The Kid Was Watching

Dispatch ALS- Syncopal Episode

Dry, sunny, 40s. Typical row home in this impoverished area. Greeted by the aunt of pt. Pt is seated on couch just inside the front door. There is little to no other furniture. A mattress on the floor. A kid on the stairs, he may have been 7 or 8. A man in the kitchen doing dishes stops and looks at us.

20yoM said he got dizzy came downstairs and his aunt called 911 for him. I grab both radial pulses. They are a bit fast but strong, equal and regular. Pt is AO x4, (alert and oriented), Pt skin is warm, dry and true to skin tone. His arms and legs are shaking a bit, mildly. He is scared. He says he is having a heart attack and his heart is going so fast. He does not smell like alcohol. He does not have tracks or recent injection sites on his arms and hands. His pupils are normal and reactive. He has no shortness of breath (SOB), has bilateral chest rise and fall, no dyspnea, no adventitious breath sounds, speaks in complete sentences with appropriate words and no slurring.

Okay first impression is done, I am not worried. But lets keep moving down the list.

My EMT partner is already putting on the BP cuff and pulse ox as I get the Hx and take a blood sugar (BGL). Sugar is 89 which is within the normal range. Pt states he is on no medications, has no health hx including no cardiac Hx. He said this happened once before in the summer and he was dehydrated. He denies chest pain or any pain. He denies any sensory changes, tingling, numbness or pain anywhere else.

Initial vitals: 137/91, 115HR sinus tach 4 lead, 98% SpO2 RA, 16RR normal, BGL 89

I tell my partner we are going to do a 12 lead.

I lean in so the aunt cannot hear me across the room and ask about drug use. He wont answer. I assure him I am not the police and he is not in trouble. I just need the full picture in able to help him. He sighs and tells me he has done Robutussin, Benadryl and weed in the last 24 hours. He said he was in rehab 2-3 weeks ago. He said he probably wasn’t drinking enough and that he hardly ate today. I thank him for his transparency and move on.

We apply the electeodes for the 12 lead which means lifting up the shirt to access the chest. The patient all of a sudden gets nervous and says “Is this going to hurt?! What happening?” His aunt rushes over to see what we are doing. We stop and say no no it is just taking a picture, it will not hurt at all. You’ll feel nothing. He settles again. The aunt stays with us. 12 lead is Sinus Tach. I had to take 3 because he had trouble sitting still. I coached him on his breathing the 3rd time and we got a pretty clean strip.

I tell him what I know: his vitals are good. His heart rate is a little elevated. I am not a doctor. I want whats best for him. I ask if he wants me to call my med command doctor to talk to him. The patient says yes.

I call command, tell him what I have, what I think. Command sounds like a resident. He is stoked to talk to the patient and glad I called for advice.

The patient immediately panics and tells the doctor he is having a heart attack and said he wants to be transported. The doctor agrees with transporting. I now feel like an idiot. I take the phone back, go outside, thank the doctor for his time and hang up.

Upon re entering the house, the pt is back to being unsure about transport. I take a deep breath. I call to the aunt who had returned to the kitchen. She rushed back over. I asked her to get him a cup of water. I said to the patient: “we are going to pack up our bags and hang out for a few minutes. Drink some water. Your heart rate has already dropped a bit since we have been here. I am not in a rush to leave you. I have time.”

EMT partner takes another set of vitals:

124/71 BP, 108HR sinus tach 4 lead, 98% SpO2 RA, 16RR normal.

My partner starts packing the bags. He could read the room and see I was not rushing. Nice and easy. A sibling comes home and tells his aunt he missed the bus to planet fitness because he was on the wrong side of the road. I make a joke about the disgrace of our public transportation system. Both of them look at me stunned. Then laugh.

My Partner returns. We re approach the pt. Pt states he is feeling “a lot better” and does not want to be transported. I tell him I need to call the doc back and let him know the decision. I step outside. Make the call. State I think it is a mix of dehydration and withdrawal and pt is stable. Doc approves refusal and does not want to speak to pt.

We get the refusal signed etc. Tell the pt and his aunt they can call us back anytime and we will be happy to reassess and/or transport. I make the pt promise me he will eat something and drink more water. The Aunt says she will make sure he does.

We leave.

Dispatch to refusal signed was maybe 30 minutes. We were on scene 20 minutes.

On the way back to the station my EMT, who has been working for high quality services for 20 years, said “you are far more patient than most people.” I brushed it off and responded “first call of the shift, ya know?”

There is a stigma in EMS that we are not allowed to be soft. Or patient. Or kind. That we are to be rough around the edges and unfazed by anything or anyone. We are supposed to have the emotional capacity and expression of a house plant.

Later that night my partner and I are eating dinner. He said:

“You know you really treated that whole family well. Don’t ever lose that. That little brother on the stairs was watching your every move on the call. How you treated his brother. The Aunt, her husband. They were all watching you. You showed them that race doesn’t matter and that there are good providers. So many medics would have loaded him into the truck and dumped him at the hospital but you gave him a thorough and full assessment. You did not rush, you listened to him. You built provider trust between him and his family. I will work with you anytime.”

I quite honestly was stopped in my tracks and told him “you were just as much a part of the call as I was- I cannot take all this credit”. He disagreed and again told me how important it is that a white provider took care of a poor black family without pushing them along to some conclusion that would end the call faster. That extra time on scene saved the triage nurse time. Saved the kid an 8 hour wait. One less patient dumped into an already full hospital system.

Race relations are so deeply engrained in this society whether or not you see it. We do not know what crews have been through there before, how our patients were treated. What family history lies in those walls. I did not think much of this call until my partner said something. I am glad he did. I am glad he was also watching.