Listen and learn

Newguy is out today. He and his wife are finding out the gender of their new baby, so he is going to the appointment. Well, Mrs. Newguy says they aren’t going to find out, but Newguy says he is going to cheat and sneak a peek at the ultrasound. He even has a plan and everything for how he is going to do it.

Nobody tell Mrs. Newguy, okay?

I’m working with a kid today. I did the math, and he was in diapers when I started in EMS. And he already has a bad attitude.

There is a difference between burned out and a bad attitude.

We get a call for a lady who is sick. It turns out the lady is visiting her daughter from Oregon, and has been confused, febrile, and weak for the past few days, and it is getting worse.

Daughter hands me an insurance card and says she needs to go to the hospital about 45 minutes away. While she is saying this, Babyface pipes in.

“Well, we could take her to Local Hospital, and they can just transfer her if needed, but they will probably just let her go if she just has a fever.”

Daughter looks excited, then goes on to explain that the sick lady is allergic to Tylenol and Penicillin, and has a diagnosis of primary biliary cirrhosis. No other medical problems though, which is good for a grandmother in her late seventies.

Finally we see the patient. She’s confused, sure enough. She’s pale, and the jaundice is pretty apparent in her sclera. (What is the plural of sclera? Is there one?) So, she’s sick, and probably needs to spend a day or two in the hospital for some IV antibiotics.

“Okay, we’ll take her to Westside Hospital. We are going to go bring our stretcher in here, and we’ll be out of the way.”

Babyface is absolutely apoplectic. “Why can’t we just take her to Local Hospital? It’s across the street. Westside is forty-five minutes away.”

I get stern with him. “I know where we are, and I know where the hospitals are, and we are going to take her to Westside Hospital.”

Later, at Westside, he decides to assert his position once again.

“Man, we should have just taken her to Local. This doesn’t make any sense.”

“What is primary biliary cirrohsis?”

“She’s probably an alcoholic, and she drank too much, and now her liver is shutting down.”

“Wrong. What is the first thing that comes to your mind when you hear that a person is confused, weak, and febrile?”

“Sepsis?”

“Fair enough. Does the diagnosis of primary biliary cirrhosis change that? You still thinking sepsis? What about her jaundice?”

“I don’t care about her cirrhosis, she just has a fever.”

“No, her ammonia levels are high, and she needs lactulose. She is very confused, and only responds to verbal stimuli, which suggests hepatic encephalopathy, and she needs an ICU. Taking her to Local Hospital would have been a bad decision, and a waste of time.”

He was still mad at me for the rest of the shift.

I don’t chase patients

A call for a person “out of their mind.” PD is already there.

“He’s crazy.”

“No joke. The dispatcher told us that. Why does he need to go to the hospital?”

“His mom wants him evaluated.”

“Why?”

“He’s crazy.”

I’m getting nowhere with this guy, so Newguy and I walk into the house and find the alleged patient and his mommy. The patient is in his mid-thirties, so I don’t know why he calls her “mommy” but who am I to judge?

“Ma’am, why does your son need to go to the hospital?”

“Because he’s crazy.”

I don’t even bother asking again. I just turn to the dude on the couch.

“You ready to go?”

“I guess.”

Cut to 10 minutes later, going down the road. The dude on the couch, who is now the dude on the stretcher, hasn’t said a word. He won’t answer my questions, or talk to me at all, so I’m just sitting in my chair catching up on paperwork.

The ambulance comes to a stop at a red light. Newguy is listening to a Handel on the Law podcast, and I’m kinda trying to pay attention to that.

‘Click click click.’

Before I look up, dude on the stretcher is now dude jumping out the back door. He takes off like an NFL running back with an open field in front of him.

I mean, he is gone.

“Med four radio.”

“Med four.”

“Show us ten-eight. Our patient left the ambulance and ran. Maybe PD might want to look for him.”

“Which direction did he go, med four?”

“I think north.”

“You think?”

“Yeah, I don’t chase people.”

No comprende’

A call for a “person choking” at the nursing home, in the “Memory Care Unit.”

Caring for something that isn’t there any more.

On the way in, we walk through the obligatory keyed-entry door, and Newguy points out a sign just inside the unit.

“New Memories Made Here!”

Kinda ironic.

A crowd of people is gathered around an old feller in a wheelchair at a dining table. Sure enough, he’s choking. As in, not breathing. He’s blue, but looking around. Close to death.

Newguy springs into action like some sort of caped superhero, sans cape, and performs a few abdominal thrusts. Our patient becomes unresponsive, and we move him to the floor, when I swoop in like the superhero’s sidekick with my trusty laryngoscope.

“What the hell is that? Bro, hand me the forceps real quick.”

There’s something in the airway, sho’ nuff. And I’m about to get that junk out.

The forceps go in, grab the food bolus, and I withdraw it slowly. As the food comes into his mouth, the patient starts to gag, cough, and miraculously, his skin changes color. This guy might be a chameleon.

I look at Newguy. “Just who is the sidekick NOW?”

Somebody examines the food bolus, and quickly deduces that it is roughly two-thirds of a lightly chewed Nutter Butter bar.

“Who gave him the cookie?”

“I did.”

“His arm band says ‘Nectar-thick liquids only’.”

“Oh. I didn’t know. I don’t read English.”

“Narc-what?”

“Person choking” is what the dispatcher says. A young person, too.

We skedaddle on over there, to find the nice fire crew already on scene. From what the friend says, the unconscious guy on the floor took a bite of a chicken sandwich then passed out and turned blue.

Somebody is bagging this guy, but “his sat is good with the bag, so I didn’t tube him.”

His vitals are okay, except for the unconscious part. He is breathing on his own, about 10 times a minute. Sugar’s normal. Heart rate is normal. Pressure is better than mine. Something about pinpoint pupils, but whatever. Everything is going smoothly so far.

While I’m thinking of the logistics of how to get this unconscious fellow up two flights of stairs, I hear some wonderkid say “Narcan.”

My ears immediately perk up, and my head turns as I say “dowhatnow?” But they don’t hear me. They are too busy talking amongst themselves.

“Yeah, we might as well.”

“It ain’t gonna hurt nuthin.”

“Yeah, it can’t hurt.”

“How much you want me to give?”*

“Give half of it.”**

“Okay.”

I interject. “Uh, if we’re gonna give naloxone, how about we go with point-four milligrams instead of one?”

“So you want me to give a fourth of the vial?”***

“Uh…”

The other guy speaks up: “Just eyeball half of it, it’ll be alright.”****

Before I can begin to process the shit show of patient care that just occurred right in front of my eyes and ears, someone gives ‘about half the vial’ of naloxone.

You know what happens next, don’t you?

Homey promptly awakens, retches, and coughs up a humongous piece of a chicken sandwich, which was obviously lodged somewhere north of his vocal cords.***** (It was just too big to go past the cords. Imagine you took a huge bite of a sandwich, and decided to inhale it without chewing. Yeah.)

My head is literally about to explode at this point.

 

* Personally, I don’t want you to give any, but the question wasn’t being asked of me.

** ”Half?” Is your partner not intelligent enough to read the numbers on the side of the little cute glass tube?

*** Okay, now we know you can’t read, and you suck at math. For the record, zero-point-four is one-fifth of 2 milligrams. Or twenty percent.

**** Seriously, I heard a paramedic say this. In the company of 4 other paramedics. Have you no shame, mustachioed dude?

***** Seriously, what the hell is going on here? The call was for “choking” and you arrived on scene to find an unconscious guy lying on the floor with a fucking chicken sandwich in his hand missing a bite. Did nobody think to look in his airway? A blade and a set of forceps would have done fixed this problem a long time ago, but now this guy’s going to have to sit in a hospital for a few hours.

 

Newguy and I are left to try to pick up what remains of our jaws from the floors. We literally can’t believe the serious shit-show we just saw happen. And meanwhile, these yahoos are patting themselves on the back.

What the hell is wrong with people?

TBD: Think Before Denying

Newguy and I are inside the home of a delightful lady who was complaining of chest pain, at least according to our dispatchers.

Our intrepid local first responders are huddled around the patient, in a mad dash to save her from the throes of death.

They seem to be succeeding at preventing her imminent demise, and also are sucessful in their attempts to create a large pool of blood all over the patient’s hardwood floors.

It’s a win/win situation so far.

One of the patch-wearing heroes rattles off some vital signs, and they are all better than mine, with the exception of her blood sugar: 331. Alas, she is a diabetic.

I really enjoy when the pieces of the puzzle assemble themselves.

Our infirm female has said several times now that she needs to “tinkle,” and asks if she can go. Newguy wants to get the 12-lead first, so he asks her to wait just a minute or so. It’s normal, by the way.

“Okay then, can I have a glass of water while I wait? I’m really thirsty.”

“Nothing to eat or drink until you see the doctor” the intrepid hero reflexively replies.

Newguy is nonplussed. “Why can’t she have anything to drink?” he asks.

“I don’t know” is his reply. Clearly, he has no idea.

“Were you guys going to put saline in that IV over there?”

“Well, yeah…”

 

Why don’t we think about these things? Don’t we all recognize what is going on here? This lady is hyperglycemic, and polydipsic and polyuric. Because her blood sugar is ridiculous. Granted, I’ve seen higher, but she’s going to get a large amount of fluids in her IV on the way to the hospital, so is there really any harm in giving her a glass of ice water?

The Curious Case of the Bumbling Buglers

“Hey man, wake up.” urges our bantam hero from the driver’s seat of the ambulance, “we’ve got a call.”

Arising from his light slumber, our second, slightly more portly hero reads the information on the MDT and presses ‘RESPONDING’ with an undaunted confidence that is rarely seen.

Then mumbles “bullshit.”

Over the radio crackles updates from dispatch: “PD-related call…male says he overdosed on cocaine about an hour ago and feels light-headed…requests EMS and Fire to check him out…PD is also enroute…”

Slimm deftly maneuvers the ambulance through traffic, never making contact, nor spilling his coffee.

The heroes with the big tank of water and fireproof clothing announce their arrival at the home of the cocaine-sniffing dipshit over the radio, making sure to establish command and set up a landing zone. No need to launch the water rescue though, this is on dry land.

Returning to our ambulance, we find the first two heroes moving in the direction of the distressed person with an alacrity only seen in nursing homes. Shortly, they arrive on scene, making sure to check in with the incident commander.

“Med 4 on scene with two personnel.”

As they deftly maneuver across the barren land, interspersed with pine cones and the remnants of a despair-filled, low-class life, they are intercepted by a first responder; Slimm executes a spin move but is still stopped in his tracks, just short of the goal line. Even Slimm can’t get past a man with bugles on his collar.

“This guy in here snorted some cocaine a little over an hour ago and says he feels funny.” he informs our altruistic, polyester-clad heroes. “His vitals are fine. He wants to go get checked out. No LOC, no medical problems, nothing like that.”

Slimm finally speaks since arousing his best friend in the world from his slumber earlier “you mean he don’t want to go to jail” he says, as we are granted access to the rust-streaked home that is easily moved.

The bugle-collared gentleman has associates, two of which are standing around what appears to be a dude afraid of the Iron Bar Motel. Local law enforcement stands back a little bit, contemplating his impending lunch hour, and the laborious task of deciding where to drive his cruiser. The third associate, who looks more like a nefarious cohort, wields a metal clipboard with an expertise rarely seen in the field, his ballpoint pen perfectly poised to write down any information at a moment’s notice.

Slimm notices one of the Bugler’s friends has established access for intermittent needle therapy on the Sniffer. The Bugler’s friend proudly turns and proclaims, loud enough for the neighbors to hear, “I gotchew an ate-teen in his raht arm.”

The Bugler interjects: “we gave him 2 of Narcan right before you pulled up.”

A look of perplexed bewilderment crosses the faces of our heroes. Slimm’s head instinctively cambers a few degrees while his brow furrows “WHY?”

“Well, cause he overdosed on cocaine. DUH.” is the reply from the Bugler.

Slimm turns to C: “I can’t man, I just…I…man, I gotta go…I’ll be in the truck” he stammers, as he turns and walks back to the ambulance with a mixture of incredulousness, disdain, and sadness.

“We got it from here, fellas” our portly hero informs the Bugler and his Nomex-clad cohorts. Turning to the Sniffer, “come on man, we better get out of here before that Narcan wears off.”

 

 

Cath lab

I’m running a call with Joe again. A little old lady fell down.

Literally.

Fire is on scene. We all mosey into the house.

“Hey, guys. Whatchagot?”

“Hey, this is Maude*. She fell right here walking to the kitchen. She has a complete heart block.”

“Okay. Is she hurting anywhere?” to Maude, “Hi. Are you hurting anywhere-”

“Dude, she has a complete heart block.”

Joe and I both notice the leads are on Maude, but not the combo pads. That, along with the fact that Maude looks like she feels better than 50 percent of us on scene, don’t worry us too much.

“Yeah, I heard you. How about we get her on the stretcher and out to the truck?”

“Man, I don’t think you understand. She has a complete heart block.

“Okay, okay. I get it. Let’s get her on the stretcher and move her to the ambulance.” Joe is good at hiding his annoyance. Very good. But someone has a point to make, apparently.

“Dude! Listen to me! You aren’t hearing me! She has a COMPLETE HEART BLOCK!”

Joe turns to the Captain on the engine, who, up to this point, has been expertly wielding the clipboard.

“Hey, man. Can y’all run out to the truck and grab the cath lab? We forgot to bring it in.”
“Dowhatnow?”

“The cath lab. I left it in the truck. Can someone run out there and get it for us? Oh, that’s right, we don’t have a cath lab in the truck. Maybe we should take her to one?”

 

*obviously I made that name up.

Sometimes we should refuse transfers

Almost once a month, I see in my Facebook feed a link to the article from several years ago in which a Florida ambulance service was ordered to pay a 10 million dollar settlement to the mother of a baby that was born in the back of one of the service’s ambulances. The mother was being transferred from one hospital to another, due to the patient’s (apparently) precipitous labor. The mother’s water broke, and the baby was delivered (and heroically resuscitated) in the back of the ambulance. Unfortunately, the baby suffers from cerebral palsy, and a jury in Florida found that the ambulance service was liable for the injuries to the baby, because they did not have the appropriate equipment on board.

I trust that the story is easy to find, and has been read by the majority of us already, so I won’t link to it here.

I’ve argued that the service never should have taken that transfer in the first place, and that the service is most certainly liable.

Most of the Facebook comments on these threads follow a common pattern; that: 1) the paramedic performed a heroic thing by resuscitating a 25-week fetus, 2) the ambulance crew should have called their supervisor or medical direction prior to taking the call, 3) shock that an ambulance service would be held liable when they saved a very difficult patient, 4) the plaintiff must be money-hungry, and 5) the ambulance service should have demanded that a hospital employee ride in the back of the ambulance with the patient.

I will never argue with anyone on the first point. I know several people who work for EVAC, though not this particular paramedic. I can only imagine the difficulty this paramedic encountered when faced with having to resuscitate a pulseless, apneic 25-week fetus with only the help of their EMT partner. This was very strong work by an EMS crew, with a much better outcome than would have occurred in a lot of other situations.

I don’t agree with calling a supervisor or medical direction. Calling a supervisor for guidance would be only minimally helpful, and a medical director phone call does nothing to remove liability from the providers. This ambulance service was most certainly liable, from the actions of the call-taker to the paramedic who accepted the transfer.

All too often, if the paramedic had refused to take this patient (as some would), they would be viewed as a “problem” employee who was “refusing to run a call.”

To address point number four, I don’t believe the mother of the baby is “money-hungry” in the least, but that she is now faced with paying for a lifetime of care for a baby who suffered injury at the hands of the ambulance service.

And to address the final point, asking for a rider from the hospital only provides the paramedic with another pair of hands. Hospitals (in my experience) are hesitant to send riders for several reasons. First, because they lose the nurse for several hours, and staffing levels are affected negatively. Second, many nurses are not protected from liability when they leave the hospital grounds. Nurses operate under a physician while in the hospital, much like paramedics operate under a physician while in the ambulance, which begs the question; which physician does a nurse riding along operate under?

Several years ago, I was called in the middle of the night to a small, rural hospital to transfer a patient to a very large hospital that was more capable of taking care of him. The patient was incredibly sick, with a PaCO2 in the 90s, with a PaO2 in the 70s. This patient was on BiPAP, and the sending hospital was absolutely bouncing off the walls to get him out of their hospital. While I was working on a critical care truck, my ventilator at the time did not have the capability to provide BiPAP. I informed the sending physician that I wasn’t able to transfer this patient in this condition, and he was apoplectic. The sending hospital was not in the position to send their BiPAP machine with me in the back of my ambulance, as it was the only one they had, and they couldn’t be without it for the 5 hour round trip.

While the physician was incredibly mad at me, I stood my ground, and he finally asked what needed to be done to have the patient transferred, and we discussed the case. The patient was sedated, paralyzed, intubated, then placed on my ventilator for the transport, which was uneventful.

When I got back to the station in the morning, my supervisor called me into the manager’s office to discuss the call. The phone call they received from the sending physician led them to believe that I did not want to run the call, and that I was rude, and incapable of handling a patient on BiPAP. After explaining the potential liability that the company would face had I transported that patient as he was, everyone agreed that I did the right thing.

I was fully prepared to walk out of that hospital that morning without a patient. I act in the patient’s best interest first, as we all should, but I also keep in mind the company’s position. Those two don’t have to be in contrast to each other. If we act for the company first, by taking the call because it is a paying patient, then that is not always in the patient’s best interest. If we do the right thing for the patient, then the company will, more often than not, be okay.

MCI review

When at an MCI, assignments are given to you. For example “take those three patients from that car right there to Local Hospital.” But we all knew that already.

When those instructions are given, it isn’t necessary for you to hang around and give scene reports to the arriving units, directing them to where their patients are.

Incident Command is the one with that responsibility.

When informed that you are to “transport them to Local Hospital,” that doesn’t mean you hang around for another 15 minutes with your thumb up your butt then ask the IC “hey, is it cool if we leave now?”

“Your ambulance should have left 15 minutes ago!”

MCIs work much, much smoother with just a tad bit of cooperation.

Phone calls

FEM/22YO/BLEEDING FROM MOUTH” says the MDT.

We arrive on scene to find a pleasant looking female, approximately the age stated on our mobile dispatch terminal thingie. We don’t notice any obvious trauma or distress, but we haven’t made it to the apartment door yet.

Slimm takes point.

Good morning, ma’am. What seems to be the problem today?” he asks.

I’ve got this thing on my mouth and it burns.”

And then we see it.

A cold sore.

I bet that burns and hurts. How long have you had it there?”

I woke up with it this morning.” (and decided that a call to 911 was in order, apparently…)

Have you tried putting anything on it?” Slimm asks, knowing full well the answer will be a resounding ‘duh, of course not.’

I don’t know what it is! Shouldn’t I see a doctor or something?!”

Well, ma’am,” Slimm replies, being the consumate professional that he is “it appears to be a cold sore. There are lots of treatment options at the pharmacy.”

What is a ‘cold sore’?”

It is a type of herpes infection. They are pretty common, actually. They usually go away in a few days, but they can come back at any time really.”

Sometime in the past few days, Slimm has become a dermatologist.

I HAVE HERPES?! ON MY FACE!?”

It really isn’t that big of a deal. Most people get them…”

OhmygodIhaveherpesonmyface!”

We are sliding quickly down the slope towards an anxiety attack.

Am I, like, contagious?

Well, yes ma’am. If you share utensils, or drinking glasses or straws, or kiss, or have oral sex, you can pass the virus to the other person.”

A gasp audible from ten yards escapes her mouth.

I need to make some phone calls…”

We make our way back to our ambulance and climb in. Slimm turns to me. “I wonder who she is going to call?”