It’s like a Hollywood script

Finally, Slimm and I are back together. This will be our first time back on a truck together in what feels like years, but has really only been about one year.

I have to wake up 5 hours earlier than I am used to, but I think it’s worth it.

We hugged in the parking lot. It was a brief hug, but it was a hug nonetheless.

Then we got breakfast.

And our breakfast was interrupted because some guy fell out of bed. Now my gravy is going to be cold, and nobody likes cold gravy on their biscuits.

“Radio Med One.”

“MmmmGohead” I reply sleepily.

“Caller is advising agonal respirations.”

“Mmmmkay.”

I turn to Slimm. “I hope the caller is just stupid.”

“Me too, bro. Me too.”

“Radio Med One”

WHAT?! “Gohead”

“Caller advises full arrest. They are starting CPR.”

Shit.

This sucks. The sun isn’t up yet, and neither am I.

Sure enough, it’s a full arrest. The fire guy recognizes me.

“What’s up, C?” he asks as he’s doing compressions. “You pick up an extra shift?”

“Naw, man, I’m back on the truck with Slimm again. Whatcha got?”

“Glad to hear you guys are back. Wife woke up and found him here about ten minutes ago. AED says ‘no shock,’ Bubba got the LMA in, and Chester is about to start the IO.”

I feel around this guy. I don’t see any obvious trauma, but his skin sure is cyanotic. And cold. I mean, remarkably cold. Most people I have felt this cold before have either had lividity or rigor, but he has neither. He is in asystole, and his pupils are dilated and fixed.

Basically, he’s dead. But not dead enough to stop working.

“C, you want us to stop, or keep going?”

“Nah, keep going, let’s move him out into the kitchen, and we’ll work him there. We have more room there.”

Somebody gets the IO, and I see Slimm putting together the bicarb and epi. He looks over at me. “We going to do the two rounds then call it?” he asks.

“Nah, buddy. We’re gonna get him back.”

I wink. Just joking, of course.

But we did.

Five minutes later he had a pulse, was breathing on his own about ten times a minute, and had a blood pressure of 130/90.

“We have to stop doing this.”

“What? Getting people back?”

“Not that. But doing it so easily.

“They should make a movie about us.”

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.”

Psych eval

Emergency at the assisted-living facility. A little old lady “needs a psych eval” according to our dispatcher. Fire and PD are going with us as well.

Just like every other call.

Walking up to the door, we are met by a corpulent, thick-witted woman with a stack of paperwork and her singular entourage.

“What’s going on?” I ask.

“She in room two-oh-foh’” is her reply.

“Umm. Alright. Why did you call 911?” Perhaps asking the same question a different way will work.

“She been smokin’ in her room.”

Yes, ladies and gentlemen, 911 was called because a resident was smoking in her room. 3 paramedics, 3 EMTs, 2 police officers.

All for an octogenarian smoker. Who, as it turns out, was ‘smoking’ an electronic cigarette.

A long story, Part III: The Poignant Question

…continued again from the other day, and the other day’s other day…

 

So while we are all sitting in front of my friend’s garage, watching the big red truck and the small red truck pull up to the house, Bubba looks confused. I don’t have much to say, because things are going to get busy in a few seconds, and I’m trying to stay out of the way.

They unload their equipment and make their way up the driveway, introduce themselves, and begin to work on Bubba.

I’m standing somewhat back, ready to answer any questions they may have, but the situation is very well in hand. I’m not a paramedic right now, I’m just a guy standing with a patient.

I can see Bubba looking at their patches, and we all notice the ambulance’s arrival at the end of the drive.

“Y’all from the fire department?” he asks. It sounds more like “fur duhpurtment,” but we all are fluent in Southern drawl.

“Yessir, we are.”

“Well, what are y’all doing here?”

“Sir, you called nine-one-one. We come to all emergency calls.”

“Well that’s just stupid, ain’t it?”

“Why would you say that, mister Bubba?”

“I called for an ambulance, man, not a fire truck. Why did anyone send a fire truck when there wasn’t a fire?”

 

Later, I told him that I’ve been asking that same question for somewhere near fifteen years, and when he found the answer, to let me know.

A long story Part II: The Mix-up

…continued from the other day…

 

So I gave Bubba some aspirin, Vicki chilled the hell out, and we moved Bubba outside near the garage. Mainly to keep everyone away, but also to make it easier on the first responders.

Stairs and all, you know.

So the responders arrive, first the big red truck, followed by the small red truck, and then, a few minutes later, the ambulance. It was at this point that Bubba asked a very poignant, pertinent question, which I will save for tomorrow’s post.

These guys are doing the whole ALS thing to him. The guys in the small red truck leave seem anxious to leave, but the guys from the big red truck have their cardiac monitor, so they can’t go just yet.

Bubba’s getting a 12-lead.

One of the guys from the small red truck is looking at it, and he turns to one of the guys from the ambulance and says “looks like a real slow sinus brady with a real long first-degree block.”

“Hmmmm” says the ambulance man.

Mind you, I took Bubba’s pulse several minutes ago, and it was in the 80s. Bubba doesn’t look like a guy would have a “real slow sinus brady.”

“Can I see that real quick?” I ask.

One of the guys from the big red truck looks at me quizzically, as if to say “what the hell does this strange fellow want to see the EKG for?” but the ambulance guy hands it over to me, as they start to move Bubba onto the stretcher.

It’s pretty clear that it isn’t a sinus brady at all. And there isn’t a first-degree block anywhere.

I hand it back to the ambulance man. “That rate is somewhere near 80, and there isn’t a first-degree block.”

Before the ambulance man and the man from the small red truck can lecture me on how they know how to read an EKG, and I’m just some doofus with a party hat, I point out the answer printed right there on their paper.

“Your printer speed is set to fifty.”

He looks like I just explained string theory.

“Normal is twenty-five.”

“…Oh…”

 

A long story, Part I: The Freak-out

So, I’m visiting a friend’s house for a child’s birthday. I know what you’re thinking: I don’t have any friends. And you are right. Sort of. I have, like, three. And I was at the home of one of them.

His father-in-law was also there. A large, hulking man, built like a defensive lineman. Sort of like a big square with legs.

He comes up to me, and kind of hushed, says “my chest feels a little tight, C. What do you think I should do?”

I ask him about his medical history and all that good jazz. He’s 62, mildly overweight, hypertensive, with high cholesterol. He had a normal stress test a few months ago, and his EKG was “normal” according to the doctors. He’s never had a heart cath, or a heart attack, or anything major happen to him. He takes his medications regularly like he is supposed to, and everything is managed appropriately.

Our conversation is noticed, and his wife comes over and wants to know what’s going on. “My chest feels a little funny, I was just talking to C about what I should do” he tells her.

The next few minutes saw his wife almost have a syncopal episode, fan herself with a paper plate, say “lawdy jeezus” at least three times, and she summoned no fewer than two of her middle-aged concerned friends over. The next conversation went something like this:

“What should we do?”

“Probably put him in a car and take him to the hospital.”

“We should take him to an urgent care center!”

“Urgent care would be a waste of your time. Go to an Emergency Room.”

“Should we call 911?”

“No, just leave now and go to the hospital right up the-”

“I’m calling 911!”
“There isn’t really any need for that, he could be at the hospital before-”

“VICKI! CALL NINE-ONE-ONE! BUBBA’S HAVIN A HARTATTACK!”

“I really think that he would get there quicker if you just drove to the hospital yoursel-”

“BUT HE NEEDS PARAMEDICS! VICKI! WHERE’S THE AMBULANCE!”

“You do realize that I am a paramedic, right?”

“Yeah, but you aren’t working right now!”

 

I sighed, went off to find some aspirin, and sat down to wait.

 

To be continued…

These people got lights and siren responses

These are calls I have heard dispatched over the radio, or ran myself in the past few weeks or so since the implementation of the new policy that requires an “emergent response to all requests for services generated through the 911 system.”

  • A male with CHF who just got out of the hospital and wants to know how to take his meds.
  • A female with a swollen knuckle who can’t get her ring off (the ring isn’t stuck, her knuckle is just swollen.
  • A female who is depressed and ‘wants to talk to someone.’
  • A male in the waiting room of the emergency room who has been waiting too long and wants to go to another hospital.
  • A female who ‘has anxiety and witnessed an accident and is now having a panic attack.’
  • A male who ran out of gas on the interstate and is demanding PD drive him 40 miles home, but now PD wants EMS there.
  • A  very elderly male who is dead in bed, cold to the touch and stiff, with family refusing CPR instructions.*
  • A female who wants her blood pressure checked.
  • A school bus with 14 children on it was struck by the arm of an apartment complex gate. There are no injuries on the bus.
  • A male who was in a fight last week, and now has a swollen hand.
  • A male sitting behind a strip mall, dirty, and talking to himself.

There were others, but these are just the highlights.

But we want people to take us seriously.

*I sort of understand this one, but in reality, this family just needs a coroner.

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.

Yes, Community Medics

I’ve been low on blogging inspiration, so a big thanks to Mr. Morse for his post on Community Paramedicine. He seems not to care for it much, and lists 10 of his top reasons why.

My reply to his ten reasons:

  1. I may not know much about insulin pumps and how best to maintain proper insulin levels, but I want to learn. I don’t care to learn about how to perform high-angle rescues, but I won’t put down the person who wants to learn how.
  1. The emotional well-being of our patients should be a priority of ours. This includes counseling drug addicts, or at least referring them to the persons who can provide them with adequate psychological care. When we revive a heroin overdose, do we just spend the next several minutes ignoring the patient in the back of the ambulance? Or do we initiate a conversation with the patient?
  1. See #10. Why are we afraid to learn about drugs and therapeutic regimens?
  1. “Ambulance” is not synonymous with “Paramedic.” If a registered nurse can provide the same level, or higher level of care than a paramedic, then why are we concerned? Isn’t the care of the patient our foremost concern?
  1. I don’t see this as a “cradle to grave government funded approach to healthcare” at all. Even though Congress and our President would disagree with me. But I also work for a private service.
  1. It probably takes more thought to learn how to counsel people on how to avoid things that may trigger allergic reactions. We might as well stick with what we know, right? See # 10 and # 8.
  1. I also like nurses. Especially pretty ones who smile and talk to me. Nurses like what I do as a community paramedic, because I can reduce their workload. If I can prevent one readmit to the Emergency Room, that makes triage times quicker, allows nurses to focus more on their patients since they have less of a workload, and can raise reimbursement rates for the hospitals.
  1. At least 80% of our job consists of responding to non-acute problems. But yes, we should forget about that 80 percent and instead focus on the remaining 20. I work in a very busy area of the country, and probably run one or two true emergencies per month.
  1. Why would the concerns of another group be a concern of the community paramedic? There is a void in healthcare, and nobody is stepping in to fill it. Paramedics already work in the community, and are a logical solution to the puzzle.
  1. Ah, yes, the image of EMS.  Maybe, just maybe, members of the community will see the paramedics in a different light: perhaps they will have the image of the paramedic that is willing to make appointments to follow-up, check-up, and to help them meet their healthcare needs.

He is right, we should “be excellent at what you do, and respect those who are excellent at what they do.” Mr. Morse seems to only focus on one-third of the initials in our profession: the “E.”

Emergencies is what we do. But we also do Medical Services. There is a huge gap in our healthcare system, and we are positioned to fill that gap.

We should be more invested in the health and well-being of the members of our community. We should be proactive and prevent emergencies from happening, instead of reacting to them.

Community Paramedicine isn’t just about checking insulin pumps or reconciling med lists. It is about preventing the little old lady from the fall, and answering questions, and so much more. It is about keeping people from needing the trip to the Emergency Room. I believe community medicine will play a large part of the future of EMS and healthcare in general.

We can either lead or follow.

Those who don’t want to lead, and aren’t willing to follow, should simply get out of the way.

Things I said today

“I really like this crown molding. Do you think I could get your carpenter’s name and number later? Now, which hospital do you want to go to?”

“She really doesn’t have room to call anyone racist. There’s a framed picture of Huey Newton hanging on her wall.”

“I don’t know what it is. Call it atrial bigeminy. That should confuse them long enough.”

“No sir, I don’t want to see your testicles. I believe you.”

“I’m sorry you are having a bad day. Perhaps you shouldn’t have come to work?”

“Dude, we just hiked half a mile in 90 degree heat to get to you; you’re going to the hospital.”

 

It was a busy day.