PMM - The Magazine

For many months I was suffering from headaches, from mild to severe.  Many told me to see a doctor but as most of them also knew, I am very stubborn.  Finally it came down to my annual physical.  After discussion and a few tests I was diagnosed with Subarachnoid Hemorrhage (SAH). SAH is sudden bleeding into the subarachnoid space of the brain.  The most common cause of spontaneous bleeding is a ruptured aneurysm. Symptoms include sudden, severe headache, usually with loss or impairment of consciousness. Secondary vasospasm (causing focal brain ischemia), meningismus, and hydrocephalus (causing persistent headache and obtundation) are common. Diagnosis is by CT or MRI; if neuroimaging is normal, diagnosis is by CSF analysis. Treatment is with supportive measures and neurosurgery or endovascular measures. 

Symptoms and Signs

Headache is usually severe, peaking within seconds. Loss of consciousness may follow, usually immediately but sometimes not for several hours. Severe neurologic deficits may develop and become irreversible within minutes or a few hours. Sensorium may be impaired, and patients may become restless. Seizures are possible. Usually, the neck is not stiff initially unless the cerebellar tonsils herniate. However, vomiting, and sometimes bilateral extensor plantar responses. Heart or respiratory rate is often abnormal. Fever, continued headaches, and confusion are common.

Diagnosis

Diagnosis is suggested by characteristic symptoms. Testing should proceed as rapidly as possible, before damage becomes irreversible. Noncontrast CT is > 90% sensitive. MRI is comparably sensitive but less likely to be immediately available. False-negative results occur if volume of blood is small. If subarachnoid hemorrhage is suspected clinically but not identified on neuroimaging or if neuroimaging is not immediately available, lumbar puncture is done. Lumbar puncture is contraindicated if increased intracranial pressure is suspected because the sudden decrease pressure may lessen the tamponade of a clot on the ruptured aneurysm, causing further bleeding.

Prognosis and Treatment

About 35% of patients die after the first aneurysmal subarachnoid hemorrhage; another 15% die within a few weeks because of a subsequent rupture. After 6 mo, a 2nd rupture occurs at a rate of about 3%/yr. In general, prognosis is grave with an aneurysm, better with an arteriovenous malformation, and best when 4-vessel angiography does not detect a lesion, presumably because the bleeding source is small and has sealed itself. Among survivors, neurologic damage is common, even when treatment is optimal.

Prognosis

SAH is often associated with a poor outcome. The death rate for SAH is between 40 and 50%, but trends for survival are improving. Of those who survive hospitalization, more than a quarter have significant restrictions in their lifestyle, and less than a fifth have no residual symptoms whatsoever. Delay in diagnosis of minor SAH (mistaking the sudden headache for migraine) contributes to poor outcome. Factors found on admission that are associated with poorer outcome include more blood and larger aneurysm on the initial SAH (bleeding around the mesencephalon in the brain), however, has a very low rate of rebleeding or delayed ischemia, and the prognosis of this subtype is excellent.

The prognosis of head trauma is thought to be influenced in part by the location and amount of subarachnoid bleeding. It is difficult to isolate the effects of SAH from those of other aspects of traumatic brain injury; it is unknown whether the presence of subarachnoid blood actually worsens the prognosis or whether it is merely a sign that a significant trauma has occurred.People with moderate and severe traumatic brain injury who have SAH when admitted to a hospital have as much as twice the risk of dying as those who do not. They also have a higher risk of severe disability, and traumatic SAH has been correlated with other markers of poor outcome and longer stays in the intensive care unit. However, more than 90% of people with traumatic subarachnoid bleeding and a Glasgow Coma Score over 12 have a good outcome.

Long-term outcomes

Neurocognitive symptoms, such as fatigue, mood disturbances, and other related symptoms are common. Even in those who have made good neurological recovery, anxiety, depression, posttraumatic stress disorder and cognitive impairment are common; 46% of people who have suffered a subarachnoid hemorrhage have cognitive impairment that affects their quality of life. Over 60% report frequent headaches. Aneurysmal subarachnoid hemorrhage may lead to damage of the hypothalamus and the pituitary gland, two areas of the brain that play a central role in hormonal regulation and production. 

So to make a long story really short, I no longer can be in the line of duty due to possible head trauma which is a liability to the department.  Thankfully, I am able to stay with the department and work on the Arson Investigation Team and train the "Newbies" on Saturdays.

I had been on the department for about four months when I went to my first "real" fire. I'd been to quite a few medical calls, chimney fires, minor M.V.A.s (motor vehicle accident) and of course plenty of false alarms, but nothing very serious. I was about two blocks from the station when we got toned out for an R.V. on fire. I was the first one in and the adrenaline was already pumping. Within a few seconds we had a crew of five and Engine 4 was headed to the scene code 3. Within a few seconds of leaving the apparatus bay dispatch informed us that it was a mobile home fire rather than an R.V. fire. About 30 seconds later the Chief was on scene and reported TWO mobile homes burning, one fully involved. We were about 3 blocks from the fire coming down a hill when I looked out the window and saw it. What a scene it was. Two mobile homes ablaze and Engine 2 just pulling in. We pulled in just behind 2 and I jumped out ready to go. I walked around the front of the engine and froze. The Engineer of Engine 4 looked at me and said, "What are you doing? Get in there!" I shouted back "What do I do?" Engine 2's Engineer yelled, "Get your ass in there and fight fire!" That was all I needed to hear. I grabbed a hose line to back up another firefighter and we started fighting that fire. I'm still not sure why I hesitated, but it never happened again and I took it as a learning experience.

We had to knock down the fire in the first mobile home as the winds were pushing the flames into the second. Once we had it knocked down enough we headed around to the other side of the second trailer and prepared to make entry and attempt to save as much as we could. There were two doors at a right angle to each other. First I grabbed the sliding glass door to open it and it wouldn't budge. Then I grabbed the doorknob of the second door and it was locked. I grabbed the sliding glass door again and still nothing. As we were about to break the glass one of our veteran firefighters came up. He grabbed the doorknob and nothing. Then he grabbed the sliding glass door and it opened right up. To this day I haven't been able to figure that out.

The firefighter I was with had been on the department about a year longer than I. He knew I'd never made entry before and he handed me the nozzle. I started heading into the house when he grabbed my shoulder and said "Get down!" Another mistake I never made again. Crawling on the floor I felt my way through the smoke and heat. I made my way through and soon saw that orange glow. We knocked the fire down and saved most of the house.

I learned a lot that day. The most important thing I learned was that this was definitely what I wanted to do with my life. That was the day I became a fireman.

I knew my calling right after my twin brother, Shawn, died.  It was my brother's dream to be a firefighter.  To honor him I wanted to live his dream through me.

Shawn was a third-grader when he told us in no uncertain terms he wanted to be a fireman, our mother was devistated. Recalling how as a youngster he often disappeared, she said she always knew where to find him: hanging out in the firehouse across the street from the family's home.  Punishment didn't dissuade him. She was fighting a losing battle. So much so, her Dad pleaded the case for letting him be. At least we know he's safe there.

I called my  first fire truck "my girlfriend." I washed it every chance I got. And when I was off duty, the crew knew they'd better spruce up Shane's "girlfriend" before I returned or they'd hear it from me.

My Mom was my hero, when she passed, I told myself I lost my right arm. Then I realized I just gained another guardian angel.