Location: Behind St. Vincent’s
Time: 00:57 Wednesday
Conditions: Cold, heavy rain
Equipment: fully stocked
You just picked up a little 14-year-old girl with a congenital autoimmune condition; her mother called from home due to intractable nausea and vomiting. It’s a disgusting day with heavy torrents of drenching, ice-cold rain, and you’ve piled blankets onto her and heated the patient compartment while you provide an easy ride over to St. Vincent’s. Steve has a soft spot for kids and actually volunteered to tech this one, so you’re behind the wheel for once, and the mother is in back as well.
As you drive down Claremont Ave toward the ED entrance, you’re blocked by a delivery truck, motionless with its hazard lights flashing. You stop in irritation, and shortly the driver appears, walking back to you and hunching against the rain.
You roll down the window, and he says, “Hey buddy. There’s some guy sitting in the road up there, he won’t move. I don’t know what’s going on. Thought you were here for him, but I see you’ve got one already. Can you take a look?”
You frown. It’s a few hundred feet to the ED entrance at most. So close. Sighing, you poke your head into the back. “Sit tight for a second, okay? There’s some guy down in the road up here.”
Steve gives you a beady eye as his patient retches into an emesis bag.
“I’ll try to be quick,” you tell him.
Pulling the 61 around the delivery truck, you park under a pull-through overhang of the neighboring building. You slip on your hat to ward off the rain, hop out, and walk to the front of the truck.
Scene
You see what appears to be a middle-aged man, kneeling in the exact middle of the road. He’s staring intently at the ground four feet in front of him and appears to be wearing several layers of clothing, including sweatshirts, ski pants (one leg nearly ripped in half lengthwise), and the dangling end of a hospital gown visible underneath it all. He’s completely soaked through.
Initial Assessment
Approaching him with gloves donned, you briskly shake him by a shoulder. “Hey!”
He looks up foggily.
“What are you doing? You’re in the middle of the street.”
He mumbles something incoherently. He seems to be making words, but they’re so heavily slurred you can hardly make anything out.
“My friend, you’re standing in the rain. Aren’t you cold?”
He laughs.
Taking him by a hand, you note cold, pale skin with dark patches. You are barely able to palpate a very weak, modestly rapid radial pulse. His breathing is difficult to appreciate with the layers and other conditions, but he doesn’t appear to be shivering.
Now you’re the one getting cold and wet, so you tell him, “Look, let’s get under the overhang here, okay? Come on, let’s try and stand.”
Pulling at his hands, you make an effort to bring him to his feet. As he rises, his pants stay around his ankles, exposing his bare legs and genitals. Although he manages to stand, and takes a couple stumbling, boneless steps, he immediately plows downward at a diagonal angle; you’re barely able to catch him and cushion his fall. He is floppy and nearly toneless muscularly.
Now back on the ground, he rolls over slightly and laughs again, pants still around his ankles. Rain is pelting both of you. You’re only a half-dozen yards from the overhang and the ambulance is not much farther; the ambulance entrance to the ED is perhaps 100 yards down the road, although the walk-in entrance is about twice as far.
Reaching for your portable radio, which you wisely grabbed on the way out, you call:
“Operations, Ambulance 61.”
“Answering 61.”
“Dispatch another unit priority 1 to Claremont Ave, behind St. Vincent’s… it’ll be… 32 Claremont, just down the street from the ambulance entrance. We have a man down in the road here, conscious but altered, we won’t be able to transport.”
“61… copy, 32 Claremont behind the hospital. Is BLS okay?”
“Affirm, that’s fine.”
“Operations has it. Break. Ambulance 42, can you clear for a run?”
A moment later, a grudging voice answers. “A42… sure, show us clear from St. V’s.”
“Thanks 42. It’s going to be just down the road, 32 Claremont Ave… you should see them to your right when you pull out. A61 is already transporting one, requesting assistance for a second patient.”
“Received, we’re responding.”
Your guy makes a half-hearted attempt to stand again, but you shoosh him back down before he face-plants. “What’s your name?” you ask.
“Buhhhhhhh… Bern… Barnaaar.”
“Bernard?”
“Burharaaaaa.”
“Okay, Bernard. Listen, we’re going to have somebody give you a ride over to the hospital. You’re soaking wet and you can’t walk, we have to get you somewhere warm and dry. Just hang on for a second and we’ll sort you out.”
“Uhhuhhh.”
You could probably pick him up and plop him onto a stair-chair or even a backboard, but not without help, and you’re not going to pull Steve away for this. Aside from being illegal, he’s got a hand to hold.
Fortunately, the 42 is a stone’s throw away, and it’s only moments until you see their lights blinking down the street. Steering for your parked truck, they pull up alongside. You meet them halfway.
It’s Jenn Steele and Sarah McGuire, a couple plucky but good-natured EMTs you’ve known for a while.
“Hi folks. You’re gonna love this one.”
Sarah chuckles as she heads for the back and draws out their stretcher, adorned with a protective plastic sheet. “Don’t you ever sleep, Sam?”
“Not on Tuesdays. So we were pulling up to drop someone at St. V’s, and this delivery truck is blocking the way because there’s someone in the middle of the road. We find this guy just kneeling there, soaking wet, cold as hell, pants down, old hospital gown on, slurring so badly you can’t make out much of anything, almost totally unable to walk. I’d just toss him in back and roll down the street, but we have this little sick girl in there, it’s a full house.”
“Okay, okay, I forgive you.”
Together, you roll over to where Bernard is lying on his side, staring at his forearms vacantly. They try to make contact, but get about as much out of him as you did, so instead you just help them pluck him up and drop him onto their stretcher.
“We’ll get these clothes off him in the truck,” says Jenn. “Just toss a couple belts over so we don’t dump him on the way.”
You do, and they roll over to load him into the 42. As they hop in back, you ask, “Just gonna bang him down the road?”
“Yep, once we get him straightened out.”
“Cool. Thanks girls; I owe you one.” You wave, feeling like a drenched rat.
“Oh no,” Sarah answers. “Thank you.”
With that, you slide back into your own ambulance, call an apology into the patient compartment, and head the short distance remaining to the hospital.
You drop off your patient at the St. Vincent’s ED, and Sarah and Jenn show up only a few minutes later with Bernard. As they roll in the door, a chorus of “Him again!” erupts from the staff.
Turns out, this gentleman is Bernard Howard, a 48-year-old man who arrived at St. V’s by ambulance several hours ago. He was transported from the east side of town for an apparent seizure, and between the medics and the receiving doc he ended up snowed heavily on lorazepam. But he was abusive and obnoxious, so staff eventually shoved an AMA form into his hands and booted him out the door. (“It’s raining?” they ask incredulously.)
“Totally inappropriate,” the charge nurse says with exasperation, redirecting Mr. Howard from the lobby (where triage tried to send him) into a monitored room.
“Yeah, he can’t really walk… or talk… or stand… or think… and it’s like 40 degrees out there,” notes Sarah. “He needs some babysitting.”
By the time you’re ready to take off, they’ve got his wet clothes removed, and he’s gradually thawing under a pile of blankets. He’s also starting to find his sea-legs, and has refused a finger-stick, begun berating staff and taken a few swings. Four of the security personnel are holding him down.
You try not to giggle as you pass the crew of the 42 on your way out. Jenn fixes you with a look of death. “Strong work, lifesavers!” you exclaim, clapping her on the back.
“Sure thing. Hey, don’t call us… we’ll call you.” A pointed finger punctuates the promise.
Ah well. Some nights you can’t win.
Discussion
Diagnosis: benzodiazepine overdose
Loading someone up on benzos (usually one of the big three: diazepam [Valium], lorazepam [Ativan], or midazolam [Versed]) tends to produce an effect similar to loading them up on alcohol. Slurred speech, weakness, sluggishness, a generalized ataxia (largely cerebellar in quality), and anterograde amnesia are common. Generally it’s not harmful — it’s tough to actually die from a pure benzo OD — unless you fall or do something dumb, or combine ’em with other substances (alcohol, for instance). But in sufficiently high doses, you certainly shouldn’t be wandering around. Mr. Howard, of course, may have indeed had other substances in his system.
The legalities and local policies behind picking up additional patients while already transporting another vary by region. Sometimes it’s not permitted at all, although if you witness a significantly ill person you may still be expected to stop and render aid. Generally ambulances are capable of transporting at least two patients safely, although it may get cramped; however, actually stopping en route to accept totally unrelated parties can make you resemble a city bus. You are also limited in that strictly speaking, the tech cannot leave the side of the current patient without constituting abandonment, so hands are limited. (This is one reason why, at scenes with multiple patients [such as MVAs], while it’s nice to get them onto the stretcher and loaded up early in order to reach a controlled environment, it can create problems, because it means losing one of your responders.)
Remember that this is a team sport, and more resources are rarely far away.
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