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 New Guy

I haven’t given him a name yet, but I’m working on it.

Sort of.

Newguy seems alright by me. He’s a medic with a few years under his belt. I’m not sure I’m feeling the double-medic thing, mostly because I hate to drive.

He also hates driving.

But we spent 4 hours discussing Russell’s teapot and the barber paradox.

He likes Pink Floyd and found Malcolm Gladwell to be fascinating.

He literally has no idea where he is at any given moment, besides inside an ambulance, house, or hospital.

We’ll figure it out, though.

Ghosts

I don’t believe in ghosts, or aparitions, or supernatural beings, and I certainly don’t fancy myself a modern-day Frank Pierce, but I can’t forget these people.*

Don was a middle-aged, middle-class guy with a normal job and a normal family living in a normal house. He was having a heart attack, and had been for quite some time. He told me in the ambulance that he was going to die, and later begged me not to let him die. I told him, and his wife before we left the house, that I would take good care of him.

The next time Don’s wife saw me, I was doing chest compressions on her husband. A few days later, I saw her as I slipped into the back of the church during his funeral, but I didn’t have the courage to approach the new widow.

Julio was a precocious young boy, with the horrible diagnosis of an inoperable malignant growth in his brain. I never saw him as a playful child, but only after it was too late. His Lightning McQueen pajamas are something I will remember until my last day. I can still hear his mother’s wails of grief when I walk past that room, a room I have been in many times since.

I can’t help but cry a little bit inside when I see my own son, who is now Julio’s age, wearing those same pajamas, smiling, playing with his Lego blocks, and healthy.

Cheryl was simply getting a quick tennis game in before going home to get ready for a Junior League function. Her tennis shoes, skirt, and visor all matched, a shade of green rarely seen in nature. Her body wanted to continue playing, but her heart soon played its last beat. It happened right in front of us, we knew it was going to happen, and we were prepared. But we still failed. I know nothing else could have been done, but I also know that mine was the last face she saw.

I saw a man who was obviously her husband hurrying into the hospital while I was sitting in the ambulance, looking concerned. I reached for the door handle and briefly thought of approaching him, but once again couldn’t muster the courage.

De’Andre was much too young to make such adult decisions. Instead of choosing a movie to take a pretty girl to, he chose a life of crime, and decided to run with gangsters. Rival gangsters don’t care if you don’t have a driver’s license, and they don’t care if you have a family. De’Andre was too young, and too immature, and paid for his choices.

He cried for his momma on the way to the hospital.

I’ve talked about these people, and others, with the nice lady with the soft couch. Sometimes it helps, but mostly it’s futile. I don’t think that nice lady can understand, and I don’t think I can make her understand.

*you know these aren’t real names by now, right?

Community Paramedic programs won’t work in private EMS

Money. That’s why.

There simply isn’t a financial incentive for a private EMS service to run a community paramedic program.

Hospital-based EMS services have a financial incentive to run a community paramedic program. If the hospital-based service can reduce ER visits, and therefore reduce hospital admissions, then there is a financial incentive for them to run a community paramedic program.

Fewer chronic visitors in the hospital = more ER beds = more available inpatient beds = more insurance payments for the hospital.

Plus, with new healthcare regulations stipulating that hospitals won’t be payed for re-admissions within 30 days for the same problem, hospitals really have an incentive to reduce visits by chronic users. Visit the patient in the home, keep them at home, and they won’t come to the hospital as often.

County-based EMS services likewise have a financial incentive to run a community paramedic program. Specifically, the county third services, not fire-based services, but I will get to them.

County-based EMS services have more leeway to deny or refuse transport to patients who meet certain criteria, or at least they do where I have worked. Having trouble urinating? We aren’t gonna take you to the hospital. Can’t sleep? Take a melatonin. We aren’t taking you to the hospital. But those chronic users learn how to work the system. Having trouble urinating turns into abdominal pain with difficulty breathing. Now we have to transport. Can’t sleep turns into headaches and dizziness, or general weakness, and now we have to transport.

These patients either aren’t insured, or won’t pay their bills. If, on the off chance they are insured, reimbursement from their insurer are low, and the copay won’t be covered. Transporting these patients becomes a net loss for the county service. Keep them at home, and more units are available to transport the patients for whom reimbursement rates are higher, or who actually need an ambulance to take them to a hospital.

It seems like ‘want’ and ‘need’ have become synonymous lately.

Fire-based services also have a financial incentive to implement a community paramedic program. If the fire-based service can send a community paramedic to a chronic EMS user’s house, and keep that user from activating 911 or requesting EMS, then those EMS units are available to run more calls that actually require EMS, and it keeps other fire units in service and available for fire calls. Or the EMS calls that fire services shouldn’t be running anyways.

But the private service that operates on a ‘you call, we haul’ basis has no incentive like the other three models. There is only an incentive for the private service to transport.

Transport – get paid. Don’t transport – don’t get paid. Pretty simple.

I have worked at various private EMS services for the past 10 years, and not once have I told a person that I was not going to transport them to the hospital. Every single time someone wants to go, we put them on the cot and take them to the hospital of their choice.

If the chronic EMS user does not have insurance, or doesn’t pay for their use of EMS, then the difference becomes a tax write-off, or is covered by a government subsidy of some sort. Private services aren’t concerned with readmission penalties at hospitals, and they aren’t concerned with overburdening an already busy ER.

More paramedics in ambulances = more paramedics to transport patients. Why would a private EMS owner or manager intentionally take a paramedic off of an ambulance, and put that paramedic into a vehicle to visit patients at their homes? That goes contrary to the very mission of the private service, which is to transport anyone and everyone who wants it.

More paramedics on ambulances = more paramedics to transport patients.

I wish it weren’t this way, and I wish that community paramedic programs could flourish in a private EMS service, but I don’t see it happening.

Maybe I’m cynical, but maybe not. I would be interested to see the private EMS service that has implemented community paramedic program with success.

So long, Slimm

After three years, and thousands of calls, the end of C and Slimm is here.

Management has seen fit to end the best work relationship either one of us has ever had and give us two new partners.

We did the math a few days ago, and figured we have run 3,285 calls together. Give or take a few. That figures 6 calls per day on a 12 hour shift. We’ve run some awesome calls: together we have almost 25 saves (seriously, he is that good), delivered 5 babies, one being a set of twins, and we even made the news a few times. He looks handsome on film. I just look stupid. We’ve run the bad calls too: nasty car wrecks with fatalities, more than a handful of deceased shooting victims, both homicides and suicides, a person hit by a train, and the man who asked us not to let him die. We failed him.

It’s been more good than bad, and even through the bad times we had each other.

We’ve laughed. A lot. We’ve cried. Not really. We’ve spent dozens of hours throwing a football, and even more arguing about what to get for lunch.

We had lengthy conversations during the Presidential election, and I couldn’t win the arguments. Slimm was hung up on the Mormon thing.

So now I get a new guy. He’s from Minnesota or something like that. Some state that isn’t Mississippi, but starts with an ‘M.’ I haven’t given him a nickname yet. I guess he’s going to have to earn it.

I often call Slimm my ‘brother from another mother of a different color,’ and I mean it. Slimm has become a trusted confidante, and an even better friend. I’m sure going to miss working with him.

The Pepsi Challenge, New Coke, and Fire Department Tiered Response to EMS Calls

(I began thinking about writing this post a long time ago while reading Malcolm Gladwell’s book blink. Being from the South, I am intimately familiar with the Pepsi Challenge, and ‘New Coke’ and the ensuing disaster for Coca-Cola. I got tired of thinking about writing this post, and decided to do something about it.)

 

First, a little bit about the system in which I work: My county sends the closest fire engine to virtually every EMS-related call received in the 911 system (92% of EMS responses included an engine in 2012). That engine may be ALS or BLS, but it is always the closest engine no matter what, so ALS engines are frequently sent to BLS-level requests. The county also requires that an ALS ambulance is sent to every response, with response time requirements that don’t really matter for this discussion. For those of you familiar with ProQA, an additional ALS component is sent to every Charlie response and above, regardless of the level of care of the initial engine response.

So a 4 year old with croup in the middle of the night very well may receive three different pieces of apparatus, and between 8 and 12 responders, all because the patient is “under 15 years old” and is having “difficulty breathing” and is “making noises when he breathes.”

The citizens absolutely love this. They are just the most important thing in the world, and it only takes 3 pushes of buttons on a phone, 30 seconds with someone on the other end, and a dozen people will drop everything and rush as fast as they can to the citizen’s house.

But is it necessary?

Of course not.

I have my own issues with ProQA, or MPDS, or whatever it may be called in your area, but the bigger issue is with the tiered response.

One paramedic will do just fine, yet we find it necessary to send 3, 4, 5, and sometimes more to virtually every call.

So what does this have to do with the Pepsi Challenge? I’ll get there. But first, a little background.

In the 1970s, Coca-Cola had an almost 5-1 market share over Pepsi, and Pepsi wanted more. Like any business would. In the early 80s, the two products were virtually tied, with Coke having a 12 percent market share, and Pepsi having 11 percent. This is in spite of Coke’s wider availability and advertising spending.

Pepsi decides (brilliantly, I might add) to introduce the Pepsi Challenge, in which self-described dedicated Coke drinkers were asked to take a sip of two different beverages, in two different, unmarked cups, one containing Pepsi and the other Coke. The majority of the tasters preferred Pepsi, and the results were confirmed by Coke executives doing their own market research. Coke executives blindly ignored the inherent problem of the blind taste test, much to their later chagrin.

But why did Pepsi continue to win the Pepsi Challenge?

Because Pepsi is much, much sweeter. And the test was a sip test, or a central location test (CLT). Tasters didn’t drink and entire can, and they certainly didn’t take home an entire case to enjoy in front of the television.

So Coke decided to change. They changed their formula, after continued alterations and their own taste tests, and finally came up with a product that rivaled Pepsi. They marketed their product as New Coke.

And it was horrible. An absolute disaster.

I remember New Coke vividly. I remember people who refused to buy another Coke product until Coca-Cola Classic was brought back. People wrote letters, and executives got fired. People literally picketed in front of Coke’s headquarters. Coke was forced to tuck their tails between their legs, apologize profusely, and reinstate Coca-Cola Classic.

Only 79 days elapsed between the introduction of New Coke and the return of Coca-Cola Classic, but it was quite the time.

So what does this have to do with tiered response?

When I first started in this business, we only saw the fire department on fire-related calls. Occasionally, they were requested for extrication of victims from a motor vehicle crash, but that was not often. People called 911, asked for an ambulance, and they got an ambulance.

But now it is different. Fire departments are no longer “Fire Departments,” they are “Fire-Rescue” departments, or “Fire and EMS” departments. EMS has been taken over, and now ambulance standards are being written by NFPA.

The citizens seem to love the tiered response. As mentioned earlier, three button pushes and thirty seconds on the phone, and a dozen people will stop whatever they are doing and drive as fast as they can to get to you. All in an effort to mitigate liability, but that’s another post.

The citizens, the taxpayers, are the taste testers. They are taking a sip of this drink that is tiered response, but they aren’t being offered the alternative. This is just the way it is.

Somehow, this is going to have to change. The response that I outlined above is not just common, it is the norm. And it is a waste of money.

But money is the answer, isn’t it?

If the fire department doesn’t send their vehicles and their people to these calls, then the fire department runs a lot fewer calls. When the fire department all of a sudden runs 80 percent fewer calls, then local government wants to know why there are so many firefighters and so many pieces of apparatus for so few calls.

This tired response may not have begun to justify a larger budget, but that is certainly where it is now.

Everyone deserves better.

“Fixed it”

Slimm and I are taking some poor lady to the local rehab hospital. This poor hapless soul made the mistake of slipping on ice, and banging her head on the pavement. Now she has a tracheostomy and needs a ventilator.

Unlucky for her, she is now here.

We make our way to the room after the obligatory signing in of the patient at the front desk. Which makes no sense to me, but I’m just an ambulance driver transporter paramedic, and not a policy maker.

We hear the alarm before we make it to the room.

Slimm makes it to the door first and I can hear his eyes roll from the other end of the cot.

Inside the room is an obviously exasperated respiratory therapist, fumbling with the hospital ventilator. Obviously, something is not like it should be.

“I can’t get it to work! Something is wrong!” she says very excitedly. “I’ve never heard it do this before!”

Slimm catches my eye, and his eyes glance at the wheels of the hospital bed, and back up to mine, and I get it. Three years of silent communication are good for a partnership.

Meanwhile, the RT has reached the end of her wits. She looks like she is about to quit.

She pulls out her phone and punches the numbers violently. “SOMETHING IS WRONG WITH THE VENT IN FOUR EIGHTEEN AND I NEED ANOTHER ONE AND THERE IS A PATIENT HERE ON A VENT WITH AN AMBULANCE AND I DON’T KNOW WHAT IS WRONG WITH THIS VENT AND I KEEP HITTING ‘SILENCE’ BUT IT WON’T GO OFF AND SOMETHING IS WRONG.” she says, to someone who might have more experience in these matters.

She turns to us: “I’m going to have to go get the vent from across the hall” she says as she walks out.

Slimm’s face doesn’t move, and his eyes don’t turn. His right foot makes an almost imperceptible movement to the foot of the bed, and activates the bed’s lock.

The alarm stops. Like we both knew it would.

Our patient continues to be unconscious and unresponsive on our cot.

The respiratory therapist reappears at the door, less exasperated and more perplexed.

“What happened?” she asks.

“I fixed it.” Slimm replies. “It’s cool now.”

 

Teddy and John Grisham

Teddy* is ‘just another homeless bum’ we picked up more often than occasionally, but not enough to be classified as frequently. Just another drunk that lived in a camp behind the empty shell of a former K-Mart.

Nobody asked him about his past. He was seldom half-sober, and even more rare was a time when he was clean. There was a rumor that he came from money.

A rich aunt, or sister, or somebody in some place far away.

Teddy got taken into the hospital not too long ago, for being either drunk in public or in public drunk. It was always the same routine: someone would see Teddy stumbling along the main drag, usually near the Taco Bell that is nearby his camp, and the concerned citizen would call 911 and then go about their merry way.

For some unknown reason, this time the ER doctor actually did a work up on good ol’ Ted. Sure, he was drunk, but the tangerine-sized tumor was probably the cause of his stumbling gait and garbled speech. Sure, the point-two-six ETOH probably had something to do with it also.

The H&P only mentioned the recent discovery of his glioblastoma. There was no mention of his social history, except for a short description: “Pt. Homeless. Poor historian.”

Teddy just never talked much.

The relative was somehow contacted, and Teddy was going home. His sister, in a small suburb of a larger city up north. I don’t know if it was home or not, but it was somewhere to die. Hospice had been arranged, and now it was up to us to deliver him there.

600 miles away.

Slimm and I volunteered for the out-of-town trip without knowing who it was, or where we would be going. We enjoy taking trips, and we could both use the overtime. We are both still reeling from Christmas with a combined six children who want one of everything.

Teddy was clean and sober. His face looked defeated. He knew it was over for him, and as if he hadn’t been humiliated enough by taking rides in our ambulances over the years, covered in vomit and urine, we were now transporting him to his deathbed.

His expression gave away recognition of ours, but he didn’t say anything to us. He refused to allow us to move him to our cot, and insisted on standing under his own power and then sit down.

“I ain’t no gimp.” he gruffly mumbled.

Fifteen minutes later, we were on our way, Slimm accelerating the ambulance down the interstate on-ramp. The first set of necessary vitals had been obtained, and dutifully logged into the computer. Our patient was sufficiently comfortable on the narrow cot, and the temperature in the ambulance was acceptable.

“Teddy, I’m going to have a seat behind you if that’s alright with you. Let me know if you need anything, okay?”

His reply was unintelligible.

Several minutes later, his voice was more clear: “Whatcha reading back there?” he asked.

“John Grisham. The Broker.

“I always enjoyed Grisham. A little dramatic at times, but he writes a good page-turner.”

I didn’t know Teddy could read, much less that he cared to read.

“I was a lawyer once.” he said.

My interest piqued, I moved to the bench seat. “Oh, yeah?” I asked.

“Yeah, once. A long time ago.”

His story went on for about sixty miles. He was married, and said he made a middle-class income working as a lawyer in his town. No exciting work, just the usual stuff. Divorces, real estate, wills, the occasional drunk driver defense. He always had a drinking problem. “Started in high school, after daddy gave me a drink” he said.

His wife left him for reasons he didn’t disclose, and I didn’t pry. She took the kids and moved away. Lonely, he turned to the bottle and quickly spiraled down. He lost everything. Not that there was much of anything left to lose after his wife and children. His dad succumbed to liver cancer, his mom wasted away in a “shitty nursing home.” He lost business, and eventually his home was foreclosed on, and he was forced to live in his car, which was also eventually repossessed. Somehow he wound up in our city, and he wasn’t really sure how.

That was more than 15 years ago.

And now he was going back home, sober and dying, with his tail between his legs, and his head down in shame.

“At least I get to die with what is left of my family.” he said, more than once.

He didn’t know if his former wife or his children knew of his current whereabouts. He was convinced he was forgotten about.

He stared off out the back windows, watching cars pass on the other side of the interstate. Our conversation was over. I hadn’t talked much, but there was nothing much to say.

I went back to the captain’s chair, and my novel, seeing the words, but not reading much.

Half an hour later, he spoke up. “Hey, C?”

“Yes, sir?” I asked, moving back to the bench seat.

“I know it sounds strange, but, would you read to me? Read me some of your book?”

“Sure, I guess.” It was certainly one of the stranger requests I have ever heard. “You want me to start at the beginning, or what?”

“No, just read from wherever you are in the book. If you don’t mind.”

I didn’t mind.

I cleared my throat and took a sip of my water.

“Chapter Twelve. Marco escaped his claustrophobic room, or apartment as it was called, and went for a long walk at daybreak. The sidewalks were almost as damp as the frigid air. With a pocket map Luigi had given him, all in Italian of course, he made his way into the old city, and once past the ruins of the ancient walls at Porta San Donato, he headed west on Via Irnerio along the north edge of the university section of Bologna. The sidewalks were centuries old and covered with what appeared to be miles of arching porticoes…”

Slimm drove a little slower, and we finished the book in the ambulance, sitting in front of his sister’s driveway. Nobody was in a hurry to go inside.

I never checked up on Teddy. I know he died, but he was forgotten in my corner of the world.

There is always another Teddy.

 

*That’s not even close to his real name. Duh.

Drunk drivers belong in prison

I’ve come up with a way to truly punish drunk drivers. I think it will work.

It goes something like this.

Upon being pulled over and failing the field sobriety tests, drivers are given breathalyzer tests. If they fail the breathalyzer test, they are immediately transported to a hospital, where blood is drawn and sent to two separate labs.

If the lab reports come back and the driver was impaired, straight to jail. Period. No bail. Held until trial.

If found guilty, five years in jail for the first offense.

Do it again, and get found guilty again? Twenty years.

Third conviction? Life. No possibility of parole.

I fail to see why driving drunk isn’t treated the same as attempted manslaughter.

Drunk drivers deserve to be behind bars for a very long time.

I have a story for you if you want to try to convince me otherwise.

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.”