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From: patti k (pattik1@hotmail.com)
Subject:
Torch on the Porch
Sent: Thu 8/12/10 6:20 PM
## Go ahead, 51.## came Dr. Brackett's reply over
the intercom from Rampart.
Johnny finger snapped at Roy for his notebook for comparison. DeSoto
handed it over. Johnny laid both out in front of him on the biophone's open lid
and began broadcasting
a patient report. "Rampart, we've a six year old, victim
of apparent ingested poison. He weighs approximately
fifty five pounds. He's
unconscious, diaphoretic and being breath supported by ambu on 15 liters
with an oropharyngeal airway. Physical signs are bloody emesis, rales in
both lungs. Vitals signs:
BP: 70/30, pulse is regular but tachycardic at 128,
respirations unassisted were eight and shallow.
He shows little response to
pain. There is thin venous blood showing out of both nostrils so we have
him
on continuous light suction while in lateral left side positioning. Additionally,
there are
signs of cyanosis despite the high oxygen ventilations along with
very slow capillary refill at the
fingernails. Pupils are dilated. Abdomen is soft
on palpation in all quadrants. There are no apparent
signs of physical trauma
or bruising on the skin. He has no known allergies and last food intake
was
four hours ago. Standing by to send you a strip."
##51, sounds like he may be hemorrhaging
internally through the stomach and
internal organs. Go ahead with your EKG telemetry. Do you have
any clue as
to what he may have ingested?## Kel asked, biting on a pencil eraser. He stared
holes
into his notebook as he thumbed down his talk button.
Johnny replied.
"Rampart, we have a best
guess of prenatal vitamins. We found nineteen
missing adult iron supplements from a new prescription
bottle. However,
we can't be sure as to exact cause as there were a large number of unsecured
medications
and chemicals found within a child's reach a very short distance away
from where he was found."
##Bring those in as well. Does he have a gag reflex?## Kel asked as he
carefully reviewed Ryan's EKG
strip noodling out of the transmitter.
"Stand by, Rampart." Johnny said, setting the phone over
one shoulder. "Vince,
hold off a second." he said, asking the officer to pull away the bag and mask
for
a moment.
Gage leaned over and purposely ran the suction wand in a little deeper to the
back
of Ryan's tongue in a test. The boy did not react to the stimulation.
"That's a negative
Rampart." he replied, picking up the phone again from his
shoulder.
##Intubate him with a
peds E.T. to secure a better airway. Keep maintaining
light suction to continually handle heavy secretions.
I want you to start an
intraosseous I.V. through the tibia just below the knee cap. If it's iron
he's taken,
his veins are collapsing from hypovolemic shock so I want a guaranteed
secure route
for his I.V. meds. Give him 50 cc of 50% dextrose and water
in a child 1 gm/kg dose followed by 2
ampules of Narcan, and 50 mgs Thiamine
I.V. push. Then follow up with a supporting line of 5% Dextrose
and normal
saline, TKO. Titrate to normal systolic BP, if needed, to maintain adequate
internal
core pressure.##
Johnny repeated his orders back to Dr. Brackett and soon, the two paramedics
got to work preparing injectable syringes and the bone gun.
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Vince looked at Barry. "Let's get an eyeball on the situation outside. I felt
activity on the hillside
just before we came in here." he ordered Baricza.
"So did I." said DeSoto biting off an I.V. bag's
wrapper.
"You did?" Gage asked, getting nervous for the first time since entering
the house.
Roy nodded his head with conviction.
"Hmmm." said Howard, thinking. "Barry, keep Mr. Diaz
inside until we're ready
to call in the EMT ambulance for a pickup. He's better off in here if one
or
more of the gangs decide to come calling."
Alannah lifted a tired head. "They won't. They
know we don't do drugs and
love each other. They never bother us."
"They might tonight."
DeSoto told her.
"Why?" Mrs. Diaz asked, wiping her frustrated, tearing eyes.
"Because
we're here." Vince answered.
That quieted down the young mother more than a sedative.
Barry
nodded at Vince and left for the living room, taking the rifle he had
placed outside of the bedroom
door with him.
----------------------------------------------------------------------
At
the hospital, Brackett rapped on the window of the base station to
get Dixie's attention.
McCall
opened the door and stuck her head in. "Kel?"
"51's got a possible iron toxicity case coming in.
If he's positive for excess iron,
I want blood drawn for a CBC with a differential, electrolytes,
a serum glucose,
an arterial blood gas, a PT, PTT, and a full series toxic drug screening. Also,
I
want a type and cross match, aminotransferases, and a bilirubin. Have them test his
bicarbonate
and his BUN/creatinine levels. Have X-ray standing by for an simple
abdominal plate. Maybe we can
spot a bezoar on films for a second confirmation
on a positive I.D."
"Charcoal?" she asked,
writing down his orders on a new chart.
Brackett shook his head. "It won't react. Set up for a
gastric lavage
of half normal saline at a 10 cc/kg rate. He's a small kid, so make it a 28
French.
If that doesn't bring up anything when he gets here, set up a whole bowel
irrigation with a polyethylene
glycol electrolyte and deferoxamine at a 15 mL/kg/h
flow rate. Use a foley to speed up kidney excretion.
We can use it to look for
positive vin rose'. Monitor his serum pH if we need to stop the deferoxamine
at some point for profusion problems. We have to make sure he doesn't retoxify
with iron coming out
of his tissues. Also stand by with sodium bicarbonite,
dopamine, nitroprusside, and fresh-frozen
plasma. He might test out as acidic."
"And if that isn't compensating fast enough?" McCall anticipated.
"We set up for a surgical intervention with an emergency gastrotomy. Schedule Joe."
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"How long to you want to run in the whole bowel?" Dixie asked for the ICU's
nurse's orders.
Kel
bit his lip, starting to sweat.
"Twenty hours, at least, but no longer, or his pressure will start
to drop.
Deferoxamine's a parasympathetic. We have to guard against
pulmonary toxicity. He's a
high candidate for acute respiratory distress
syndrome as it is." he said, thinking to himself frantically.
Smiling, Dixie placed a gentle hand on his arm to calm him.
"You know what to do, Kel, so relax.
That little boy's already getting his one
shot to survive this and it's starting right now with Roy
and Johnny. They're
the best hands you've got out there."
"You really think so?" he asked
quietly, worried.
"Yes." McCall said with conviction, not looking away. "I do."
Brackett
didn't say anything and he looked back down to his notes, not
seeing the words he had written down
for a moment, really feeling his stress.
Dixie quickly kissed him on the cheek.
"I'll put him
in One. It's closest to the entrance, Kel." Dixie promised with a reassuring
grin.
"Thanks,
Dix." Dr. Brackett replied with a half smile as she turned to leave. Then Kel
turned back to the
intercom, waiting for successful word of intubation and cannulation
from Squad 51. He couldn't keep
away a worried frown. ::I hate pediatric calls.:: he
thought vehemently. ::I wish kids could be born
fully adult. We're a h*ll of a lot easier
to treat.::
----------------------------------------------------------------------------------------
Roy didn't look up from the drug box and the tape strips he was getting
ready for Ryan. "Alannah,
you're not squeamish are you?"
"After birthing a baby, I should think not." she declared, anger
flashing in
her Irish eyes.
DeSoto smiled, dipping his head in acquiesence.
Johnny glanced
up at her, concentrating very hard to keep himself fast and accurate.
"We're going to have to place
a tube into Ryan's lungs to help him breathe
and then we'll be securing a needle into Ryan's lower
leg for these medications."
Gage said, laying out the vials and mixtures they were going to need.
"Do anything you have to do to save my first born." she said fiercely. "Just quit worrying
about
me and focus on him. I only get weak if my husband bleeds, for he's not
just an easy child for me
to fix with simple mothering." she lilted.
Vince lifted his radio with his free hand. "Seven Charlie
Six to Seven Mary David."
##Seven Mary David.## replied Baricza from his post by the front door
looking
cautiously out the window near the Diaz's front door. Sancho was sleeping
against the chair,
still upright on the floor and sitting where he had been left.
"Status?" Howard asked.
##Fog's
thickening in the park. So far, unfounded.## Barry replied, being vague
intentionally about his inability
to spot trouble outside. ##Mayfair Five is four away
with large escort.## he shared. ##E.T.A... Very
soon.##
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"10-4." Vince answered.
"Is that the ambulance for Ryan?" asked Alannah.
"Yeah." Vince
told her. "It's less than four minutes away from us and coming closer."
"Good." she whispered.
Some of the worry left her face.
Johnny began to swab down the inside groove of Ryan's upper leg
tibial notch
and skin with betadine. He fitted a large bore sterile needle hub into the nose of
the bone gun and carefully palpated near the proper place with a gloved set of fingers
to be assured
of his landmarks. He pulled the trigger. Bang! Then he lifted the
tool away. The hub was deeply
embedded into the skin. As Gage removed the guide
needle, it slowly began to ooze out dull red marrow.
This Johnny wiped away with a
sterile gauze before aspirating and flushing the catheter port's delivery
channel
with a saline syringe to clear it of materials. He quickly snapped in Roy's hastily
offered
flowing I.V. line and began to add in Ryan's ordered medications rapidly.
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DeSoto looked up toward Howard who was bagging in Ryan's flowing oxygen.
"Vince, hyperventilate him
for a few and then help me tip his head, angled down,
my way." Roy pulled on his gloves and waited.
Soon Vince completed a rapid
set of breaths to Gage's satisfaction. Together, both of them helped
turn the boy
ninety degrees until his head hung over the edge of the bed on Roy's side with his
chin
pointing towards the ceiling.
"What do you have out?" Johnny asked his partner.
"A 4.5."
"For a cuffed? Yeah." Gage agreed. He handed over the active suction flange to
Vince to hold
ready and pulled out a curved MacIntosh laryngoscope the right
size to hand to Roy from the drug
box. He opened it and turned on its light.
Then he began to hold cricoid pressure over the cartilage
in Ryan's throat
just under his adam's apple to close off his esophagus in a safeguarding
move.
DeSoto had a fitted and bent stylus already down the French endotracheal tube
and he quickly
took the scope from Johnny to use. Roy pushed aside Ryan's
tongue and lifted his upper palate slowly
until he visualized vocal cords. "He's real
wet. Looks like more blood." he reported. "But there's
no obstruction." He inserted
the tube's rounded end to just below them and removed the tongue blade
carefully.
"Okay, let go cricoid, I'm in." He held the tube in place with some finger tips over
Ryan's teeth, while Johnny inflated the cuff at the bottom of the tube for him with a
10cc syringe
full of air through the feeder line.
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Gage put his stethoscope hubs into his ears.
"I'll take it from you." Johnny said, grabbing the tube's
head end from Roy's grip.
He studied how it protruded from Ryan's mouth. "He's at... sixteen and
a half
centimeters." he said reading the measured marking chock exactly where the
boy's teeth
rested where they were loosely clenching on the tube. "Test him."
he nodded.
Roy pulled off
the flowing ambu bag's mask and fitted its hollow connector to
the end of the endotracheal tube snugly.
Then he gently squeezed in two breaths
while Johnny listened with his free hand using his stethoscope
over Ryan's lungs.
"Chest rise." Gage confirmed. "Breath sounds on the right...." He moved the drum
over to the other side. "But not on the left. We're too deep."
Roy lifted up on Ryan's tube
in between Johnny's fingers, barely an inch, then
he bagged him twice again with both hands.
Gage smiled as he listened. "Okay both sides are good." He moved
the drum down to Ryan's stomach.
"And.....nothing over gastric.
We're set." he said, keeping his airway hand very still.
"15
and a half." DeSoto shared for their notes.
"Got it." Gage said, writing it down.
Roy
surrendered the bag over to Vince again and added a bite guard
and tube holder using a strip of ribbon
gauze tied around Ryan's head
over his cheeks to keep the airway from slipping further in or out
before he
taped it off securely in place.
Johnny let go of the endotracheal tube gently.
"Vent him better than easy, Vince. His airway's real open with this." Roy
warned. Then he suctioned
out more reddish saliva before leaving it on
slow draw in the space between Ryan's inner gums and
lower jaw. Liquid
hissed loudly for a few seconds into the catch reservoir but then softened
into
a healthy, dry air flow.
The burly officer nodded, using only lightly compressing fingers on
the bag to control Ryan's breaths, just to the barest beginning of chest
rises.
"That's it.
That's how." Gage encouraged him. Johnny dragged Ryan
toward him by his two bare feet until the boy's
head was back level onto
the bed and lying on his back.
Roy reassessed the boy's breath sounds
and continued tube placement
with Johnny's stethoscope. "Still rock solid after move." he announced.
Gage picked up the biophone receiver. "Rampart, this is Squad 51."
##Go ahead, 51.## Brackett
said in an instant.
"All meds have been delivered push I.O. We've a patent, running colloid line
and the endotracheal tube has been placed without any complica---" Johnny
shared.
Brackett
walked all over Gage's transmission in his eagerness to get the
patient ball rolling. ##10-4. Continue
monitoring his airway and vital signs.
Bring him in FASTER than A.S.A.P. And that's an order.##
Johnny grinned. "Right away, Rampart."
"You heard your doctor! Move!" Alannah said, lifting her
heavy bulk off the
hamper.
---------------------------------------------------------------------------------------
Mayfair Five pulled into a sharply blowing night wind in the driveway of
the Diaz's side of the
triplex. It was surrounded by two more police cars
from the city, all running silent with no emergency
lights.
Sea fog made the dark neighborhood even more sinister with clouds
of billowing mist.
Barry met two of the officers to explain the current situation in the house
while two more escorted
the EMTs and their gurney into the living room.
"Oh, that for me?" Sancho asked cheerily when
he stopped trying to
reach for another beer with his elbows. He seemed not to register
that his
hands were handcuffed behind his back.
"Take it easy, Mr. Diaz. Just stay comfortable." Baricza
suggested.
"He a threat?" one of the new officers asked Barry when he saw
bloody scrapes on
Mr. Diaz's face and smelled pepper and beer
in the air.
Baricza shook his head. "Friendly
fighting. The wife was better at
it than he was. Even seven months pregnant."
"Oh, really?"
The cop chortled. Then he followed the EMTs into
the hallway Barry had indicated.
--------------------------------------------------------------------------------------------
"They're here." Gage announced, starting to gather up the gear boxes
they had closed up for carrying.
"Fellas, let's use that peds spine
board and head block." he said without looking up as he hurried.
"He's
got a tricky E.T. t---" he broke off when he saw that one of the EMTs
was Rosalie Arnold,
Mayfair company's newest rookie. "Oh, sorry,
miss. I..I..didn't see you there." he stuttered, tongue
tied in front of
his latest crush. "I..was doing other things.." he finished lamely.
"It's
okay. My hair's short." smirked the petite fawn haired athletically
built female EMT. "And I'm buff.
You're forgiven."
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Johnny goggled uncomfortably for a few seconds before getting down
to business with securing Ryan
onto the EMTs' spinal board. They stabilized
him with the headblock to double safeguard his working
endotracheal tube.
The male EMT took over Vince's ventilation tasks on the boy. "Thanks."
he
said to Howard. "We've got it from here."
Ryan was covered up snugly with a light beige wool blanket
after he
was transferred off the bed onto the gurney. The resuscitator apparatus
and its active
suction was nestled in at his feet along with the EKG
monitor. A brief low tone sounded on the machine.
"A PVC. Just one." Rosalie announced, turning on the EKG tracing tape
to record it.
"That's
uh,, that right." Johnny told her, surprised at her knowledge. "He's
doing okay. I've still got a
pulse down to his brachial." he said, showing her
the grip he had on the boy's upper arm. EMT Arnold
took the bag
of medications and chemicals that Howard had been holding to take with
them. "Any
ideas?" she asked turning to Roy, pointing to the bag.
"Iron supplements." DeSoto replied.
"Watch for vomiting." Gage said unnecessarily. "Uh, I mean.."
he checked himself, not wanting to offend
the lady EMT of his
dreams.
"I know about poisonings. Thanks." she smiled at Johnny, grinning.
Gage just about melted under her attention before he hid it again
under a thick layer of professionalism.
Roy gathered up the black drug and I.V. boxes while Johnny took
to carrying the orange biophone
and white defibrillator cases.
They wheeled down the hallway, fully laden with their patient and
their equipment.
Sancho finally noticed them. "Hey, is that my boy? Where are you
taking him?
What happened?" he asked trying to get to his feet in
alarm. He couldn't manage it because of his
obese size. Alannah
stepped in to confront him, bending down to look at him in the face.
"Love,
Ryan got into something that's made him ill. He's going to
the hospital. Now settle down and let
these good people---"
"I'm not letting anybody take my son!" Sancho roared, not thinking
clearly,
shouting very loudly. "You can't do that! I'm his father! And
she's his mother!"
Outside the
house, his frantic shouts echoed through the wide open front
door and into the rising, thick fog.
The sounds were carried away in a
brisk wind.
Inside, Howard attempted order. "Get him on
his feet. He needs some
time in Detox. I think he's too inebriated to stay at home safely."
"I
agree." said Alannah, waving on the EMTs and their gurney. She
dashed to a living room table for a
set of keys. "These are for
the house. We're locking up and we're leaving, Sancho." she told her
husband. "I won our wee bout so I have the final word on the matter!"
"..if you say so, dear.."
said Mr. Diaz meekly.
"So I do!" she declared, handing the keys to the city officer.
Barry
shouldered his rifle and then he and the city policeman helped
Diaz up, holding him steady so he
wouldn't fall for being handcuffed
behind his back.
Sancho's half hearted protests bubbling
from his lips began to die
away when the colder night air hit his wet T-shirt, making the pepper
spray start to burn his exposed skin again. "Ow." he mewed, cringing
in his sneakers.
The
Mayfair attendants pulling Ryan, with Roy, Johnny, and Alannah,
all headed outside into the darkness
for the street behind an escorting
city officer who had his weapon drawn.
Vince and his colleague
led Sancho out between them.
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Barry shut the house door and locked it firmly after turning the house
lights off.
A sharp
whistle from the city officers by their squad cars outside got
all of their attention. Baricza and
Vince's radios snapped into active
life. "Heads up! We've got a problem in the park!!"
Vince
and Barry swiftly pulled out their guns.
"Keep going! Get into the Mayfair! All of you!" Vince
ordered. "Take
Mrs. Diaz with you. We're leaving Sancho here. He's too slow!" Howard
said, getting
himself and Sancho under cover behind a post on the porch.
Mr. Diaz looked around for a moment
in a fuzzy curiosity towards the park
but Howard quickly pulled the man's head back into hiding.
The city officers ran for their squad and stealth cars and opened their
car doors to use
as shields against gunfire.
But none came.
"What's the situation, City P.D.?!" Vince demanded
over his radio,
not seeing anything at all through the clouds of streaming fog tearing
itself into
tatters on the brisk wind.
##Gang activity on the hill. At eleven o'clock!##
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The male EMT was already in the captain's seat, continuing the boy's
careful ventilations. Roy was
on the rider's bench, switching out
the resuscitator's power source and plugging in for fresh oxygen.
"Oh, boy." DeSoto said feeling a very familar, much hated clench in
his gut. For him, the war zone
had totally awakened after his
senses had picked up on a tiny thing.
"What?!" Gage startled,
ducking, as he finished guiding Alannah into
the ambulance after her son Ryan. Then he smelled it;
coming out
of the thick fog, like a disease.
Fire smoke.
A faint orange glow began
to light up the horizon on the hill like
a cancer. It was slowly growing brighter, filling the whole
sky as
it advanced.
Then came the sounds of triumphant shouts and hostile heckling, all
around
them from the peach glowing fog, that seemed to be moving
farther away into the darkness among the
rows of quiet houses.
A powerful wave of gasoline stench hit their nostrils.
It was a
huge brush fire, intentionally set by the fleeing, hidden gang.
And it had been left behind to blaze
out of control.
"Those little cretins! They lit up the whole park." said a stunned Alannah.
Baricza startled, coughing. The CHiP officer slammed the door of the
ambulance shut protectively.
"Stay there!" he shouted to all of them
inside. "Don't move until I say so!"
He threw the
Diaz's house keys high into the air towards Howard
who caught them. The burly cop quickly bustled
Sancho back inside
the house and locked him in.
Then he and Barry ran into the foggy darkness
for their vehicles and more
equipment.
The police channel began to chatter with high paced
activity between
their dispatcher and the communications of the seven city officers
located at
the Diaz house.
One by one, all four police cars lit up into red light flashing life, with full
sirens, where they idled. A loud speaker began issuing police commands
for the neighborhood gang to
obey in the attempt that the action would
buy them all time for more help to arrive.
"...oh
sh*t." said EMT Rosalie Arnold, looking up from where she
was settling her patient hastily for a dubious
departure. "I think that fire's
engulfing the only road leading out of here."
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