Play the ball as it lies

When I was but a little boy, my father began taking me to the driving range, and eventually to the golf course with him. Soon, at around 8 or 9, I graduated to playing rounds of golf with him and his friends. Golf, and especially my father, have taught me many important life lessons.

Golf has taught me how to be gracious both in victory and defeat. When playing a contested match or tournament, I learned to shake my opponent’s hand with the same enthusiasm, regardless of the lower score at the end of the round.

I learned to leave the course better than I found it, so that others may enjoy the course as I have. We do this by replacing divots, fixing ball marks, and raking bunkers.

My father always stressed several fundamentals: grip, head, focus, and rules.

He would periodically inspect my glove and grips and tell me what I was doing wrong. He would take me to the range, grab a handful of my hair, and have me hit long irons. He would call out math problems or historical facts while I was in the middle of my backswing. My father was making me a better golfer. It worked, and I was able to beat my father, a 5 handicapper, on a regular basis before I was a teenager.

The most important lesson he enforced was the rule book. Especially rule 13. “The ball must be played as it lies.”

He used this as a metaphor for life. Just as in the course of a golf round we aren’t allowed to move our ball to a spot that affords us a better shot, we aren’t allowed to cheat in life. We take what the golf course of life gives us, and we make our best attempt on the next shot. Some times we hit the ball fat, some times it slices into the woods, and some times we hit the ball flush, and it stops on the green, inches from the cup.

Sometimes the lie of our ball is perfect: in the middle of the fairway, a perfect distance for a 7-iron approach, flat, with no breeze. Most of the time, something is wrong with the ball’s lie. It could be above or below our feet, in the rough, underneath some branches, or blocked by a tree.

Sometimes we can pull off a 40 yard snap hook to win The Masters like Bubba Watson did from the woods on 10. Sometimes we are coasting to a win at the same tournament a year earlier with 9 holes left to go, and wind up having a colossal meltdown, taking a triple bogey on the very same 10th hole. Just ask Rory McIlroy.

Right now, I have a shitty lie in life. The ball is below my feet, in deep, wet rough, embedded in a divot 240 yards from the green with a 50 foot pine tree between me and the green. And it’s raining with a stiff breeze in my face. Laying up isn’t an option.

I’ve never hit a shot like this, and don’t really know how to approach it. All I can remember is my grip, keeping my head down, and maintaining focus. I’ve taken enough time thinking about how to hit this next shot in life, and now it’s time to swing the club. My focus is aided by several quotes that have been circulating in my head. I believe they are applicable to both the game of golf, and the game of life.

“The most important shot in golf is the next one.” – Ben Hogan

“I never learned anything from a match that I won.” – Bobby Jones

“Play the ball as it lies, son. Play it as it lies.” – Dad

Why can’t EMS interpret ECGs?

Every single day (okay, most days) at work, I am presented with simple ECG mistakes. Simple mistakes are the reason physicians don’t take us seriously.

How often do I see limb leads placed on the chest? More often than someone calls me “ambulance driver,” that’s for sure. It’s called the “left arm” and not the “left pectoralis major” for a reason, you know.

How often do providers actually touch the patient’s chest and count the intercostal spaces when placing electrodes? Not very often, I presume. My favorite is the straight line that can be drawn connecting all the precordial electrodes.

“Hey, let’s just slap some sticky things on your chest. It doesn’t really matter where they go, anyway.”

How often do providers read the interpretation on the top of the strip and take the computer’s random assumption as fact? Quite often I would bet.

“Junctional tachycardia with a right axis deviation. You should really go to the hospital!”

“Hey, buddy. Those are P waves right there. You can see them in front of each QRS complex. And this guy is 6 foot 9.”

Shortcuts drive me insane. I actually heard a paramedic say “if I is positive, and III is negative, it means LVH.”

Is that Sokolow-Lyon, Romhilt-Estes, or Cornell Voltage criteria?

Interpretation of ECGs is much more than reading what the computer thinks. And it’s much more than finding ST elevation. I could teach a 5 year old to find ST elevation in 10 minutes. ECG interpretation should be about following a systematic method every single time.

ECG interpretation should be about being able to recognize the man in front of you who looks like death eating a cracker has a right bundle branch block along with a left anterior fascicular block, and needs to be seen in a cath lab, regardless of the fact his ST segment is normal.

ECG interpretation should be about Sgarbossa’s criteria, instead of just saying “oh, it’s a left bundle, you can’t recognize a STEMI when the patient has left bundle branch block.”

EMS 12-lead does fantastic work, and I enjoy reading their posts. There are countless other wonderful blogs out there, but EMS 12-lead is by far my favorite. Unfortunately, not enough of EMS reads their blog, and takes the time to learn what they are teaching.

We need to do better than we are now.

Pills, Douchebags, and the 10-minute ER visit

“20 year old male. Woke up with back pain” says the dispatcher, a little too chipper for so early in the morning.

“That’s funny.” says Slimm. “I woke up with back pain this morning, too.”

Map books and GPS aren’t needed on this call. It’s a familiar area, full of delightful, contributing members of society.

You know, the ones who live off of productive people.

“You know what I did after I woke up this morning with back pain?” asks Slimm.

“What’s that?”

“I went to work.”

I guess that explains his presence next to me. Come to think of it, I think I feel a twinge in my lumbar area as well.

We arrive on scene quickly, and see the fire department waiting for us at the front of the apartment building which is supposed to contain this alleged patient. All four firemen are standing out side the building. I think I notice one of them cutting his fingernails.

“Hey, where’s the patient?”

“Looking for his keys” is the reply, as an obviously not-in-distress guy comes bounding out of a crappy apartment, walking right past the four firemen and two ambulance drivers technicians.

Walking straight to his car to obviously retrieve something of dire importance. More important than any other resident of this community. And obviously more important than my cup of coffee I left back at the station.

Damn. I needed that coffee.

“What’s going on today, sir?”

“My back hurts.”

No shit. “What can we do for you?”

“I need to go to Local Hospital so they can refill my oxycodone.”

“Ummmmm.” comes the reply from Slimm. “We are happy to take you there, but they aren’t going to refill your prescription. You are going to need to see your doctor for that.”

“No, they will refill it. They have to, since I’m in so much pain. I threw my back out a few months ago lifting weights at school”

Right.  As if “lifting weights” is some sort of other language for “lifting a bong from my coffee table.”

Sure enough, we don’t even make it into the assigned room when Dr. VonAccent walks up to inquire as to the life-threatening nature of the patient’s illness.

“No, sir. We do not refill prescriptions written by other doctors here. You need to see your primary care physician.”

“But I am hurting!” comes the reply from the douchebag terribly ill young man on my stretcher.

 

I don’t think Mr. Thrownoutback even made it to a hospital bed before being escorted out by security. It’s a shame when patients are leaving the hospital before the ambulance crews.

He was last seen asking a taxi driver for a ride to the Methodist hospital.

Here’s my homework, Mr. Grayson

Nobody in EMS is paid what they’re worth. 25% are paid far less than what they’re worth, and 75% are paid far more than what they’re worth.”

-Kelly Grayson

 

I couldn’t have said it better myself. But then, I’m not quite as eloquent as Mr. Grayson.

I would love for us EMSers to make more money. But we don’t deserve it.

The most common argument I hear is “but we do the same work as nurses, we should make the same money.” With all due respect to EMTs, Paramedics, Ambulance Drivers, and Trauma Junkies; that argument doesn’t hold water.

Nurses rarely only have to take care of one patient at a time, and they almost always spend more time than we do with a patient.

Pay is commiserate with your education, and your performance. Or, as my father used to tell me: “You make one dollar per hour for what you can physically do. Every other penny you get is for what you know how to do.”

We, as a profession, aren’t paid more because we haven’t earned it.

Our education requirements are ridiculously low, and some of us get all hot and bothered when others try to improve those requirements.

One year to become a paramedic is not enough time. (I understand you have to have at least EMT-Basic to go to paramedic school. Let’s not argue over another 3 months, please.)

I would advocate doubling the required class hours, as well as clinical hours. Make Paramedic an Associate’s degree program across the board.  Stop letting paramedic students begin their clinical work three weeks after they start classes. I could go on, but won’t.

National Registry is trying to do their part, by requiring paramedic candidates to have graduated from an accredited agency before taking the exam. Registry is trying their hardest to advance our profession. While some of us are trying to make it more difficult.

Join the National Registry, if you aren’t already a member. Get involved in EMS at the local level, state level, and national level. Demand more stringent education requirements, and demand more class and clinical time.

You want to make more money as an EMSer? You want more respect from the medical community? You want more respect from the general public?

Then prove that you deserve it.

Airplanes and ambulances

I hate flying. I love Wikipedia.

I promise, these two things are (sort of) related.

When I say that I hate flying, I mean that I hate flying. I would rather drive ten hours then get into an airplane and take a two hour flight. I don’t care how convenient or quick flying is, I still hate it. I hate flying for a good reason: it scares me.

I’ve heard all the excuses in favor of flying, but still, I can’t get over sitting in a tiny metal tube with 200 other people 6 miles up in the freaking air. Oh, and the WINGS MOVE! I don’t mean the flaps and ailerons, and control surfaces, I mean the WHOLE WING FLEXES!

That can’t be good.

“Do I want a drink? Are you kidding me? How could I possibly drink it? My hands are numb, and I don’t think I can pry my fingers out of this arm rest.”

I’m starting to get anxious typing about this. On to Wikipedia.

I can spend hours on Wikipedia. I surf Wikipedia like people surf channels. One minute I’m reading about ichthyosis, and the next I’m reading about naphthalene. Checking my phone, I have a Wikipedia page open to Operation Ranch Hand.

I learned about the other “agent colors.” It wasn’t just orange.

Any way, while sitting (seriously) in the airport waiting on my flight to board, I stumble onto a page on Wikipedia about air safety. Specifically, the Sterile Cockpit Rule. Reading through that page took me to Crew Resource Management. And right before my xanax kicked in, I had an epiphany. It was so good, I wrote it down on a napkin, and put it into my jacket pocket.

“CRM & SCR for EMS” it says.

I’m genius, I tell you.

I have heard of Crew Resource Management in the fire service, or something similar, but nothing like the Sterile Cockpit Rule.

I’ll come up with something intelligent in the next few days and post my ideas how these two concepts can have a place in EMS.

Right now, I need some alcohol. I have to get on another plane tomorrow.

Tough guy

A person shot at a seedy apartment complex. Not all too unheard of. I never get shootings, though. Mostly little old ladies with balance problems.

PD arrives on scene when we are about 2 minutes away. Their update says something about “a whole lot of blood.”

It’s probably kool-aid. Or someone else’s blood.

Sure enough, the cop is right. It’s the blood of our “victim.” He has been shot square in his left ass cheek.

Sorry. “Medial aspect of the inferior left buttock” for you serious types.

This would be funny, if this dude in his early twenties wasn’t screaming and crying like a little bitch.

“Man, don’t let me die, man, don’t let me die! I DON’T WANT TO DIE, MAN!”

“Hey, buddy,” says Slimm, “I think you’re gonna make it.”

“Come on, man, this aint funny, man! SOMEONE CALL MY MOMMA!”

His clothes are cut off, revealing his tough guy tattoo on his abdomen. A crappy attempt at old English letters, with inconsistent shadowing.

“TOUGH-ASS <racial slur>”

Tough, indeed. “What’s your momma’s number?”

He made it.

Not really hurt.

A call for an accident with injuries in a gated neighborhood.

Yeah, right. Like that ever happens. Well, it did that one time, but that’s another story.

Enroute, things become a little more clear: “21/F IN MVC EARLIER/BACK PAIN/REQUESTS CHECK/” the MDT tells us while we are on the way. Slimm and I make eye contact, and reflexively turn off the lights and siren.

This call is going to be stupid.

Humongous house. Million dollars plus. A lawn manicured with a very small pair of scissors wielded by midgets with monocles. More than three German luxury automobiles in the driveway. All black. All big.

A butler (no shit, even wearing a uniform) directs us to the elevator (no kidding), and to the “lady’s wing.”

Some cute chick laying on a bed big enough for 8 with enough pillows to smother several gaggles of geese.

“My back, like, it like, totally hurts and stuff.”

Interesting. Once again, something I already knew. “What happened to your back?”

“Well, I was like, driving, and like, I totally got hit by another car, and I was all like spinning in circles and stuff, and I didn’t want to go to the hospital, because, you know, I felt okay at the time, but like, after I came home, my back started to hurt and stuff, and now I like, can’t move, you know?”

Blank stare.

“How long ago was the wreck?”

“I dunno, it was like lunchtime.”

A quick glance at my watch informs me that lunchtime was approximately 5 hours ago.

As I turn around to lower the stretcher, because this obviously traumatically injured female is not capable of ambulating, I notice it:

A large television on the wall, across from her bed.

It is paused.

On a commercial.

For a local ambulance-chasing lawyer. His number prominently displayed on the bottom.

“Make your WRECK into a CHECK!” “Call NOW! 1-800-SUE-THEM!”

I wonder if we were her first, or second call?

He hugged me

She wasn’t going to make it. There wasn’t any chance, and everyone knew it.

She was young, in her early 40s. Her husband informed us that she had been the recipient of a heart transplant 8 years ago. 8 years she never would have had. 8 more years to be a mother to her 3 children. 8 more years to be a wife.

The husband had come home from work for lunch, he said, and found her on the floor of their bedroom. She was unconscious, and barely breathing. No, she hadn’t been sick, or complaining of anything when he left only 5 hours ago.

He kissed his wife and told her he loved her before grabbing his suit coat and heading out the door for another day at work.

Her heart was trying to keep up, but it just couldn’t any more. It was still producing electrical activity on the cardiac monitor, but nobody can survive for very long with a heart rate that slow.

We tried valiantly, and even got some improvement with chest compressions. I dropped a tube in her trachea, and the capnography readings seemed to be a positive sign. There was at least something to work with. We loaded her quickly into the ambulance, and headed towards the hospital, which was only a short distance away.

But then her heart really quit. Defibrillation gave us the rhythm we all knew was going to come soon, and one that will plague every one of us who is ever born: asystole.

We kept working all the way to the hospital, knowing our efforts were futile. But we all gave it all we had.

She was too young to have her ribs broken in such a violent manner.

The resuscitation was brief at the hospital. The physicians and nurses knew what we did: her end had come, and we were powerless to do anything about it.

The ER physician mentioned he was on the way to make the notification to the patient’s husband. I asked if I could come along.

Too often, I drop my patients off, like a warm slab of meat, and I don’t appreciate how much this life that I was entrusted with impacts the lives of others. I want to be a better provider, and I want to understand the emotions that loved ones feel, without becoming emotionally involved.

I remained quiet while the kind physician informed the husband that there was simply nothing that could be done to bring back his wife of 20 years. Yes, we tried everything, and no, she didn’t hurt at the end. She simply went to sleep.

The patient’s husband, being the consummate gentleman, rose to his feet, and extended his hand to the physician, and thanked him for his efforts, and for the efforts of the hospital staff. Then he turned to me, and I could see the tears forming in his eyes. His voice was wavering, but stoic.

“Thank you for taking care of my Susan” he said. “I wish there was something I could say or do to show you how much I appreciate the work you all do.”

Then he moved towards me, and hugged me. He is a strong man, but his hug was somewhat weak, almost as if half of his person, his soul, had left, leaving him half the man he was this morning.

I didn’t know what to say.

My hug in return said much more than I could have with words.

Things that bother me: Poor post-nominal letter usage

Post-nominal letters. Ahhh, the confusion that they create. But they shouldn’t.

For example: if you didn’t attend a course offered by the University of Maryland Baltimore County, but instead sat in a class for 16 hours at your ambulance service, where they taught you how to set up a ventilator, and maybe the difference in LAE and LVH, then please, don’t use the post-nominal letters “CCEMT-P.”

By the way, it’s not “Critical Care Emergency Medical Technician,” it stands for “Transport.” Nurses take that class too.

CCEMT means you attended a UMBC course, period. UMBC is widely respected, with a known curriculum. It’s kind of like NREMT, but not. The NREMT tests all paramedics to the same (debatable, I know…) standard, and UMBC does the same with CCEMT.

And what’s with all the dashes thrown up in there? What exactly is “CC-EMT-P” supposed to mean?

There is also an order these things are supposed to go. Academic degrees should go first, in ascending order. Bachelor’s degrees, then master’s degrees, then doctorates. So, “PhD, MBA, BS” would be inappropriate.

There should also be an ascending order of academic education, or titles. “FP-C, NREMT-P, CCEMT-P, LMNO-P” wouldn’t be appropriate, either.

Not that post-nominal letters mean anything to anyone outside of this business, anyways. Not that post-nominal letters mean anything to anyone in this business, either.

But let’s try to get it right, or not do it at all, shall we?

 

Things that bother me: Uniform shirts

Uniform shirts drive me bonkers. There’s really only three options, not counting the t-shirt, which never looks good, in my opinion.

There’s the omnipresent cotton button-down uniform shirt. Usually with patches, and maybe some embroidery on it. Cotton shirts breathe well, and are generally comfortable in the hot, muggy summers. Long sleeve cotton shirts aren’t very warm, and usually require me to wear a long sleeved t-shirt underneath if I want to have any semblance of comfort.

Cotton uniform shirts look absolutely snazzy when ironed and starched with sharp creases in them. But they look like crap about 12 hours later, which makes them impractical, unless you have an outrageous dry-cleaning budget, lots of time with an iron, a devoted house spouse, or all of the above.

Oh, and to those dry-cleaners who put creases on the sides of the patches, as opposed to straight down the middle, STOP IT. It looks stupid.

Polyester button-down shirts look real sharp, and don’t require that much work. I’ve never starched a polyester shirt, mostly because I have never needed to. Usually, I pull them out of the dryer when they are good and hot, hang them up quickly, and sometimes touch them up with an iron if needed. They stay ironed for days, and good, sharp creases stay put for weeks.

Those polyester shirts are like COPD patients though. They don’t breathe well. They are incredibly hot in summer time, and make me a sticky hot mess by the time I get home.

Polo shirts look good, but management hates them. We have strict rules for when we can wear the polo style shirt. Only between April 15th and October 15th, and only if our partner is wearing the same shirt. It’s easy to coordinate with partners, but it’s hard to convince an EMS worker to shell out 50 bucks for a shirt, when the ones the company buys are free.

Our polo shirts have our name and title embroidered on the right chest, with our company’s logo on the left chest. They look good, and are comfortable. Unfortunately, I don’t get to wear it too often.

This has been me complaining. Back to suffering in my own perspiration I go.