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.

“Yeah, but…”

I’m doing an ACLS check-off for a group of physicians as part of their biannual renewal. It is some of the easiest work I have ever done, and I have a blast doing it.

I give the delightful gastroenterologist his scenario, a middle-aged male who is waking up from his lower GI study. He doesn’t feel good, and it is only going to get worse from here.

Doctor Endoscopy asks for a set of vitals, and learns the patient is hypotensive, bradycardic, with pale, diaphoretic skin, and very weak.

“Okay, I want to put him on the cardiac monitor.”

“Sure thing. That’s what you get when you turn on the monitor” I say, as I press the button on the rhythm generator that hints it will display something resembling a a complete heart block.

“That is a third-degree heart block. I need someone to start an IV, and put the pacing pads on him.”

“Okay, your secretary has started an IV, and the janitor has applied the pacing pads.”

“Okay, I want to give point-five milligrams of atropine.”

“Are you sure?”

“Yes.”

I pause the scenario, as best as a scenario can be paused. “Um, atropine isn’t going to work in a complete heart block.”

“Well, I’m the doctor, and that’s what I want to give.”

“Yeah, but…”

A conversation about plethysmography

“What’s that?” asks a student on another ambulance, pointing to my cardiac monitor.

“It is the plethysmograph” I replied, most likely butchering the pronunciation.

“What’s it for?”

—–

After dropping my patient off, I made my way back to the EMS room where I found the student. It turned out he is a paramedic student, just finishing up his intern rides. He has a few weeks to go before he takes his exam. He has been an EMT for roughly 4 years, and by all accounts, is a good student, and a fast learner.

The fact that he asked a paramedic whom he didn’t know bodes well for him. He is engaged, and wants to learn.

We spent the next 15 minutes or so discussing the plethysmograph and its usefulness in assessing patients. What struck me most about our conversation was the fact that he had no idea whatsoever that there was even such a thing, much less that it could be used to assess patients.

We talked about how vasoconstriction can cause an increase in amplitude, and what could cause vasoconstriction. We talked about how vasodilation would cause a decrease in amplitude, and the causes of vasodilation.

We discussed how waveforms would change in a hypertensive patient with chest pain to whom we were administering nitroglycerin. The mechanism of nitro’s action, in decreasing systemic vascular resistance through causing vasodilation. It seemed to make sense how waveforms would change, and how that was directly related to afterload.

My patient happened to be septic, and I could show him how plethysmography could help confirm that diagnosis. My patient was an infirm older woman who had a mildly altered mental status, hypotension, and some mild tachycardia. The fact that she had a chronic Foley catheter with cloudy urine in the bag made the diagnosis of a UTI fairly easy, but the plethysmograph showed a very deep, prominent dicrotic notch.

He asked, appropriately, how the waveform would help me in my assessment, and I explained that the deep dicrotic notch showed me a low SVR, and there was no need to assess orthostatic vital signs.

He was receptive, inquisitive, and it was a refreshing conversation.

—–

I’m just a regular paramedic, and nothing special. I only learned about this stuff because I asked and because I wanted to learn. I enjoy showing students, and other EMS personnel, things that I have learned along the way, and I enjoy learning from others. Our education doesn’t stop when we get that paramedic patch, it begins.

What is disheartening is the fact that a paramedic student, only weeks away from testing to become a paramedic, had never heard of a plethysmograph, a dicrotic notch, and did not understand the relationship between waveforms and vascular resistance.

We have a very, very long way to go in the education of our paramedic students.

 

The student and the hurt feelings

I hurt that poor paramedic student’s feelings today. Poor guy. I’m always cordial with students, and nice as I can be. But I was apparently very mean today.

First, I hurt his feelings when I suggested he get some real-world experience as an EMT before even thinking about taking the National Registry exam for paramedic. I know the commercials on late-night TV make this job look easy, and they tell you that you won’t get judged for not working on an ambulance until you have “P” on your patch, but that’s not true.

Then I hurt his feelings when I wrote in his evaluation something along the lines of “there is a lot that happens in the back of the ambulance, but this student wouldn’t know, since he spent the entire 12 hours napping, playing on Facebook, or staring out the back of the ambulance with his hands in his pockets. I guess my suggestion that he spend his time asking questions or reading his book didn’t go over too well.

I hurt his feelings once more when I suggested that he could start an IV if he wanted to, but he had to actually want to try and that it would be his responsibility if (God help us, when) he becomes a paramedic.

And lastly, I hurt his feelings when I suggested his bedside manor was more in line with someone who made a living selling used clothes on eBay.

This ain’t no Sadie Hawkins dance. I’m not going to grab your hand and tell you what to do.

Poor guy. I guess his complaint was warranted, after all.

Do your time first, hero

I can remember the day I first started in EMS like it was yesterday. It was a brisk November morning about 15 years ago. I was really excited to save lives and be a hero and get on the news, and all that. I had a fancy stethoscope that I bought at the College’s bookstore (for like $10! What a deal!) around my neck, a neat black glove pouch on my belt, and a nice trauma shear/bandage scissor combo that I had in my right leg pocket.

I was a hero.

I was also too young to buy alcohol, so cut me some slack, okay?

As I strode into the station, I admired the sharp creases that I had spent countless minutes and an immeasurable amount of starch ironing into my patches. Then I saw him: my new partner.

He was about six-three, and easily weighed three hundred pounds. And it wasn’t necessarily “fat” pounds, either. This guy was built like a defensive end. And his face was mean, too.

“Damnit. Another new kid! They always put me with the new kids.” were the first words out of his mouth. He sounded, in a word, angry.

“Hi, I’m C” I introduced myself in an effort to break some ice.

“I don’t care who you are, or what you think. Keep your mouth shut and do what I say, and you will do just fine.” was his reply.

While his reply was gruff, I listened to it, and heeded his advice. I kept my mouth shut, and I did what he said, and we got along great. He taught me a lot, and I am grateful for his tutelage. I didn’t get my feelings hurt, and I wasn’t offended by his manner. I was really okay with it. He was the veteran, and I was the rookie, so I knew he could teach me a thing or two, perhaps even three.

But nowadays you can’t get away with that. You have to treat the kids with the “kid gloves.” You have to be all tactful and mindful of the self-esteem of the new kids. Especially when they are kids.

Saying something like “I’ve been doing this since you were in Kindergarten, and we need to do things a certain way” can’t be said. Because the new kid runs to the supervisors and tattles on you, saying “he was really mean to me and hurt my feelings, and I need to cry about it a little bit, but he needs to get in trouble!”

There is a lot that the new people could learn from those that have been around for a long time. It’s just too bad that I have to be concerned with someone’s feelings. Especially when I have been in EMS since they were in Kindergarten.

How an intern got sent home

Over a delicious, yet artery clogging breakfast, our student rider tells us his story: always wanted to be a fireman, but only has a real chance of getting hired if he is a paramedic first, finished EMT school and was signed up for paramedic school before taking National Registry, never worked a single day aside from intern rides on an ambulance, and 9 months into his 13 month paramedic program. Already got all the alphabet cards, CPR, ACLS, PALS, PHTLS, NRP, yada, yada, yada.

Slimm gives me the side-eye that tells me not to pre-judge this kid. I nod and shrug my shoulders in response, and the “okay, whatever…” message is received.

Whatever.

It’s a quiet day so far and there isn’t much for the kid to do.

Until some helmet-less skateboarder face plants after trying to jump over at least a dozen stairs.

Seriously, if it weren’t for alcohol, genetics, or stupidity…

This is a messed up skater. Smashed face, extremities angled in ways they shouldn’t be, a chest that doesn’t rise symmetrically, an altered mental status, and irregular respirations, with blood and teeth filling the airway.

“Slimm, toss me the airway bag and suction, lets check out that chest, and cut these clothes off. Kid, I need a good rapid trauma assessment” I call out as we walk up, with first responders several minutes away.

The kid doesn’t move.

“Buddy, I need some help here. Rapid trauma assessment. Cut those clothes off, please.”

While Slimm assists ventilations, the airway has been suctioned, several teeth removed, and the airway secured with an OPA while I am preparing my intubation equipment.

Kid is still standing there.

“Cut this shirt off, please” I say, attempting to convey just a little more authority in my voice. “He’s probably going to have a pneumo we need to stabilize, if not a big flail segment.”

Hesitantly, he begins to cut the shirt off, seemingly taking the time to sever each and every thread individually. Meanwhile, the tube is in, first responders have arrived, and Slimm takes over the duties requiring the shears, and confirming both a large flail segment and absent breath sounds on the affected side.

The rest of the trip is a whirlwind of activity with a paramedic from the fire engine riding in back with myself and the kid, and the now unconscious patient. It is a short trip to the trauma center, and the hand off is smooth.

“What was that back there about, man? We needed some help, man!” asks/exclaims my trusty partner. “Where were you at?” Slimm is typically very quiet, and raising his voice is very out of character for him.

“I’m just here to watch, man.” is the kid’s reply.

“No, you aren’t. You are here to learn and take care of patients with us.” is my reply.

“Who told you that you were here to watch?” is the quizzical response from the thin, short, obviously irritated partner of mine.

“That’s just what I’m here for. I don’t really want to be a paramedic, anyway. I just want to be a fireman.”

Slimm turned and walked away. He had nothing more to say to the kid, but says to me: “Back to the station, man. We are going back to the station.” It was a quiet ride, with Axl Rose providing the soundtrack to the tense situation.

Next stop: the station, to the parking lot, more specifically.

 

 

Things that bother me: Lazy students

I loathe the lazy student. Seriously, education costs money, be it is your money or money belonging to someone else.

Students should have more respect for themselves and/or others.

Every once in a while, about 10 percent of the time, I will have a student third rider who doesn’t want to do anything. They don’t want to start an IV because they “don’t want to miss” or they are scared to touch people.

That’s what we do. You can’t get good at starting an IV if you never miss, and you can’t be any sort of competent provider if you don’t touch people. A large part of what we do is learned through trial and error.

Anyone else remember MAST trousers, or the blind administration of bicarb, or atropine in asystole?

The students who come to me for tutoring that are lazy bother the crap out of me as well.

Without fail, the lazy ones never studied in school, and usually don’t care. I usually get the same story time after time:

“I failed National Registry, and have to pass the next time, or I don’t have a job.”

Then they balk when I give them reading assignments and tests to take home. Like they can’t find 12 hours over the next 7 days to dedicate to studying.

I know that studying takes time, and lives are busy these days. People have full-time jobs, and kids, and other responsibilities, but if you can’t make school a priority, then you shouldn’t be surprised when you fail.

I have a house, and a full-time job, and a part-time job, and two children, and a wife, and I run a business as well. I make studying and reading a priority because it is important to me to be the best paramedic that I can possibly be.

If you can’t put your education near the top of your priorities, how can you expect to have any notion of a successful career in the back of an ambulance?

ACLS megacode fail

Recently, during a private ACLS class for a few members of a local ambulance service, I ran into a scenario which I had never seen before.

I’ve been teaching ACLS for about 4 years now, give or take a few months. I am in the (admittedly bad) habit of using the same scenario for my mega-code. It is the same scenario which my paramedic instructor used the first time I took ACLS.

A husband (or wife, or daughter, or boy/girl friend) was driving his/her wife (husband, father, mother, lover, landlord) to the hospital because he/she was complaining of chest pain. They find your ambulance/fire truck at an intersection/fire station, doughnut shop, and pull up to you. The driver states the patient suddenly became unconscious while enroute to St. Elsewhere. “Go!”

The first few students went through the scenario, and miraculously saved the patient’s life. Well done, ambulance technician, well done. The last two were remarkably different. Once “go” had been uttered, it got strange.

“Okay, lets get him out of the car, and on to the ground. I have my gloves on. Is the patient breathing?”

“No, he is not breathing.”

“Okay, lets put in an oral airway and begin bagging him with 100% O2 at a rate of 14. Call for backup”

“Ventilations are being delivered. Additional help is on the way.”

“Does he have a pulse?”

“He does not have a pulse.”

“Okay, let’s start chest compressions at a rate of no less than 100, 2 inches deep.”

“Compressions are being done, and a pulse is palpable at the carotids with each compression.”

“Let’s put the AED on the patient and press ‘analyze’.”

“The AED is on the patient, and after analyzing, it says “Shock advised.”

“Deliver the shock, and re-check the pulse.”

“The shock is delivered, the AED says ‘no shock advised’ now, and the patient does not have a pulse.”

“Okay, I’m going to have my partner attempt an IV or establish IO access to the anterior tibial tuberosity.”

“IO access is obtained without difficulty, and with good flow noted.”

“Okay, how far away is my backup?”

“Your backup is 4 minutes away.”

“Okay, let’s continue BLS until they get here.”

 

At this point, I am literally speechless. This is a person with a paramedic license, mind you. I have delivered this scenario literally a hundred different times. Had this scenario been run the way it virtually always is, they would have seen pulseless ventricular tachycardia on the monitor, defibrillated, seen asystole, given epinephrine 1:10,000, then seen ventricular fibrillation, defibrillated unsuccessfully, pushed 300mg amiodarone, defibrillated, then seen a sinus rhythm with a pulse at a rate of 70, then they would have hung an amiodarone infusion, and the patient would have awakened on the way to the hospital. But, alas, that was not done. And the hypothetical patient had a hypothetical bad outcome.

 

“I’m sorry, could you show me in the ACLS textbook where they advocate continuing BLS until firefighters arrive?”

“Oh, it probably doesn’t say that in the book, but that’s how we do it where we work.”

“Interesting. Unfortunately, I cannot pass you, and suggest that you read the textbook again, and obtain your ACLS card elsewhere.”

I am interested to know where, or if, this student actually passed ACLS, and am also interested to know what the student’s supervisor/training director would have thought had they been there to witness this horrible ACLS failure.

Old-school assessments

When I first started this field, we didn’t have the luxury of a pulse oximeter in the field. The concept was hardly new, as it was being used frequently in emergency rooms and operating rooms.

Now, it has become the “sixth” vital sign, along with pulse rate, blood pressure, respirations, mental status, and blood glucose.

We used to actually assess the patient’s work of breathing, skin color, temp, and moisture, along with capillary refill time. Does anyone else remember “CRT is less than 2?” You know, squeezing the patient’s fingernail, or touching their forehead, and counting how long it took for color to return?

CRT, skin, and work of breathing can tell you a whole lot more about a patient’s status than a pulse-ox ever could. And don’t even get me started on using the pulse-ox to count a pulse.

I rarely use pulse oximetry to guide my application of oxygen. If I have a patient with a known history of emphysema, breathing 20 times a minute, with no distress, with clear breath sounds, and no accessory muscle usage, chances are that patient does not need a non-rebreather simply because “their O2 sat is 90.”

I am much more concerned with the end-tidal CO2 on the emphysema patient than I am with the pulse oximetry.

Using pulse oximetry can be valuable, but all too often, it is used in place of a good assessment, and that’s just plain lazy.

How to be an EMT student

We all had to do intern time, third rides, student rides, ride-alongs, whatever you want to call it. When I was doing my third rides, we had a 4 hour class devoted to how we were to present ourselves and behave during our rides. Obviously, students these days do not go through a similar orientation. So, allow me to give upcoming students some hints.

 

Several points for students:

 

  • Getting to your scheduled third ride on time is probably the most important thing you can do. I know this is early in the morning and all. You had all weekend to prepare for this ride. Perhaps you shouldn’t have stayed up to watch the Jets beat the Ravens. We show up 15 minutes prior to our shift time, so we can check our truck off and restock as needed. More on that in a minute.
  • Please don’t show up with your shirt untucked and yawning. This is a serious business, and I’m not going to take you seriously if you look like crap. I know you are tired from watching the aforementioned Sunday Night Football game, but suck it up and wake up.
  • Don’t show up here with a cigarette in your mouth. We aren’t allowed to smoke on company property, or hospital grounds, for that matter. Which means you will have precious little time to smoke your cigarettes. So give it up for a day.  As a former smoker, I know how tasty cigarettes can be in the morning.  But people won’t take you seriously if you smell like an ashtray.  Just don’t smoke.  It’s 12 hours.  You can do it.
  • Help my partner and I check off the truck. If I ask you for the nasal airways, I need you to know which cabinet they are in. (The answer is cabinet 2, by the way.)  We don’t necessarily like checking the truck off, but it’s a necessary part of the job. Your willingness to help will go a long way.
  • Bring your book. Or notebook. Bring something to read aside from some wrestling magazines.
  • Shave. ‘Nuff said.
  • Don’t butt in to my assessments and conversations with patients, family members and other first responders. I didn’t ask when the last time the lady who twisted her ankle ate, because I don’t care, and it’s not pertinent. Especially not before we determine the extent of her injury.
  • Perform your own assessments. Our patient’s won’t mind if you ask them the same questions I already have. They tend to know that you are a student, usually your big name badge that says “EMT STUDENT” gives it away. Performing your assessments on your own, and obtaining your own vitals (like, acutally listening to vital signs and blood pressures) will only reinforce your routine, and make you better once you finish school.
  • The time to discuss the call, why things were done, or in a certain way, is after the call. I promise, I will answer all your questions, and we can discuss anything you want. In the back of the ambulance is not the best time to ask what valacyclovir is used for. (She’s not so cute now, is she?)
  • Talk to your teacher about rescheduling your third rides. I understand that you have only 9 months to get your rides in, but that is a big part of the problem, and you are only contributing to it. There is absolutely no reason for your to come to a third ride before you can perform the most basic of EMT interventions. For paramedic students, you should have CPR, ACLS, PALS, and PHTLS cards before you schedule a ride.
  • Help my partner. When we turn over a patient, I have things I have to get done, such as obtaining signatures, and some minor documentation. There isn’t much reason for you to shadow me while I do these things. Slimm has to prepare the stretcher for the next call, restock the supplies we used, and generally tidy up the truck. Go help him, and he will teach you how to be a good EMT, and more importantly, how to be a good partner.
  • Help both of us. We spend 12 hours in this truck, and there are various things we have to restock, clean, remove or replace at the end of a shift. I know you don’t work here, but sticking a piece of paper in my face before the truck is cleaned and restocked, and demanding my signature, will only make you wait longer to be able to go home.

 

Please understand that I really do enjoy having student third riders in my ambulance. I remember fondly the third rides I did when I was in EMT school, and how new and foreign all this stuff was. I looked up to my paramedic and EMT preceptors, and I was lucky that they were kind and patient with me.  It was made perfectly clear that I was the new guy, and I was an immigrant in a foreign land. My preceptors guided me, and showed me the ropes. I will be happy to do the same, but you are going to have to at least try and show a modicum of respect for this business.

 

Let’s do better next time, mmmkay?