In Response

While I knew that Drunks 3 could ruffle a few feathers, I didn’t know that the first comment would be from an anonymous poster only hours after the post went up. I’d like to thank them for taking the time to comment and I’d like to respond. First, here is their comment:

While I agree that you (and other medics) need to do what you need to do to protect yourself, your writing style seems to show a disturbing level of enjoyment . The fact that you "got even" with your altered patient by "knocking her out and cutting up her leather coat" shows that you may need to look at your patient care/compassion skills.

I think medics should be allowed chemical sedation when needed, but from reading your take on this event, and the other "drunks" you've dealt with, you seem a little "quick on the plunger" when it comes to the potential use of inapsine.

While I will refrain from making baseless accusations about the anonymous commentator, it does sound as if this person is not a paramedic. I would like to say that the “enjoyment” they refer to is something that any paramedic or EMT takes in any skill that they perform. As an example, is it wrong for a medic to take a certain amount of enthusiastic joy in intubating someone? The medic is practicing a life saving skill on a patient having a very, very bad day, often a cardiac arrest or multi-systems trauma. Let’s be honest with ourselves, those are calls that we consider “good” in a sense that we get to practice a variety of our skills. So, is it selfish or self serving to give ourselves a high-five, pat on the back and tell our coworkers what a great job we did, after the fact? Of course not.

I performed a necessary intervention (i.e. patient care skill) when I chemically sedated this patient. I won’t lie and say that I didn’t feel an amount of justification (and the gut feeling of “getting even”) in sedating the patient. Especially considering this person had sexually assaulted my partner and myself, and caused physical injury to me. I was honest in how I felt. I wrote about the feelings that I had at the time of the incident and it is implied that I used the appropriate interventions and patient care skills to mitigate the situation and treat the patient. To imply that I am “too quick on the plunger,” well, let me quote directly from my treatment protocols.

Always consider your safety…if patient is combative [with] no known trauma cause for AMS, consider Inapsine 5mg IV or 10mg IM.

In actuality, I gave the patient an underdose of inapsine. As a paramedic, I am also thoroughly aware and take into consideration the risk versus benefit of every medication that I administer.

Finally, to imply that I need to reevaluate my patient care/compassion skills, I say to you: how dare you think you can judge me and my skills based upon one anecdotal story. I would refer you to such posts as Screamin’ Eagle, Why We Do, or Tragic to “demonstrate” my compassion and patient care. I would also like to refer you to Force, a brief essay on use of force in restraining a patient, a topic that I feel strongly about. But even if that isn’t enough to demonstrate that patient care and compassion are always at the forefront of every call I run, I’ll refer you to the two EMS Provider of the Year awards bestowed upon me by my fire department. Or even better, I’ll refer you to the Meritorious Service Medal for EMT-Intermediate of the Year and the Medal of Valor, both bestowed upon me by the State of Oregon. Oh, and after that, would you like to ask my wife, who wants nothing more than for me to come home safely after every shift, if it was acceptable patient care?

Drunks 3

And now the long awaited third in the series of drunk cases. Enjoy.

It was only eight in the evening, and really, it had been a slow shift. I was working with a part-timer that night, a cop that had just certified as an EMT-Basic. The plektron on the desk sounded and we lifted ourselves out of the recliners as the dispatcher intoned “medic 4, respond for an intoxicated female, unconscious, lying in front of the Sheldon Apartments.”

At least there won’t be any surprises.

My partner, Chris, hadn’t worked much at the south end of the county so I gave him the turn by turn directions to the apartment complex. We pulled into the parking lot to see two police cruisers and another two police SUVs parked in front of one of the five buildings. All four of the cops had shit-eatin grins on their faces and just pointed down the hallway as we walked approached. Clearly, they were enjoying themselves.

Our patient was a 230 pound female in her 50s, wearing a too-short little black dress and white leather jacket. Apparently, she already had been out on the town as she was fall over drunk. Her neighbor was standing at her side, supporting her when we came up. She was droopy eyed, smelled like booze, and had an extreme slur to her words. Of course, she told us she’d only had “a couple” of drinks, but the neighbor was reporting it was at least a whole bottle of vodka.

I directed my partner to bring the gurney up since I didn’t want her walking and falling. We spun her around and sat her on the edge of the gurney and all the while she was trying to flirt with us. “You’re cute,” she would say, dragging the words out. We started to belt her in, when I noticed a large bulge in the sleeve of her coat. I straightened her arm and extracted a near empty bottle of Smirnov Vodka from her sleeve.

“Hey guys,” I hollered over to the cops. “Do you think you might have missed something?”

“Where’d you find that?” the sergeant replied.

“Up her sleeve, man. That could have done some damage.”

At first, our patient was compliant, but became restless after we took her booze away. Chris and I were having a little trouble getting the seatbelts fastened since she wouldn’t stop moving around. I was standing next to the cot, trying to get the waist belt clasped when it happened.

She reached out with her left hand, quickly and with purpose, and grabbed hold of my crotch.

Immediately, I went from irritated to full-on pissed off. I took a step back, unlatched her hand and fired off a “you keep your hands to yourself!” I was stunned and it was the only thing I could think to say. But oh, things would get worse.

She was a loud drunk, with few inhibitions, and as my partner and I tried to finish packaging her, she started yelling. “Boy, you’ve got soft balls! I want to touch your balls!”

The cops were still standing by and began laughing. “Guys, could we get some help?”

With the cops help, we finished with the seatbelts and wheeled her towards the ambulance. I was red faced with anger and she wouldn’t stop yelling, “your balls are so soft!” And when we were just about ready to load the gurney, she reached out with her right hand and got a hold of my partner.

My patience was gone. As soon as the gurney was locked into place, I told Chris to get the restraints out. He was in the CPR seat, trying to dodge her groping and get the restraints, while I was on the bench doing the same. Through continued cries of “I want your balls!” we fought to keep her hands off of us. She was kicking her legs now, loosening the leg straps and doing her best to get off of the cot. And again, while the cops were standing by and laughing, I had to ask to get them inside to help us. One of the cops sat on her knees while the other climbed into the airway seat and put her into a kind of headlock.

She was getting more and more violent. I had to pin her arm against the edge of the cot with my knee and I worried (but only slightly) that I would break it as she fought against us. She kept trying to pick her head up and bite anyone that came near. We put the restraints on, but with her fighting, couldn’t get them tight enough to do any good. Chris put an oxygen mask over her face to keep her from biting or spitting. Her writhing and fighting was getting worse and worse. She would growl, trying to move the mask with her tongue, then try to bite it out of the way. Then she’d launch into another “I want your balls! Let me touch your balls!” It honestly reminded me of something out of The Exorcist.

Enough was enough. With two previous belligerent drunks, I wasn’t going to let another get the best of me or my partner. I opened up the drug kit and pulled out the inapsine. Using my trauma shears, I cut up the sleeve of her leather coat from cuff to collar without even a second thought and jammed that needle into her arm. I gave her a 5mg dose, slamming the plunger. I told everyone to back off, that she’d relax in a minute.

Within the next ten minutes, we were rolling were rolling our patient into the ER. By that time she was well and truly unconscious. She had snoring respirations at maybe 8 per minute and was only rousable by a deep sternal rub. If we had been any further out from the hospital, I would have considered some airway adjuncts of the nasal kind. Casey, a short, blonde ER nurse with a “if you tell me I’m cute I’ll kick your ass” kind of attitude, met as in the hall. She had her hands on her hips and her eyes were a little squinted when she asked, “you gave her five of inapsine?”

Without breaking my stride, “that’s right.” You see, this hospital recently had a patient with a poor outcome after allegedly receiving too much inapsine. They didn’t want a repeat performance. Frankly, I couldn’t have given a damn.

The cops walked in behind us, still grinning from ear to ear when I began my report. They only nodded their heads up and down in verification as I relayed the events, pantomiming the “violation” when the nurses asked, “what do you mean she grabbed you?” Having heard the entirety of the events, the nurses were sympathetic and didn’t question me again about the sedation.

I took a breath and stepped back then. The nurses were at work getting her clothes off, drawing blood and placing a catheter. Still simmering with anger, I took my gloves off only to discover three deep scratches on my left wrist. “Damnit!”

“What?” Chris looked over at me.

“She fucking scratched me! Do you realize the amount of paperwork I have to fill out now? Fucking incident and exposure forms, and I’ve got to call the Sup. Damnit!”

The officers, having had their fill of fun watching the ambulance do what should have been there job, looked at me. “Do you want to file charges?”

“No. It’s not worth the trouble.” Besides, I’d got to knock her ass out and cut up her fancy leather coat. I figured we were even, in a sense.

*****

There’s a lesson in all of these. For starters, don’t let me mislead you to think that I take pleasure in “kicking the ass” of a patient. It is my sincere hope that a call doesn’t escalate to the point where restraint of any kind is necessary. However, it is my primary responsibility to protect myself, my partner, and other responders first, sometimes to the determinant of the patient. In this particular case, it was necessary to chemically restrain the patient, to “knock her ass out,” to control the scene and maintain our safety.

The lesson here, and what I preach to my partners but took three calls to put into action, is maintaining control of the scene to maintain your safety. A drunk patient may not be acting of sound mind (we know this, of course) and may in fact want to do us harm. Do what needs to be done to protect yourself.

Stay safe.

Drunks 2

The second in a series of 3 on drunk cases.

“Medic 2, code 3 for an unknown medical, possible psychiatric problem.”

It was 2:30 in the morning and I rolled out of bed with a groan. I looked at the address on my pager: Warrenton. Great. I knew I’d be up for an hour, at least. I pulled my pants on, then sweatshirt, and finally my boots, then trudged out to the rig. My partner already had it running and put us en route as I climbed into the passenger seat. Dispatch repeated the address and nature of the call as we pulled onto the highway, our red and white strobes casting about us in the light fog.

We made for the roundabout, then south across the bay towards Warrenton. Rescue would be responding also, so I punched the SCAN key on the radio, but all was quiet—either they were already responding, or no one was. We’ll find out when we get there I thought to myself.

Going through Warrenton, we took a left at the main light, and shortly approached the scene. The fire department’s rescue unit was parked in the driveway of the single level house, its red rotators mixing with the pulsing blue and red of the police cars parked opposite the house. Everyone had come out for the show.

My partner marked us on scene, I pulled on a pair of exam gloves, then got out of the unit. We piled our equipment on the cot and wheeled towards the open front door. A police officer met stopped us short of going inside and gave me the rundown.

“So this kid shows up at these people’s home, completely drenched and drunk. He pounds on the door until they open up, then starts rambling about how it’s his parent’s place and he wants in. He’s in the living room, but he’s tweakin’ pretty good. I think he’s on mushrooms or meth.”

Our patient, a male in his early twenties, sits in a living room recliner. He’s dressed in his work uniform from a fast-food joint, soaked to the bone, and wrapped in one of FDs wool blankets. He’s fidgety and anxious, partly because he has no clue what’s going on, partly because the firemen are crowded around him, and partly (I thought) because he was high. I made a hole through the firemen, then crouch down so that I’m was at least eye level with him.

“Where are my parents?” he starts. “I don’t know who all these people are. What’s going on? Why are you all in my house?” He’s angry with us.

“Listen, partner. This isn’t your parent’s house. You woke up some poor folks and they called us. We’re going to take you to the hospital to figure this out.”

I questioned him some, tried to figure out what he’d been up to. He thought it was only 11pm. He didn’t know how he’d gotten to this house, if he’d gotten into an accident at all, or if any one had been with him. He denied drug use and—image this—denied drinking. He still thought it was his place and we had to argue back and forth a little that the homeowners had no idea who he was. I think at some level, he finally just gave up the fight and allowed us to walk him over the cot. It was when we started to put the seatbelts on him that things start to get out of hand.

“What the fuck is going on?! Fuck you people! I want to know what’s happening!”

Now, most everyone there knew my rules and I made no hesitation to educate the patient. Forcefully and sternly I told him, “you need to watch your mouth. You need to calm down and cooperate with us, or things are going to turn out badly for you.”

He was still angry, but he apologized through clenched teeth and we continued to belt him in. During this time, he’d lost a pocket full of change and as I bent down to collect it for him, he opened his mouth again. “Look at me! You need to tell me what the fuck is going on!” When I raised my head up to look at him, he was pointing his finger at me and he was red faced with anger.

“Listen. That’s your second warning about your language. You dropped your money and I was picking it up for you. We’re taking you to the hospital because you’ve had too much to drunk and you don’t know what happened tonight. Calm down, trust me, and cooperate, or things will not go good for you.”

But it didn’t stop, his bad attitude and loud mouth persisted. We had a 15 minute transport time ahead of his, so after we loaded the patient, I told my partner to just get going, that I’d handle everything in route.

Several times during the transport, he’d go from compliant and amicable to verbally combative and verbally abusive. At one point, he took his cell phone out of his pocket and after finding the battery dead, threw it against the rear doors. This was the point that I thought that’s it. I opened up my drug kit and pulled out the ampule of inapsine and a 5cc syringe. I had one eye on the patient and the other on the drug as I drew up the sedative.

“ Whoa, hey! What are you doing! What the fuck are you going to stick in me? You’re not sticking me what that fucking needle!”

“If you don’t calm down and get your language under control, that's exactly what will happen.”

“Are you trying to threaten me?”

“Nope, just giving you fair warning.”

And warning it was. Look, this is the way I see it. When you watch Cops on TV and they bring a suspect back to their car, they tell them to put their hands on the hood and not to move. After a few seconds, the suspect will take his hands off the hood and try to reason with the cop. The cop will warn him to put his hands back on the hood. This repeats three or four times before the cop finally cuffs the suspect and sits him on the curb. The cop does this to control the scene—he does this by controlling the suspect and thereby controlling his safety. My tact with this kid was the same—I needed to control the environment to keep myself safe.

Lucky for him, he kept his mouth shut and his hands to himself for the rest of the transport and the syringe of inapsine sat next to me on the bench. We unloaded him at the ER bay, and while he looked angry as a hornet, he still kept his mouth shut. The ER nurses had prepped the psych room for him and waited for my partner and I to transfer him to the ER cot, only he wasn’t getting off of the cot.

“I’m not getting off this fucking thing until somebody tells me what’s going on!”

He had a death grip on head bar of the cot and he’d spread his legs, wrapping his feet around the frame of the Stryker. We tried doing to easy things at first, just lifting him over using the bed sheet, but he wouldn’t budge. And so my patience broke. I forcefully unwrapped his feet, roughly slamming his legs back onto the cot, then I loosed his grip, throwing his arms back onto his chest. Then we roughly tossed him to the ER cot in a kind of “1-2-3-heave!” motion.

Afterwards, I told me partner “sorry. I know I lost my cool, but guys like that really just piss me off.”

“You know, you were way too nice to him,” he replied.

Too nice, huh. I guess I’d broken my own rule. I should have used to inapsine, drawn up and sitting next to me on the bench, as it was.

Drunks

The first in a series of 3 drunk cases that have given me problems over the last few months.

There's a reason that I don't like drunks. I never get called to the happy drunk, the one that wants to buy you a pint and hang out. I don't get called to the funny drunk or even the silly drunk. No, I get called to the guys too drunk to walk, too drunk to stay conscious, too drunk to be a nice. And it's never at a convenient moment, always right before or after the bars close--in other words, past my bed time. So when I'm paged out at 0230 for an unresponsive male in the parking garage of the Ocean Inn, I'm not thinking diabetic problem, stroke, or cardiac arrest, I'm thinking--I know--it's a drunk.

We had to park on the street and hike the gurney and equipment into the garage. The cop gave us his name as we walked up, Brian, from the military dog tags around his neck. He was still sitting in his enlistment bonus when we arrived. A brand new Ford Mustang Cobra, black with the twin gray racing stripes. It was a sexy ride, aside from the douche-bag in the driver seat.

The hotel worker said he'd seen the guy earlier in the day and that he'd already had a half gallon of Captain Morgans. The cop said he'd already tried honking the car horn and doing a sternal rub, both without effect. The driver's door was open and you could smell the alcohol from 10 feet away. Brian was passed out... completely... the “I just bought myself” an intubation kind of unconscious.

So I turn to my partner. "Look, we're gonna pull him out, put him on the cot, and then we're going to put in an nasal airway. We'll see if that'll wake him up."

My partner and I pulled him out of the car, roughly setting him to the ground so we could readjust our grip. Coming up under his shoulders and knees, we hefted him to the cot, then started to strap him in. His button down shirt was open at the collar, I could see a set of dog tags resting on his chest, and a couple of tatoos. His jeans were wet at the crotch.

As we strapped him in, he woke up--wide eyed and with a scrambling of his limbs. "Easy there, partner," I started to soothe him, "we're the paramedics."

"What happened?" he asked, still wide eyed and confused.

"You had a little too much to drink tonight and the hotel called 911 when they couldn't wake you up."

"I haven't had too much to drink!" he tried sitting up and getting off the gurney and only got himself tangled in the straps.

"Easy, soldier. You had enough tonight that you're either going with me to the hospital, or going with this nice police officer here to sober up," the cop raises his hand and gave a little hello.

So Soldier Boy complies and relaxes a bit on the cot. The fire department had arrived then and I told them, "we got it guys, but thanks for coming out." My partner and I slung our kits onto our shoulders, and then rolled the patient out of the garage and into the ambulance. My partner sets up the IV bag, while I go about getting a blood pressure and setting him on the pulse ox. With the IV bag set up, I told my partner we can get going, that I'll start the line in route. My partner jumps up front and we start towards the hospital.

Brian passed out again, his head rolling onto his left shoulder. We weren’t more than fifty feet down the road. My partner is eyeing me through the rear view mirror as I put the sternal rub into Brian again. He awakes with a violent start this time, flailing his arms, kicking is legs, and getting enough momentum going that he crawled right up the head-end of the gurney and wound up wedging himself into the airway seat. Honestly, it reminded me of that scene in Signs where Joaquin Phoenix sees the alien on the news clip and backs himself into the closet out of shock.

“Park it, Shane! Get back here!” I yell up to my partner. I felt the rig lurch forward as he hit the brakes and parked it.

Brian was thoroughly freaking out right now, “what’s going on! What happened! Where am I?” Over and over he kept asking as I tried to talk him down and soothe him. My partner had crawled in back and was awaiting instructions. I was trying to calm Brian down, to get him back onto the cot, at the same time I gave instructions to my partner to get the Inapsine and a syringe.

Brian had calmed a lot and was now moving back to the cot as Shane placed the drug onto the bench next to me. I settled him onto the cot, securing the straps around him again, explaining that I wasn’t trying to restrain him, but keeping him safe. He was calm enough at that point, so I told Shane to get back up front and we’d get going again.

On the drive in, I talked with Brian trying to get a little more history out of him, the entire time the Inapsine and syringe on the bench next to me. I talked him into letting me take his blood pressure and to hook him up to the monitor. He even said it was okay to start an IV, which I wrapped copiously with coban to keep it in place.

I patched my report to the hospital and soon enough, the back-up alarm was sounding as we came into the ER bay. We unloaded the cot, Brian still resting comfortably and the Inapsine still on the bench.

The nurses met us in the ER hallway, silently pointing to bed 6. Brian had tried scratching and pulling at his IV a few times and I was glad that I’d tied it down. He’d also started to have this smoldering, angry look in his eyes and I knew he was trying to work up to something. But he transferred to the ER cot on his own and I exited the ER bay with an apologetic look to the nurses.

Just a few steps outside the room though, he started pulling at his IV line again and trying to scramble off the gurney. I turned on my heel and dashed back into the room to give the nurses a hand. Brian was getting more and more agitated and I had to use my forearm to keep his shoulder pressed into the ER cot. It took a minute or so, but an ER tech came in with a set of soft restraints that we tied Brian down with. I backed away from Brian, pulled my gloves off, apologized again to the nurses, and left the room.

Maybe I should have used the Inapsine.