I Want You To Quit It

It was a familiar scene at 3:30 in the morning. We had been running all night, and just as I slipped off my boots to climb into bed, the tones went off yet again. Medic 62. Fall. Delta response at... The three of us piled back into the truck and sped off. We had been dispatched to a skilled nursing facility (and I use the term "skilled" loosely in this context), where we found our patient lying on her bedroom floor in her nightgown. "June" was in her early nineties, and was afflicted with advanced dementia as well as a myriad of other health maladies. We found her curled up on her left side, mumbling incoherently to herself. June had fallen on her way to the bathroom, and the night staff called 911 per protocol. This happens all the time at nursing homes; this type of call has become routine for me. The smell of feces lingered in the air. It was a familiar scene at 3:30 in the morning.

Quickly I went through my mental checklist. A, airway is open. B, yes she is breathing if she can mumble like that. C, weak pulse but she's over 90 for goodness sake. She was moving her head around slowly, eyeballing the newcomers, so a severe spinal cord injury was unlikely. How long has she been like this? 20 minutes? Is this her normal baseline mental status? You don't know? Has this happened before? You have no idea? June's mumbling intensified. The staff seemed to know nothing about her, including her name. They only knew that she fell, which would have been patently obvious to a third grader. As we read her medical chart, I noted a long history of high blood pressure, hip surgeries, advanced dementia and more. There was a list of prescriptions a mile long. Clearly we had found June in the same state that she had been for some time. However, any time there is a fall with possible neurological complications, it's an absolute emergency. Without confirmation from the nursing staff that all this was run of the mill for June, we had no choice but to assume the worst.

The medic asked June if she felt any pain when he firmly pressed two fingers against her neck and down her spinal cord. She could not answer, but her mumblings grew louder as he palpated her cervical spine. She had a laceration on her forehead too. I went back outside to the ambulance to grab a backboard, C-collar, head-blocks, and straps. June probably didn't want to be fully immobilized (who does?); she probably just wanted to be helped back into bed, but here we were. After fitting the collar tightly around her neck to prevent any movement, June uttered her first lucid statement of the night. Am I going to be able to breath in this? Her speech was quiet, almost normal; a wave of clarity had swept over her. We told her not to worry and to breath normally. And just like that the moment was gone. The mumbling began again.

Hospice called while we were gently tightening the straps. They wanted us to wait until one of their people could get on scene and check her out. Maybe she wouldn't have to go to the hospital after all. But they were 30 minutes away, and again, we had to assume the worst. I was in charge of her care once we hopped in the truck. Okay, I need vitals. Blood glucose for altered mental status calls. Need BP, pulse, oxygen sats... Glucose was 120 and her BP was elevated. With every bump her muttering grew louder. Lordy lordy lordy lordy! Lordy LORDY! There was really nothing I could do for June except monitor her vitals, keep her awake, and hold her hand.

We reached the UNC Emergency Department shortly. We pulled the stretcher out of the truck and wheeled June towards the glass doors. As my partner was punching in the code to get in, June was able to turn her head just enough to look at me. Her baby blue eyes were pleading. What they were pleading for I didn't know. Her bed? Her family? For us to take her away from this hospital, from more tests? I could fill none of these requests, and I was left feeling helpless. So I offered her the only thing I could. I smiled at her, knowing that she probably would forget about me moments later, but that it was the only care I could give. To my surprise, the emotion in her eyes changed. She smiled right back at me, a toothless grin. It was as if in that instant, everything was all right. It was a transient moment; we rolled through the double doors and it was back to reality.

The reality was that June was going to receive more labs and tests than anyone could ever want. The EM residents did a full trauma exam, attempting to elicit anything intelligible from her. They poked and prodded, but came up empty handed. No posterior tenderness, no deformities, only one small cut on her forehead, nothing else. The straps, board, and collar were removed, and June was rolled on her side. As they palpated her spine, June began moaning. I want you to quit it! I want you to quit it! I WANT YOU TO QUIT IT!

I just want you to quit it.

I interpreted this as her second moment of clarity that night. She simply wanted to be left alone, and there was nothing we could do. As we left the room, the chief resident sighed. Well, it looks like we're going to need imaging. A full CBC and markers too, as well as...

It is an all too familiar scene.

(Note: some details concerning "June" were subtly changed for her privacy.)