wrong."
"Ok, so she's alive, you just can't feel a pulse or BP?"
"Yea. Just let them know we're coming in."
"Alright, thanks, I'll call right now."
We pulled into the ambulance bay and brought her in. Usually, BLS crews stand around waiting for upwards of 30 minutes for a bed in the ER, regardless of the patient'scondition. Today was different.
"Is this Mary?" a nurse asked me.
"Yea. Can't palpate or auscultate any BP or pulse. Caught a weak rapid carotid but lost it pretty quick. She's awake and talking but not making much sense and she's really ashen."
"Ok, bed 5. Hook her up to the monitor, let's try to get some vitals. Why didn't you call for paramedics on scene?"
"I, uh... I don't know. She looked okay, she just started... doing this... enroute. We thought she was okay." I replied, wheeling her into a room. A nurse came in and scowled at us, irritated with our lack of a full medical history and medications. I explained that her caretaker would be here any minute with all of that information, but she waved me away.
"Sixty over thirty, pulse 140. She's compensating, get the doctor in here." she yelled out the door suddenly. I spun around and stared at the monitor, disbelieving the numbers that had popped up.
"She was okay.... I don't understand... When we got there.... She was okay I thought.." I heard my voice trail off towards the end. I turned to walk out of the room and talk to our nurse when a doctor ran into me in the hall.
"Why didn't you ALS this?! This is NOT a BLS call!"
"Her mentation dropped enroute, and her color changed. She was alert and oriented on scene, even though we couldn't get a pulse, she didn't LOOK seriously ill."
He, like the nurse, waved me off and went into the room.
My partner and I left the ER like 2 puppies with our tails between our legs. We pulled out of the bay and parked down a nearby street so I could finish writing my report. I re-wrote the PCR at least 4 times, trying to detail everything so that I could unravel it all in my own head. Everything sounded right; at her house, she seemed to be doing alright. In the rig, she changed. I diverted to the ER like I was supposed to. So why did I feel like I had done something wrong? Kyle admitted his own guilt, saying he felt that he, too had done something wrong. When we got back into station we went over the call again with our supervisor.
"We just wanted to know what you would have done if you had been on the call."
He sighed and rested his head on his fist. "The same thing. I mean, it sounds like you guys did what you were supposed to. You're not going to get into trouble, you know. Screw the doctor, what were you supposed to do? You got her to the ER. You noticed the changes and you took her to the right place. It's not your fault, really."
"I know," I said, "and I'm not worried about getting into trouble. I'm worried that I did her wrong. That I didn't do all that I could have because I waved off the lack of pulses to her medical history. I feel like I should have caught it."
"You couldn't have possibly known. You did everything right." He replied.
I walked outside for a smoke and Kyle joined me.
"I feel a little better." He said suddenly, after a minute or two had passed in silence. I nodded in agreement. I felt a little better too, but still somewhat guilty. I brushed it off and got through the rest of my shift forcing myself not to think about it too much more.
Kyle called me the next morning while I was on my way to school.
"Mary died. At the hospital yesterday I think. I'm not really sure how, dispatch just told me. They called her house to see if we would be taking her to dialysis tomorrow and her husband said she passed away. I just thought you would want to know."
"Oh.. Yea. Um.. Thanks man." I said, slowly.
"Yea, no problem." he replied quietly.
He was silent for a second before speaking again. "I still feel bad."
"Yea, me too."
'Sixty over thirty, pulse 140. She's compensating.'
'Is it working for your patient?'
No. I thought it was, but I suppose I thought wrong.
