ma'salama

I zipped up my final  piece of luggage and started to look back on the past 14 months in UAE. This would be my final departure and now I am off to continue my education back home, wherever that may be for a serial expatriate. There were good and bad times, but in the end I have no regrets at all. This was my 4th time working in the middle east and my second contract in UAE. Everytime I come here I learn something new and take something away from the experience. I'll miss my coworkers and friends but I'll be leaving with a smile on my face and pockets full of hard earned cash. Ma'salama...

So who's the dead young woman in your spare bedroom?

ME: So who's the dead young woman in your spare bedroom?

Guy: Oh I don't know her to well, she's renting a room from me.

ME: oh ok, well I am sorry to tell you she's dead and there is nothing I can do for her, judging from the condition of the corpse Id'e say she's been dead for at least a day, but I need to collect some information from you.

Guy: oh sure no problem, please sit, sit, would you like some dates or tea?

Guy: *making dinner in kitchen *smiling

ME: No thanks, so back to the woman... I need her age and a contact for her.

Guy: Oh I am not sure, I don't know her age or anyone who knows her.

ME: ok... how about her name

Guy: I am not sure what her name is

ME: *silently signaling partner to radio for police assistance.

ME: Ok so there is a dead young woman in your spare bedroom, you don't know her name or anything about her. I need you to wait right here ok...

Hot Tamale

         Summer had announced itself in abrupt and rude manner this year. Many were not prepared, oblivious, or simply at the wrong place at the wrong time. Summer solstice had not even officially taken place but it was well over 100 degrees (38 C) outside. For one man it would almost cost him his life. He was in his early 20's and a labourer from Pakistan, surely driven to UAE for its pay and in hopes of a better future while building up his bank account. Fueled by the sweat on his brow and the epitome of working class ethic he did his job day in day out like a well oiled machine. However, on this day he would not be working outside, but in a confined space. A small room with no ventilation, a variable hot box from a wartime torture camp of days gone by. This was his office for the day and he didn't even bat an eyelash as he carried out his duties within it. Like a dog or a child left in a hot car in a searing summers day by its obvlious owner or negligent parent. It was wasn't even noon by the time he collapsed.

I found him confused and disoriented as I took him into our air conditioned ambulance. As I slide the thermometer deep into his ear canal I eagerly awaited the reading. The thermometer let loose the familiar audible tone and I gazed down at the reading in disbelief... 107.6 F(42C). It be must wrong I thought as I rechecked and confirmed it was indeed correct. At this temperature his brain was beginning to cook and if he was not cooled down he was gonna have a bad day, and could even die. 

       The man's heart was racing and I began to remove his clothes and cover him with ice packs. Ultimately  I had now done everything I could to lower his temperature by removing him from the hot environment, taking his clothes off, covering him in ice packs, and turning the air condition on max, so I now needed to move on to his other problems. He was complaining of chest pain and I connected the cardiac monitor to him and watched his heart gallop along at 150 beats per minute. I hoped by cooling him down I could reverse the problem.  I tried apply more ice packs to his face and neck which in addition to cooling him down can also sometimes lower the heart rate by triggering the mammalian diving reflex. However, despite my best efforts this also did not work.

        I pulled out an 18 gauge intravenous catheter and hoped to god I wouldn't stab myself with it; the back of the ambulance rocked back and forth as it raced down the street at 160 Kph (100 miles per hour). At this speed performing any procedure can be extremely difficult, I yelled at the driver to slow down, but to no avail. I grasped the needle as firmly as I could and just went for it. I pierced a large vein on his left arm. As I slid the teflon catheter deep into his vein I simultaneously retracted the steel needle. Blood began to liberally drip out of the IV confirming I was in. I connected some fluids to the IV and watched as they poured into his hungry veins. His tank was on empty and he needed the fluid badly. Our ambulance tires screeched into the Emergency Department entrance as I unloaded him. On arrival thee hospital rechecked his temperature and  our reading was indeed correct. They continued our cooling methods and also monitored his heart rate. He was the first heat casualty of Ramadan on my shift, but certainly not to be the last.

Take my breath away

If you're one of the few people who read my blog, my apologies for my recent absence as I was on vacation. I will be adding extra content this month to make up for it.

I stood over him in the back of the ambulance, grasping the 14 gauge steel needle in my hand. It looked more like a large metal straw for a frosty carbonated beverage than it did as a needle. He was completely helpless and I had an uncomfortable amount of power while he was at one of the most vulnerable moments of his life. I felt empathy for him and just wanted to help, but its hard to explain that to someone when you might have to perform a barbaric act on them. I had a certain level of anxiety that one gets before they are about to stab another human being in the chest. I did my best to put on a straight and calm face while I explained the procedure to the patient. If his condition got worse before we made it to the hospital, I would need to decompress his chest.

It all started 15 minutes earlier. A small grey sedan was mangled beyond all recognition. Where the trunk once existed was now an empty void, what remained of the trunk had been pushed into the back seat of the car. The durability and resilience of a human body amazed me as I saw the front seat passengers of the vehicle milling about with no injuries and speaking with police. The car looked liked it had entered the earth's atmosphere at terminal velocity and landed on its backside. The sheer kinetic energy of this entire incident was mind boggling considering how well everyone who was involved in the accident appeared. However, looks can be deceiving as I would soon find out.

As I scanned the scene and walked through debris  I came across a young man 10 meters from the car lying in the grass. He was in his 20's and his big brown eyes made contact with mine as we encountered each other for the first time. He had apparently been dragged to his current location by his associates in the car. My partner had already began treatment of another individual near by, and after searching the area for additional patients I returned to the young man in the grass. I ordered some hesitant bystanders over for help and gave them directions on how to hold the young man's head and neck while I returned to the ambulance for more equipment.

He had pain along his spine when I touched it and difficulty walking so we had to backboard him as a precaution. We immobilized his entire body to a long plastic backboard, strapped him down with Velcro, and placed a collar around his neck. He would need an xray or ct scan at the hospital before he could be cleared to rule out any spinal injuries. As I loaded him into the ambulance, the young man began to develop some minor difficulty breathing. I loosened the straps from around his chest, but it didn't seem to help much.

I looked at the oxygen monitor I had connected to him and watched as his oxygen levels began to slowly decline as be began to complain about pain in his chest.  As the ambulance began to move I listened to the young man's lungs and he had diminished breath sounds on his right side, his oxygen saturation levels where now beginning to teter on the edge of below normal and his chest pain and difficulty breathing became worse and worse with every passing minute. He likely had a collapsed lung aka "simple pneumothorax." With every breath he took air filled the pleural space around his lung, as air in this spaced increased with every breath it would become more and more difficult for the lung to expand and for him to breathe. If his condition continued to deteriorate it could get ugly. If his injury remained the same, I would simply reassure him, but if it got worse, action would need to be taken. The treatment for this injury can be pretty invasive and involves stabbing the patient in the chest with a very large needle to decompress the chest and relieve the pleural space of air around the collapsed lung. We only do this outside of the hospital when the collapsed lung develops into a life threatening condition known as a "tension pneumothorax." Unfortunately this patent's condition was continuing to deteriorate and the possibility I might have to ram a 14 gauge needle into his chest was becoming a possibility I needed to consider more and more with every passing minute.

I took the large needle out and it showed it to the guy as I explained the procedure. I then thought to myself where and how to carry out this if I needed to. I had to plunge the needle into the second intercostal space at a 90 degree angle to the chest, just over the top of the third rib, or was it he 2nd rib? Its been awhile I silently thought to myself. I was happy the guy couldn't read my mind... It had to penetrate deep into the pleural space on the right side to release the trapped air. Its not something we do very often  but I had to sell it to him  like I did it every day. As I continued to monitor him, his condition was getting worse and he began to teeter on the edge of possibly needing a chest decompression.  Soon, it would be my big moment to shine, but it would have to wait for another day as we pulled in to the hospital at that moment and his vital signs remained stable... Alas, another day...

Frogger

He was laying in the middle of the street surrounded by police cars as neon beams of red and blue lights bounced off his mangled body on an otherwise dark night. The police had blocked off the street and were eagerly awaiting our arrival, pointing to him like trained hunting dogs. I could hear his desperate screams as soon as I opened the ambulance door. I slung the trauma bag with my equipment over my shoulder and made my way to him, kneeling down beside him once at his side. We began our rapid head to toe assessment to look for major injuries starting at his face. To say he woke up on the wrong side of bed would be an understatement, he had seen better days for sure. His face was so swollen and he could barely open his eyes or talk. covered with bruises, blood and major swelling. As I made my way down his body during my exam I noticed a pool of blood on the street next to his leg. I cut off his pants for further investigation and made a shocking discovery. The 2 bones which supported his lower leg (tibia and fibula) were sticking completely out of his leg about 12 inches, after cutting the pants off they liberated themselves from the confines of his garments and were pointing in the opposite direction from the rest of his leg. This was an interesting site indeed as now the majority of his lower leg had little structural integrity. To see a human being so mutilated is  unnatural and I immediately started thinking of a butcher shop or the meat department at your local supermarket when analyzing his injury.

 A river of bright red arterial blood flowed from his legs around the injury site. It was near impossible to tell the exact location(s) of the severed artery so in addition to a makeshift tourniquet we also covered the open wound with a special powder called “Celox” which is a hemostatic agent that stops bleeding. Due to the severity of the arterial bleeding it took our priority as an immediate life threat. Unfortunately moving the patient into the ambulance and splinting his leg was not so easy. The poor fella was confused from his head injury, but was still conscious. There was no way to splint his leg or even move him off the street in the position we found him with the bone at such an unusual angle, in addition to this the injured leg had no pulse. This was a rare kind of compound fracture and precluded most splinting and moving procedures. To make matters worse, the ambulance service here is undergoing major changes and at the time of writing this has no IV pain medication such as morphine. My partner and I really felt bad for this guy, but we had no choice and began to manipulate his leg to relocate the entire thing in a neutral  position in which we could safely move him and his leg and also control the bleeding. We had to transport him to the hospital and there was no other way.  His lips opened wide and tears ran down his face as he screamed in agony while we manipulated the leg and splinted it. He almost passed out at one point and I wish he would have. I felt terrible, but there was nothing I could give him for the pain today and we had to save his life by taking him to the trauma center and stopping the major bleeding. All I could do was hold his hand, but only for a moment because I needed both my hands for the procedure. It was truly a primitive and medieval thing to do, but unavoidable. Re realigned the leg as best as possible and as non-invasive as we could.  Once the leg was splinted we applied more celox and began our transport to the hospital.  Upon arriving at the hospital the emergency doctor immediately called for an orthopedic surgeon to come down and they began to give this guy the works, along with much needed pain medication. A week later I spoke with the doctor and he said we did an excellent job of stopping his arterial bleeding and dealing with his injuries. He was satisfied with how we dealt with the leg considering what we had to work with. The injured man will have several surgeries on his leg, and also for his skull and facial fractures, but he will make a recovery, although it likely won't be %100. The patient was a victim of a hit and run accident as a pedestrian. Luckily the police caught the driver and the patient did not have any major brain damage.

Sorry for the lazy writing this week folks, I was in a hurry, promise the next story will be written better.

Sugar Sugar, oh, Honey Honey...

He was a charming old fellow, full of interesting stories and rustic jargon that grew better only from age. As the captivating words continued to pour off the old mans lips, his wife was quick to correct some of his recollections and would abruptly butt in, as if right on cue. An endearing smile spread across his face and he referred to her as the “minister of interior”, alluding to her power in the household. We all had a small laugh about it while gathered together in his living room. It was a cozy setting and one of the better parts of my job. I wish I had time to stay for tea but my presence was more than a social visit. He was in his 70’s and an unflattering site, his dentures had been removed, making it difficult for us not to crack a smile when he spoke. There was sugarpaste glistening all over his leathery face, and a bloody bandage on his arm. He was in this condition because of the way we had made his acquaintance 30 minutes earlier.

 Just 30 minutes prior I walked through his doorway. It was a large apartment and the entire living room opened up into a vast area with vaulted ceilings and decorative lighting. There was a big yellow wrap around couch and a variety of comfy furniture and typical household decor that you might expect. However, even from the doorway he stood out to us like a beacon in the night, slumped over on the couch loudly mumbling incoherently and moving his legs as if he was riding an invisible bicycle. It was a queer site and certainly caught my attention. I took a knee next to him to check his vital signs but had to take evasive action immediately afterward. He starting swinging his fist at me and screaming. While avoiding his flailing extremities, we spoke with his wife. She informed us he's a diabetic and that he gets like this if his sugar gets to low. I caught one of his fist with my hands and held his arm down firmly whilst my partner poked his finger with a small needle. The bright blood slowly began to ooze from the wound and formed a perfect droplet, delicately clinging to the pad of his finger while the rest of his body was busy break dancing. We pressed our glucose monitoring strip against the blood drop and it began to analyze his sugar level. A few seconds later the reading came back as very low. I opened our medical kit and took out the oral glucose, which is essentially just sugarpaste. I began to slowly squeeze the tube of sugarpaste  in his mouth, but he was more interested in trying to bite my fingers off. His sugar level was so low that he was extremely confused and very aggressive. I needed to keep my fingers for other things, so I had to develop another plan. I got his wife to come over, selfishly hoping she didn't need her fingers as badly as I did. However, also hoping he would recognize her enough to calm down, and he did for a moment, which is all we needed. I assisted her with squeezing the remainder of the sugar in his mouth while he continued to scream, kick, and mumble incoherently. He was struggling and sugarpaste was getting all over his face in the process. It took 2 of us to hold him down while giving him the sugar, 15 minutes later and 2 tubes of oral glucose later, he was the same. It was at this point I noticed his false teeth had become loose and he was beginning to choke on them, we quickly removed them, placing them off to the side while trying to avoid being bit He had decimated our entire supply of sugar gel like it was a diabetic appetizer.

I had to move on to more invasive procedures which I was hoping to avoid. We assisted him to the floor and gently laid his head on a couple of pillows. The old man was a fighter, he was not going down easy, he began fighting, kicking and swinging. My fingers wrapped around his his left arm and I held on tightly as the large needle punched through his skin like a pincushion. As expected,  he became more livid and was struggling with more might than ever. I had managed to locate a large vein on his arm which perfect. There was not much time and it took a lot of strength to hold his arm down while the needle was in it. It was like trying to perform surgery on a rodeo bull, one wrong move and the needle would either go through the vein, miss it completely, or destroy the puncture site. The angle of the needle dropped and the teflon catheter surrounding it slid off with ease, advancing deep into the vein. I taped it down quickly, far from a work of art, but it was in. My partner connected it to the iv bag of glucose, but it was imperative the catheter remained in his vein, despite his physical movement. IV glucose can only be administered in a vein, if it touches normal tissue it destroys it. Obviously this was a risk we had to take given his condition, but we had to confirm the IV was good. I aspirated blood from the site, this was my confirmation that I was indeed still in the vein and not in the tissue. So I cranked  the administration wheel to wide open while holding the IV in place, my partner squeezed the bag, shooting the glucose directly into his veins and through his entire circulatory system.  Within a minute the man stopped fighting, minutes later he began to come around. After titrating the amount of glucose and re-testing his sugar level until it was at an acceptable level I slowed down the infusion. He was fine and began speaking with us. He apologized for the inconvenience and thanked us for coming to help. I don’t think he had any recollection of trying to kill me or bite my fingers off, but that's probably for the best. We disconnected the IV and bandaged the site while chatting with him for a bit and giving him tips on how to manage his diabetes.

The Code

I interlaced my fingers, stacking one hand on top the other while firmly placing the palm of my hand on his chest. I pushed down hard and fast, as soon as the chest recoiled I plunged back down on it. The young man was in his late twenties and had called the ambulance for trouble breathing. Unfortunately when we arrived we found him not breathing and with no pulse. As we continued CPR and slipped a simple oral airway down his mouth, I attached the cardiac monitor pads to his chest in order to see what rhythm he was in. We paused CPR for a moment so I could examine the rhythm on the monitor. The room was silent and the family was surrounding us in the living room, hoping and waiting. Unfortunately it was a non-shockable rhythm, so I went back to bombarding his chest with compressions. We really wanted to get him back for a couple reasons, his young age, and the time he had been down. My partner and I switched roles, he took over chest compressions and I began to ventilate the patient. We continued switching back and forth every 2 minutes and even managed to start an IV before our backup arrived.

Once the second ambulance crew arrived we gave them a report and assigned one of them to begin administering intravenous adrenaline, while the other took over chest compressions so I could take a look at the guys airway. I was not sure why this young man stopped breathing. I questioned the family and he had no known medical conditions. At this point we had been doing CPR for well over 10 minutes with no changes, so I went to intubate the patient (place a breathing tube in the trachea). I also began to become suspicious that maybe he had choked on something so I also needed to look for anything that may be lodged itself in his airway. I performed a laryngoscopy and suctioned, but saw nothing out of the ordinary. However, while I was perusing deep into the depths of the man's throat I encountered a problem. The breathing tube was having difficulty passing his vocal cords and I could not get it to advance. I had to go to a backup device known as a "combi-tube." The combi-tube is a monstrous and large device that you blindly insert down someones throat when intubation is not possible. I lubed it up generously and shoved it down his mouth as the family gasp and screamed. After securing it we were getting good ventilations with it and had given the man several rounds of IV adrenaline by now, but still no changes. Normally we would consider terminating efforts after about 20 minutes and pronouncing the man dead, but due to the unusual nature of this cardiac arrest and his young age, a few members of the crew decided they would feel more comfortable transporting him to the emergency department, so we did. They continued working on him at the hospital, between us and the hospital he had been worked on for over an hour, but he was a goner. Although not the most creative writing this week, I just wanted to share what we do on "a code" for those who may not have been familiar. On average we get a code about once a week on my shift.