Ambulance Driver

As a follow-up to yesterday’s post found here, I had promised to continue my discussion concerning the chronic inebriate and the cost they impose upon society. Today I’ll give a second example and wrap up with some editorial comments that tend to make a lot of people uncomfortable.

We were called to a “Wet House” (which I will describe below) and found an intoxicated individual lying in his bed. There were stool and urine all over the floor and his bed clothes were soaked with the same. He was awake, spoke in a monotone and had just awful color. He gave us a history of pancreatitis and GI bleeds that were associated with his chronic alcoholism. His main complaint today was black stools (indicating the presence of blood) and abdominal pain probably caused by the pancreatitis.

He had been having pain, diarrhea stools and vomiting for several days. He admitted to a 2 week binge of drinking a liter of vodka a day, though it is likely the time frame was closer to 2 months.

We got him on the stretcher without getting “dirty” ourselves – which was quite the trick considering that he been rolling around in soiled bedding, fully clothed for quite some time.

We then asked him about any medicines and he pointed to a couple of bottles on a bed side table. On reentering the room, I found that it was going to be impossible to reach the bottles without stepping in stuff I’d rather leave behind. It was then that I noticed a few boxes, plastic garbage bags and paper sacks at my feet. Inside were found at least 200 prescription bottles, every one of which appeared to be full.

Now we frequently see folks that are non-compliant with their meds, but never have I seen so many medicines left untouched.

 My immediate thought was: “I don’t care what the Department policy is, I’m not going to write all these down.”

We were left with three options:

1. Declare a hazardous materials emergency and call in the Fire Department.

2. Pretend we didn’t see the bottles and just leave them behind.

3. Bag everything up and take them with us.

 I asked the staffer if she had a garbage bag – a Big garbage bag. She soon returned with a bag the size you would use to rake leaves into in the Fall. We filled it up beyond half-way. As my partner slung it over his shoulder, I swore he could’ve passed for Santa Clause, except Santa has more hair on his head.

 To make a long story short, we got him to the hospital.

 ”Wet Houses” are facilities for the destitute chronic inebriates who have failed time and again to dry out. The purpose is to give them a safe place to drink. In fact, this place has a sign posted by the elevator that reads, “Drink if you want to. Stay sober if you have to.” 

They are assigned to a space about the size of a college dorm room. There is no meals provided. There is a staff that oversees the operation. If memory serves, the cost to state government is about $1300/mon. They are also provided a type of bank card in which the state deposits about $150 a month for food. In addition, they are provided a little over $200 in a monthly payment.

But the $20,000 a year described above does not yet cover their expenses. Folks like this are huge consumers of health care services. The program that this patient and the one described in the last posting has over 30,000 enrollees that have incomes of less than $7500 a year. They incur health care costs to the state of over $1000 per month per person. But that still isn’t the whole story. The reimbursements the state pays to the providers of this care is significantly less than the total cost of the service.

So how does the provider make up the difference? They charge everybody else more. That’s you and me folks. Our insurance premiums are higher and our out of pocket expenses are higher due to care given to those who cannot pay and depend on government.

 I’m not claiming that every one of those 30,000 people are drunks and beyond help. But I will assert that a significant percentage of them are and it is costing a fortune. In this instance there were several thousands of dollars of medicines in that bag which will be simply thrown away – paid for with taxpayer money.

The cost of this particular program is rising at a rate of 18% a year. Simple math tells us that the cost will double every 4 years with that level of yearly increases – and it already is a $1 billion item in the state budget.

What we are doing here is not working. The sad part is that society has tried every reasonable (and unreasonable) way to try to help people like this and none of it works. We simply end up enabling behavior and calling it compassion.

Urban paramedics see a lot of drunks and I’m not talking about people who are merely alcoholics. Those who are able to hold down a job and navigate through life in a half-way decent fashion are not the subject here.

I want to talk about the Hall of Famers, the chronic inebriates, those who have not seen a sober moment in years and attempt, if they have found themselves sober, to do everything they can to remedy the situation.

Two patients in recent weeks stand out in the annals of drunkedness and merit some discussion. The first will be dealt with in this posting

This was a fellow that was found unconscious lying on a sidewalk.  He reeked of alcohol. His best response to hard pain stimulus was to raise his head and grunt. Despite this, his blood pressure, pulse, ventilations and oxygen saturation were normal. He had no sign of trauma and the blood sugar was normal. Given that my partner and I have over 70 years experience, we were able to quickly diagnose the patient’s problem.

He was drunk.

Now I know what you’re thinking – “Those medics are sharp as tacks.”

Well, its not quite that simple. Yes, he was drunk, but this is where a little discernment is required. This patient is not one of those who can just be taken to a facility where he can sleep it off. His level of consciousness was so decreased that he was in a potentially dangerous situation. It is also possible that my partner and I had completely missed something obvious – although we try not to let that happen, as a rule.  At any rate this patient needed to be taken to an emergency room where he would be monitored closely.

And I’m not talking about just any emergency room. Patients such as these need a place where the personnel are used to dealing with those deeply intoxicated and understand the need for close monitoring. Not all ER’s can be trusted with this in my opinion.

A lot of things can happen as they detoxify. They could vomit and aspirate at any time. They are in danger of hypoventilation, where they are so neurologically depressed that their breathing becomes so inadequate that they stop altogether. They can awake in a 2-3 hours and not fully appreciate why they are lying on a hospital bed and start throwing things around – like nurses.

So what we did was to initiate our protocols for an unconscious patient of unknown origin and transported to an appropriate ER. Once there we were asked if the patient could go to the area where the less intoxicated go to sleep it off.

Our answer was “no”, not until he is evaluated by a physician. The Doctor soon appeared and agreed that the patient was too “down” and needed admission to the main ER.

Up to this point, all of this is fairly routine. It’s what we found out next that makes this a little more interesting.

I don’t know how many of you have seen how a breathalyzer works but here is what they look like:

What you need to do in order to get an accurate reading is to blow HARD into that little plastic tube until the operator tells you to stop.

Well, for this patient, having him to blow hard was not going to happen, so they merely stuck the tube in his mouth and obtained a “passive BAC.”

Which resulted in a measurement of 0.419%.  This is the mark of a true professional.

But that’s not the end of it. A nurse walked in and shook her head stating, “He was in here 2 days ago with a blood-drawn BAC of 0.80%.”

Now over the years I’ve found that 0.50 isn’t all that rare. I’ve had several patients over 0.60 and even one who measured 0.65 who was standing erect, swinging his arms around and loudly telling everyone he was going to kick my ass.

I’ve heard of 0.75% at my hospital – but I’ve never heard of 0.80% BAC.

Think of it. First of all this guy had to drink enough to get to 0.80, which is quite an accomplishment in and of itself, but then he had to live through it. In addition to that, he had to sober up in the hospital, (and I’m sure that was an all-day thing)  gather his wits, get discharged from the hospital, get outside and say, ” Ya know, that was fun. I think I’ll do it again.”

Now, my readers not in the medical profession may chuckle and shake their heads. My colleagues may shrug their shoulders. What we all need to think about, however, is the impact of folks like this on our health care system and the costs incurred in taking care of this patient over a course of years.

It ain’t a pretty scenario. It is also something that no one wants to talk about.

My next posting will drive this point home.

It is the beginning of a new work week. That makes it time for the latest edition of 911 Update.

1) The first call of the day was for a toothache, which is not as unusual as one may think. This was also the second call for this patient in the last 8 hours. Had gotten pennicillin and a pain medication on the first visit. The tooth still hurt. But, you can hardly blame the patient for running up several thousand dollars in medical bills, they are on Medical Assistance and those folks don’t pay a cent for the care they receive.

2) This patient fell on the ice this morning. Poor English. Has a history of  liver disease and is a diabetic. The fall resulted in back pain with the severity of the injury unknown, but not thought to be serious. This patient is on General Assistance Medical Care.

3) This patient was intoxicated, lying on the sidewalk not able to walk. Has a history of mental health problems. On Medical Assistance.

4) This patient fell on the ice and had pelvic pain with no obvious fractures. This patient had private insurance with premiums that are made more expensive due to patients like 1), 2) and 3).

5) Was a seizure patient at one of the shelters. He recovered quickly said he lived out of state and his ID showed that. HE was on General Assistance Medical Care.

6) Was an elderly lady with diabetes and whose feet were so bad she finally couldn’t get around. Grandson had tried to transport, but just couldn’t manage it.

7) False medical alarm, cancelled upon arrival.

Was for an auto accident with no injuries.

Yep, it was a rainy, icy windy day and the Ambulance Driver arrived home in a grumpy mood.

Go Vikings

For some reason my 8’s show as a smiley face. I’m too stupid to know why and too lazy to find out. Read nothing into it.

Today’s 911 Update combines runs made yesterday and today. Both were eight hour shifts. During those sixteen hours our department received 112 calls for help. Ambulance Driver responded to ten of them.

1) Fall in a nursing home. Patient had gotten up from wheelchair and was found several feet away, lying on the floor and bleeding from a head laceration. No known loss of consciousness. Probable fractured hip.

2) Patient is developmentally disabled with history of frequent seizures and had one today in apartment. Living in an independent living situation attempting to move to assisted living. From the looks of things, that needs to happen. Patient needs more help.

3) This run was cancelled while we were enroute. Seems a nursing home patient called 911 stating they were having a heart attack. On call back to nursing home, the charge nurse went to the patient’s room and found the resident was not in distress. Apparently this patient had done this several times before.

4) This was an accidental death that occured under tragic circumstances that I won’t go into.

5) Was for a patient with a history of mental illness and has had suicidal thoughts for a week. Went to see his physician who arranged for hospital admission. We were called for transport. Patient was cooperative.

6) Nursing home patient with severe shortness of breath from pulmonary edema. Poor vital signs. Hospital of choice too far away, in our view, so patient transported to closest appropriate hospital for emergency treatment.

7) Patient with history of back problems. Back “went out” during a job interview. Was very uncomfortable. Morphine given to make patient more comfortable during transport.

 This patient is elderly and lives at home. Is complaining of shortness of breath and is very anxious. Patient was wheezing but not nearly as sick as she seemed to think she was. Speaks in full sentences. Not hypertensive. Moves a lot of air. Neb enroute to hospital fixed her up.

9) This middle aged patient was at methodone clinic and was having symptoms related to chronic liver disease. Was mildly confused and complaining for abdominal pain.

10) This homeless patient has a history of seizures and suffered one while at the shelter.

That concludes this week week and I will enjoy my three days off.

It was a rather slow Monday for the old Ambulance Driver. We responded to just 4 of the 49 calls that came in to the Department. As always, information has been garbled in order to insure patient confidentiality.

1) Patient awoke with a buring sensation in his stomach. Was mildly nauseated but had not vomited. Up and walking around with no complaints of weakness. Was anxious but not overly so. The patient’s vital signs were stable. Our exam included a 12 lead EKG which appeared normal. Nitro did not effect discomfort.

2) Was for a false medical alarm in a private residence.

3) This nursing home patient had a leaky in-dwelling foley catheter that needed changed. By the way, EMS doesn’t do that – we transport.

4) This patient had driven their vehicle into a snowbank in a western suburb. Was found slumped over the wheel when police arrived. A medic alert tag indicated a diabetes history. Blood sugar found to be 28. An IV dose of 25 grams of dextrose woke him up in about 3 minutes. No injury from the low speed enounter with the snowbank. Was left with police and instructions to eat a meal as soon as he got home.

And that was that for this day. See you tomorrow.

Busy Sunday morning at the ambulance service, but then, predictably, calls fell off during the Vikings game. We had 77 runs during my 12 hour shift. Ambulance Driver was assigned 4 of them. We then spent the rest of the shift watching the game at a local volunteer fire station.

As always, information contained in the 911 Updates has been masked to prevent disclosure of personal information.

1) Was for a girl who, last evening, got scratched in the eye while playing with the cat. Awoke this morning with severe pain and her left eye swollen shut. Suspected corneal abrasion.

2) Called to care for a man with a history of traumatic brain injury and had suffered his first seizure in months.

3) Was for a very distraught lady with a history of bipolar disorder. Takes care of herself but occasionally suffers from panic attacks. She was alone in the home and couldn’t contact her husband.

4) Elderly male with emphyzema with increased breathing difficulty during the night. Nebs not working. Was severely short of breath on our arrival and very hypertensive. Two nebs of atrovent and albuterol enroute to hospital got things under control.

Tomorrow is an 8 hour day. Getting off work in the early afternoon is one of life’s great pleasures. Ambulance Driver is working on a couple of informational posts on how we deliver health care in Minnesota and will have them up in just a few days.

911 Updates are where Ambulance Driver gives the readers a taste of my workday. All entries are masked in a manner to avoid revealing any personal information.

Busy day in which my Department responded to 105 911 calls during my 12 hour shift. Eight were assigned to me.

1) Was a call for an elderly gentleman who fell in recent days, injuring his right knee. He hadn’t been able to bear weight for the last 24 hours. The knee was quite swollen but no obvious fractures. Being he was a hefty fellow, it was a chore to get him out of the house, through the snow and into the ambulance.

2) This patient was one of our frequent flyers. Always intoxicated and profane, this time they wished transport for evaluation of an old injury that doctors had declared healed. Given that this person had a rather odd hospital of choice this time around, we speculated that “drug seeking” was the motive for calling 911. Just a guess.

3) Was a call for a person lying on the ground and apparently intoxicated according to the caller. When we arrived with the police, no such person was found.

4) This person is a diabetic who had not taken insulin for many months and had been non-compliant with all medications for several weeks. States they just wish to die. From the looks of things they are going to get their wish if this keeps up. The blood sugar was off the charts. Family called.

5) This call was for an elderly man who was experiencing an anxiety attack due to the medical problems of his spouse. She was in the hospital and in very bad shape. Wanted to go to be with her.

6) This “patient” was driving a car that was bumped by another in a parking lot. Speed was reported to be a crawl. No damage to either vehicle. Taken to hospital for evaluation of……something.

7) Was a patient who had fallen during his daily exercise. Looks as if he broke his hip. The good news is he is young enough to recover.

8) Was an infant whose mother “thought” ill because a sibling had a cold. Baby looked fine to me and slept during transport. Mother non-English speaking so it was difficult to assess the concern.

That was it for today. Stop by tomorrow for another installment of 991 Update.

We had 70 runs today during my shift. Ambulance Driver was assigned 7 of them.

• Call #1 was for a non-English speaking patient with back pain that resulted from a chronic condition. A friend was present that spoke passable English and was able to translate. Patient was given pain medication and transported. The funny thing about this call was the friend. He was an amiable sort and was very helpful. As we lifted the patient from the floor, the guy was giving us directions. His last bit of help was a lusty, “one, two, three,” followed by a grunt. We got a kick out of it. We told him that he was going to assimilate well into this culture.
• Call #2 was for a young patient with abdominal pain that had been persistent for a couple of weeks. Had not had nausea, change of stools, fever or recent history of trauma.
• Call #3 involved a foreign visitor to this country with a fever and hypotension. Also nausea, vomiting and diarrhea. Very pale and weak as well. Sad thing about this was the patient had no insurance but had to go by ambulance. Ouch.
• Call #4 was for a very elderly patient who stumbled getting on a city bus. No obvious injury but was aphasic and could not write. The patient seemed to understand what was being said but had a very hard time communicating. This condition was obviously chronic. The patient provided a phone number but no one was home. We transported to the nearest hospital to let them sort it out.
• Call #5 was for a seizure patient housed in a shelter for those with chemical dependency issues.
• Call # 6 found us in the home of an elderly patient who had fallen in the home and discovered by “Meals on Wheels.” Patient had been lying there for several hours.
• Call #7 was for a patient who had gall bladder problems and had been putting off surgery for several months. Now had very severe upper right quadrant abdominal pain.

It was a busy enough day to keep us interested and the time went by fairly quickly. See you tomorrow.

The service responded to 83 911 calls during my 12 hour shift today. Ambulance Driver was assigned 6 of them.

• Call #1 was for a man who had subtle complaints of “just not feeling well.” He was hypertensive with a pulse rate too fast for me to count. EKG showed him to be in a supraventricular tachycardia with a rate of 200 beats per minute. The administration of 6 mg of Adenosine broke the rhythm and he settled into a atrial fibrillation with a rate of 90.
• Call #2 was for an elderly man in a nursing home who suddenly developed a fever. He was weak as a kitten, had a decreased level of consciousness, fever of 102 and with a low blood pressure.
• Call#3 involved an elderly male with a history of drug seeking behavior. Appeared to be shopping for a new hospital/physician since he had been recently dropped by the last doctor.
• Call #4 was for a nursing home patient who experienced a simple partial seizure that lasted 2-3 minutes. This was apparently a first time event.
• Call #5 was to a chronic inebriate who had fallen and fractured several ribs in recent days. The patient had been to the hospital twice already and now was treating the pain with Vicodin and several bottles of mouthwash.
• Call #6 saw us walk into a scene that reminded us of the set of the Jerry Springer Show. Several women had gotten into a shouting match that had deteriorated into a knife fight. The result was minor cuts and bruises. No one wanted treatment – which was just fine by me.

Today was an 8 hour shift during which our service responded to 48 calls to 911. We snagged 6 of them.

• Call #1 was for a patient who was suffering an apparent allergic reaction to a prepackaged nutritional supplement. Skin was flushed with no other symptoms. Benadryl was administered.
• Call #2 involved a drunk sitting on a sidewalk and was unable to walk away. He was amiable enough and taken to Detox.
• Call #3 concerned a nursing home patient with profound hypotension. While he was mentating and sitting up when we arrived, he had no palpable pulses. Very sick individual
• Call #4 was for an apparent cellulitis that had caused a leg to swell about three times the normal size. It occurred over night. Patient could not bear weight. Luckily, they were not heavy.
• Call #5 was a young person who was either very anxious because their pulse was 140/min or had a fast pulse because they were anxious. We didn’t know which, but weren’t overly concerned either way.
• Call #6 was in response to a diabetic who knew their blood sugar was low. Turned out they were correct, the reading was less than 15. An IV bolus of Dextrose made everything better.

That’s it. Ambulance Driver is going to be a soccer dad this weekend out on the East Coast. Blogging will be minimal.