Just a brief post. (Internet access is $7.50 for 15 minutes.) Interesting conference. I just got out of the Capnography class and it was great. I made some notes and will be posting when I return. I was on the EXPO floor yesterday and it was mind-numbing. EMS is such a huge business. So many gadgets and training programs and consultants. I felkt like I was in a Tijuana market and I was trying to walk through without making eye contact with any of the vendors.
I should post next with a recap of my trip on Sunday.
Thursday, September 28, 2006
Tuesday, September 26, 2006
I'm headed out to Las Vegas for the 2006 EMS EXPO.
I'm planning on attending two of the three conference days, and then spending the third day playing poker and attending the Jeff Beck concert at the House of Blues that night. I also want to get in some baking in the desert sun pool time.
The highlight of the trip for me will be the capnography class by Baruch Krauss.
Session 702: Full-Spectrum Capnography in EMS
Baruch Krauss, MD, EdM, FAAP, FACEP
ALS Track
"This class provides in-depth training in the use of capnography for: rapid assessment and triage of critically ill patients, verification of ETT placement, continuous monitoring of tube position, cardiac arrest, head trauma, chemical terrorism, asthma, COPD, seizures, alcohol and drug intoxication, diabetes and shock states."
I'm planning on attending two of the three conference days, and then spending the third day playing poker and attending the Jeff Beck concert at the House of Blues that night. I also want to get in some baking in the desert sun pool time.
The highlight of the trip for me will be the capnography class by Baruch Krauss.
Session 702: Full-Spectrum Capnography in EMS
Baruch Krauss, MD, EdM, FAAP, FACEP
ALS Track
"This class provides in-depth training in the use of capnography for: rapid assessment and triage of critically ill patients, verification of ETT placement, continuous monitoring of tube position, cardiac arrest, head trauma, chemical terrorism, asthma, COPD, seizures, alcohol and drug intoxication, diabetes and shock states."
Sunday, September 24, 2006
Mortal Men (Chapters 16-20)
Five new chapters added to Mortal Men. It will probably be a couple weeks before I add anymore because in the next section I have to insert two new chapters which are as yet unwritten.
Saturday, September 23, 2006
A Life
I recently did a presumption. A sixty-eight year old man found cold and stiff in bed in his one bedroom apartment in an elderly housing complex in town. He died sometime during the night, curled on his side, his head pressed against the pillow, a quilt pulled up to his neck. I couldn’t imagine a more comfortable position to enter the big sleep in.
The officer on scene can only find the man’s name on an envelope. After I put the leads on the body and run my six second strip of asystole, and then announce the time, we help the officer search the apartment for a date of birth and a doctor’s name. The apartment is clean and ordered – it looks like he hasn’t lived there long. On the wall are pictures of a little girl from birth to maybe four, big framed portrait type pictures. There is even a picture of her sitting on Santa Claus’s knee. At first I think it might be pictures of all his grandchildren, but after looking closer, it is the same girl. “Check this out,” the officer says, looking in the man’s bureau. The top drawer is piled high in three neat rows with folded white briefs. The second drawer is the same. The third drawer contains neatly folded stacked long underwear; the fourth drawer, white tee-shirts. To the side of the bureau is a plastic garbage bag with more white undergarments.
In the bathroom closet, there are stacks of Ivory soap, piled ten bars high. In the kitchen cabinets, cans of Chef Boyardee ravioli are neatly stacked in three rows three tall, three deep. There are three identical bottles of Aunt Jemima maple syrup. Three boxes of pancake mix.
On top of the refrigerator are three pairs of worn baby shoes, each size slightly bigger than the preceding.
In the refrigerator is sausage, three sticks of butter, orange juice and milk.
Still no vial of life, no meds, no paper with a doctor’s name.
In the bedroom we find a plastic filing bin. We open it on the kitchen table. More photos -- all of the same little girl who never appears more than four or five years old. There are lab results from the doctor’s office – pediatric clinic. The girl’s HIV tests are negative. There is a copy of her birth certificate – dated 1995. There are copies of police reports. Domestic violence. Restraining orders. All from 1997-1999. We get the man's date of birth from one of the police documents. We crosscheck the mother’s name and the child’s name with a few names scrawled on pieces of paper by the phone, but there is no match.
The officer finds some medication – but it is just a physician’s sample – Viagra – in a cabinet by the easy chair which faces the TV. Next to the sample are five aged Polaroid’s – A tall thin woman in her late thirties or maybe younger with hard years accounting for the lines in her face and the darkened eyes. In the first photo she is lifting up her tank top to reveal large oval shaped breasts. In the next, she has one of the breasts lifted up to her mouth as she licks it with her tongue. The next shows her on the bed with her legs open. The fourth is a close-up shot.
We finally find some medication wrapped in a CVS bag shoved in the back of a drawer. Zoloft and Aricept. Zoloft, of course, is an antidepressant. Aricept is for Alzheimer’s.
The officer writes down the prescribing physician’s name, and then calls the Medical examiner’s office. We walk out passing some of the deseased's neighbors in the lobby who are speaking in hushed tones about the goings on in the man’s apartment this morning. He just moved in recently, I can hear them say, they really don’t know much about him.
The officer on scene can only find the man’s name on an envelope. After I put the leads on the body and run my six second strip of asystole, and then announce the time, we help the officer search the apartment for a date of birth and a doctor’s name. The apartment is clean and ordered – it looks like he hasn’t lived there long. On the wall are pictures of a little girl from birth to maybe four, big framed portrait type pictures. There is even a picture of her sitting on Santa Claus’s knee. At first I think it might be pictures of all his grandchildren, but after looking closer, it is the same girl. “Check this out,” the officer says, looking in the man’s bureau. The top drawer is piled high in three neat rows with folded white briefs. The second drawer is the same. The third drawer contains neatly folded stacked long underwear; the fourth drawer, white tee-shirts. To the side of the bureau is a plastic garbage bag with more white undergarments.
In the bathroom closet, there are stacks of Ivory soap, piled ten bars high. In the kitchen cabinets, cans of Chef Boyardee ravioli are neatly stacked in three rows three tall, three deep. There are three identical bottles of Aunt Jemima maple syrup. Three boxes of pancake mix.
On top of the refrigerator are three pairs of worn baby shoes, each size slightly bigger than the preceding.
In the refrigerator is sausage, three sticks of butter, orange juice and milk.
Still no vial of life, no meds, no paper with a doctor’s name.
In the bedroom we find a plastic filing bin. We open it on the kitchen table. More photos -- all of the same little girl who never appears more than four or five years old. There are lab results from the doctor’s office – pediatric clinic. The girl’s HIV tests are negative. There is a copy of her birth certificate – dated 1995. There are copies of police reports. Domestic violence. Restraining orders. All from 1997-1999. We get the man's date of birth from one of the police documents. We crosscheck the mother’s name and the child’s name with a few names scrawled on pieces of paper by the phone, but there is no match.
The officer finds some medication – but it is just a physician’s sample – Viagra – in a cabinet by the easy chair which faces the TV. Next to the sample are five aged Polaroid’s – A tall thin woman in her late thirties or maybe younger with hard years accounting for the lines in her face and the darkened eyes. In the first photo she is lifting up her tank top to reveal large oval shaped breasts. In the next, she has one of the breasts lifted up to her mouth as she licks it with her tongue. The next shows her on the bed with her legs open. The fourth is a close-up shot.
We finally find some medication wrapped in a CVS bag shoved in the back of a drawer. Zoloft and Aricept. Zoloft, of course, is an antidepressant. Aricept is for Alzheimer’s.
The officer writes down the prescribing physician’s name, and then calls the Medical examiner’s office. We walk out passing some of the deseased's neighbors in the lobby who are speaking in hushed tones about the goings on in the man’s apartment this morning. He just moved in recently, I can hear them say, they really don’t know much about him.
Friday, September 22, 2006
Hacking
We spent the first three hours of the shift covering a suburban town while their ambulance was on a call. There were reports of gunshots in the city, but when the ambulance got there the supposed victim had fled. Nothing else was going on anywhere, so it wasn’t like we missed a lot.
My preceptee and I went over various drugs and situations. I was really hoping we would get him a bad trauma to put him over the top. Don’t worry about the IV, I said, get the patient on the board, on the stretcher, on the way to the hospital, protect the airway, and get the patient stripped. I told him about how I always preach the IV only comes when everything else is done. I told him how one of my preceptees we had gone over that time and time again and then on our first big trauma, the first thing she did, the very first thing, was to put a sixteen in the man’s arm. No BP, no survey, no oxygen, nothing. She just jabbed him with a sixteen. She hadn’t even spiked a bag. She realized what she’d done and she’d looked at me for help, and I was just shaking my head. The large bore on the trauma is a powerful urge.
But there was no trauma call coming for us. We were sent back to the city and were given a GI bleed at the nursing home. Then it was back to posting, waiting.
Twenty two minutes before our crew change and two minutes before we normally are sent in, they gave us a colds and flu call. A healthy four year old who vomited an hour earlier. His mother wanted him checked even though he was playing with his toys when we got there. We transported to the children’s hospital on the other side of town. I’d been keeping my cough pretty well under control, but then a couple blocks from the hospital, I just started hacking away in the driver’s seat. I was hacking so hard, my brain hurt from all its rattling around inside my skull. When we got to the hospital, I got out and opened up the back door, and helped the mother waddle down.
She looked at me and said, “Maybe you ought to be the one seeing a doctor.”
I was tempted to say, “Yeah, maybe I ought to call an ambulance to take me to the hospital.” But I try not to be a wise guy. I just gave her a tired nod.
I didn’t punch out till quarter to one this morning.
They wanted me to come in to work today, but I said, no. I need the day off. I’m still run down.
My preceptee and I went over various drugs and situations. I was really hoping we would get him a bad trauma to put him over the top. Don’t worry about the IV, I said, get the patient on the board, on the stretcher, on the way to the hospital, protect the airway, and get the patient stripped. I told him about how I always preach the IV only comes when everything else is done. I told him how one of my preceptees we had gone over that time and time again and then on our first big trauma, the first thing she did, the very first thing, was to put a sixteen in the man’s arm. No BP, no survey, no oxygen, nothing. She just jabbed him with a sixteen. She hadn’t even spiked a bag. She realized what she’d done and she’d looked at me for help, and I was just shaking my head. The large bore on the trauma is a powerful urge.
But there was no trauma call coming for us. We were sent back to the city and were given a GI bleed at the nursing home. Then it was back to posting, waiting.
Twenty two minutes before our crew change and two minutes before we normally are sent in, they gave us a colds and flu call. A healthy four year old who vomited an hour earlier. His mother wanted him checked even though he was playing with his toys when we got there. We transported to the children’s hospital on the other side of town. I’d been keeping my cough pretty well under control, but then a couple blocks from the hospital, I just started hacking away in the driver’s seat. I was hacking so hard, my brain hurt from all its rattling around inside my skull. When we got to the hospital, I got out and opened up the back door, and helped the mother waddle down.
She looked at me and said, “Maybe you ought to be the one seeing a doctor.”
I was tempted to say, “Yeah, maybe I ought to call an ambulance to take me to the hospital.” But I try not to be a wise guy. I just gave her a tired nod.
I didn’t punch out till quarter to one this morning.
They wanted me to come in to work today, but I said, no. I need the day off. I’m still run down.
Thursday, September 21, 2006
Cold
Once a year -- sometimes twice -- I get a really bad cold. It starts with an itch in the back of my throat, and then one snuffy nostril, and then a night of not being able to sleep, a low-grade fever. Then the cold descends into my chest where it will remain for a couple weeks, sometimes a month of coughing up clear pleghm.
At at its worst moments I feel like I will never be well again. Such a wussy am I.
I have that cold now. I've spend the day on the couch watching TV. I have to go in to work tonight at six for a six hour shift. I'm precepting so I can be the invisible man, just observing. The fever is past so I should be all right, and I am off again tomorrow.
My preceptee needs one good "big bad one" to show he can do the job. He's doing great, but we haven't been to the hospital once lights and sirens. Maybe tonight.
I'll report in the morning.
At at its worst moments I feel like I will never be well again. Such a wussy am I.
I have that cold now. I've spend the day on the couch watching TV. I have to go in to work tonight at six for a six hour shift. I'm precepting so I can be the invisible man, just observing. The fever is past so I should be all right, and I am off again tomorrow.
My preceptee needs one good "big bad one" to show he can do the job. He's doing great, but we haven't been to the hospital once lights and sirens. Maybe tonight.
I'll report in the morning.
Wednesday, September 20, 2006
Tuesday, September 19, 2006
Who Mash Me Up!
I carry a small digital camera in my pocket. I’ve written about it before in New Frontier. It is great for taking mechanism of injury shots – the smashed up car, bent steering wheel, picture of the roof the patient fell off showing the height of the fall. The trauma team loves to see the pictures at the ED.
This afternoon we were called for an 88-year-old Jamaican man who had been drinking and fell, tripping over his walker and cut hit head in multiple locations. He was bleeding from the ear, nose and forehead. He swore he was okay. “Why you bother my peace!” He shouted at us. “I’m awwright. I’m in my own house. I not sick. Leave me alone!”
We tried to explain to him that he probably needed stitches, that his nose might be broken, and that he had a huge hematoma on his forehead. He denied it. “I’m awwright,” he said.
I took out my digital camera. I asked his wife for permission to take his picture to show it to him. She said fine. I photographed his ear, his forehead, and then a picture of his entire head and face.
"This is you," I said. I showed him the shots. He stared at the last one, recognizing himself.
“Who mash me up!” he shouted. “Who da bad man?”
He didn’t resist when we put him on the stretcher. “What hoppen?” he shouted. “Who mash me up?”
This afternoon we were called for an 88-year-old Jamaican man who had been drinking and fell, tripping over his walker and cut hit head in multiple locations. He was bleeding from the ear, nose and forehead. He swore he was okay. “Why you bother my peace!” He shouted at us. “I’m awwright. I’m in my own house. I not sick. Leave me alone!”
We tried to explain to him that he probably needed stitches, that his nose might be broken, and that he had a huge hematoma on his forehead. He denied it. “I’m awwright,” he said.
I took out my digital camera. I asked his wife for permission to take his picture to show it to him. She said fine. I photographed his ear, his forehead, and then a picture of his entire head and face.
"This is you," I said. I showed him the shots. He stared at the last one, recognizing himself.
“Who mash me up!” he shouted. “Who da bad man?”
He didn’t resist when we put him on the stretcher. “What hoppen?” he shouted. “Who mash me up?”
Monday, September 18, 2006
Mortal Men (Chapters 7-10)
More chapters added to the novel Mortal Men.
Warning: I may only publish 34 of the the 47 chapters on this site. (Unless I change my mind.)
Mortal Men
Chapters Seven to Ten
Warning: I may only publish 34 of the the 47 chapters on this site. (Unless I change my mind.)
Mortal Men
Chapters Seven to Ten
Sunday, September 17, 2006
Tickets to the Ball
Yesterday we did a low speed MVA involving a police officer, who we took in for lower back pain. Another officer followed us in his squad car. I don't know if I am the only one, but I always get paranoid when I am driving to the hospital with a cop on my tail. I always come to complete stops, watch my speed. Is he going to pull me over? I wait for those lights to flick on. Damn! License and registration. What did I do officer? I haven't been drinking, I swear. I'll walk a straight line. Got any tickets to the ball?
I know its silly, but you are shaped by your youth. I didn't come to know and work with cops until I was in my thirties.
***
I look forward evey month to getting my issues of JEMS and Emergency Medical Services, the two leading trade publications in our field. This week I read the new JEMS while on duty and I have to say, it was a great issue. It had a very moving story about the September 11 EMS responders five years later and how many are suffering from respiratory problems. There was also an interesting story about "crush injury" - it gave the account of the treatment of the trapped port authority officer played by Nicholas Cage in the new Oliver Stone movie about September 11, and how proper treatment saved his life.
I haven't watched any of the September 11 movies yet. One of these days I will. I also want to write something about September 11 and the aftermath. This morning I was listening to Jamie Davis, the podmedic's regular pod cast and he was talking about the articles in JEMS and some other news stories about the way EMS responders have been treated (Listen to Episdoe 32), and this is really a topic that needs more airing.
MedicCast
Both JEMS and Emergency Medical Services have web sites and newsletters you can subscribe to that come weekly. They are an excellent way of staying on top of the latest news, and I particuarly like the updates on research. To subscibe to the newsletters go to the following sites:
JEMS.com
JEMS Newletter Signup
EMSresponder.com
(Note: Click on email alerts to get newsletter)
***
Friday night I went to a dinner for the EMS coordinator of the suburban service I am contracted to work for. He is a police officer who is leaving the position to go back to the street because his term is up, and the police chief is hiring a new person. It was a nice event. All the volunteers came. We had hot dogs and hamburgers and chicken and ribs. The local state representative came and presented him with a plaque from the legislature. We had a big photo of the three ambulances mounted on a frame and everyone signed it and wrote messages on the matting. A diverse group of people, but one big family all the same.
***
I worked yesterday with an old friend. We did five calls in eight hours and reminised about old times. Our first call was to pick up a large diaylsis patient so they switched us into our bariatric ambulance. They are supposed to send a crew to help us lift anytime the big ambulance is used. When they asked us if we needed a hand, my partner said, "I don't know, my partner is almost fifty, we might."
I made him bear the brunt of all the lifting for the rest of the day because of his comment.
His wife is sick, and he's been having a bit of a hard go lately because of it. I was glad to hear him say the company has been taking good care of him, as far as alerting him to his family medical leave rights, and being understanding. We talked about how you are healthy one day and disabled the next.
Our patient, who used to be an EMT himself, has really been going downhill. He wasn't his boisterous self. He slept most of the way, and moaned whenever we moved him.
At the end of the day, they asked us if we wanted to stay late and do some more calls, but we both wanted to go home. He needed to go home and take care of his wife. I wanted to go home and have a couple beers.
I had two little 7 ounce Cornonitas, and then fell asleep on the couch. I was beat down. I woke up two hours later with a headache. I got up and cleaned the house -- or at least part of it -- the kitchen, living room and one bathroom. I even got on my knees and scrubbed the kitchen floor.
Then I watched the Red Sox lose to the Yankees while I folded laundry, and then went to bed after laying out my work clothes for today.
***
I'm thinking about becoming a triathlete. I read this article about it in Men's Health magazine.
Anyone Can Be a Triathlete
The problem is I haven't run a mile for over twenty years and I am afraid of bicycles, especially biking in traffic. Still, that would be something to say you had run a triathlon (They have mini-triathlons 1/2 mile swim, 4 mile run, 18 mile bike ride).
I will probably take it incrementally -- swim first, and then if I can run four miles, then think about trying to get on a bike.
It's just that I have been feeling out of shape despite going to the gym twice a week. I know I should be going four times, but I have been working a lot.
A triathlon -- that would motivate me.
I just don't want to be old and sick.
***
I'm going to Las Vegas September 26-30 for the EMS Expo.
I know its silly, but you are shaped by your youth. I didn't come to know and work with cops until I was in my thirties.
***
I look forward evey month to getting my issues of JEMS and Emergency Medical Services, the two leading trade publications in our field. This week I read the new JEMS while on duty and I have to say, it was a great issue. It had a very moving story about the September 11 EMS responders five years later and how many are suffering from respiratory problems. There was also an interesting story about "crush injury" - it gave the account of the treatment of the trapped port authority officer played by Nicholas Cage in the new Oliver Stone movie about September 11, and how proper treatment saved his life.
I haven't watched any of the September 11 movies yet. One of these days I will. I also want to write something about September 11 and the aftermath. This morning I was listening to Jamie Davis, the podmedic's regular pod cast and he was talking about the articles in JEMS and some other news stories about the way EMS responders have been treated (Listen to Episdoe 32), and this is really a topic that needs more airing.
MedicCast
Both JEMS and Emergency Medical Services have web sites and newsletters you can subscribe to that come weekly. They are an excellent way of staying on top of the latest news, and I particuarly like the updates on research. To subscibe to the newsletters go to the following sites:
JEMS.com
JEMS Newletter Signup
EMSresponder.com
(Note: Click on email alerts to get newsletter)
***
Friday night I went to a dinner for the EMS coordinator of the suburban service I am contracted to work for. He is a police officer who is leaving the position to go back to the street because his term is up, and the police chief is hiring a new person. It was a nice event. All the volunteers came. We had hot dogs and hamburgers and chicken and ribs. The local state representative came and presented him with a plaque from the legislature. We had a big photo of the three ambulances mounted on a frame and everyone signed it and wrote messages on the matting. A diverse group of people, but one big family all the same.
***
I worked yesterday with an old friend. We did five calls in eight hours and reminised about old times. Our first call was to pick up a large diaylsis patient so they switched us into our bariatric ambulance. They are supposed to send a crew to help us lift anytime the big ambulance is used. When they asked us if we needed a hand, my partner said, "I don't know, my partner is almost fifty, we might."
I made him bear the brunt of all the lifting for the rest of the day because of his comment.
His wife is sick, and he's been having a bit of a hard go lately because of it. I was glad to hear him say the company has been taking good care of him, as far as alerting him to his family medical leave rights, and being understanding. We talked about how you are healthy one day and disabled the next.
Our patient, who used to be an EMT himself, has really been going downhill. He wasn't his boisterous self. He slept most of the way, and moaned whenever we moved him.
At the end of the day, they asked us if we wanted to stay late and do some more calls, but we both wanted to go home. He needed to go home and take care of his wife. I wanted to go home and have a couple beers.
I had two little 7 ounce Cornonitas, and then fell asleep on the couch. I was beat down. I woke up two hours later with a headache. I got up and cleaned the house -- or at least part of it -- the kitchen, living room and one bathroom. I even got on my knees and scrubbed the kitchen floor.
Then I watched the Red Sox lose to the Yankees while I folded laundry, and then went to bed after laying out my work clothes for today.
***
I'm thinking about becoming a triathlete. I read this article about it in Men's Health magazine.
Anyone Can Be a Triathlete
The problem is I haven't run a mile for over twenty years and I am afraid of bicycles, especially biking in traffic. Still, that would be something to say you had run a triathlon (They have mini-triathlons 1/2 mile swim, 4 mile run, 18 mile bike ride).
I will probably take it incrementally -- swim first, and then if I can run four miles, then think about trying to get on a bike.
It's just that I have been feeling out of shape despite going to the gym twice a week. I know I should be going four times, but I have been working a lot.
A triathlon -- that would motivate me.
I just don't want to be old and sick.
***
I'm going to Las Vegas September 26-30 for the EMS Expo.
Friday, September 15, 2006
Dispatchers
I worked yesterday with an EMT with extensive dispatch experience, and as always, it was interesting to hear his perspective on the dispatcher's job. Sometimes there is a natural antagonism between road crews and dispatchers because the dispatcher is the bear of bad news, but should not neccessarily be shot for it.
(Oddly, while working together dispatch sent us to a quiet location where we sat for the last six hours of our shift without a call).
I didn't mean to be totally trashing EMD in recent posts. I recognize while I may get frustrated with the overtriage of lights and sirens, EMD and the EMD dispatchers are a valuable part of our EMS system. I'd like to post a great comment I got on a recent post from a dispatcher:
As an EMD dispatcher, it is safe to acknowlege that EMD is not only to slow units responding down for the non-emergent calls. EMD also provides callers with post dispatch instructions and this ranges from CPR, Choking, Maternity, bleeding control and much more. In a sense the 911 call taker is the virtual first responder. As we are unable to see the patient, as we are trained to treat a patient as an EMT-B & EMT-P, we rely on the callers information. Getting an out-of-control caller to calm down is difficult even for the experienced dispatchers, but non-the-less needs to happen in order to improve the quality of life for the patient. EMD provides a set of protocols that allows the call taker to reduce the agitation or excitment of a caller much easier. Yes, in the past it was "winged" but as Medics & EMT's alike know it is risky to provide pre-hospital instructions to a caller with out being able to see the patient. Also, in the excitment of the call and reducing the callers "freaking" a call taker, even medically trained, may miss important questions that is nessecary to assit that patient. A caller may give information that the patient is not breathing. A call taker, not using protocols may get tunnel vision and start working the patient over the phone, but fail to ask the pertinent questions that EMD will make you ask. Now you find out, using EMD, the patient fell down a flight of stairs and is not breathing. There is instructions for the caller to use jaw thrust to protect the patients c-spine. In the delivery of a baby over the phone, as a call taker even trained medically, you do not want to miss ANYTHING. One missed step could mean life or death for the infant or mother. As EMD may not work for the response level of the responding units all the time, in my view I have seen a reduction in the amount of calls that are being sent on a priority one. It also does not help when a company deviates from the response algirthym such as making all "E", "D", "C", "B" responses priority responses, when EMD protocol states that only "E" & "D" are Hot responses all the time. The protocol states that "C" response is BLS "Hot" with ALS "Cold" (The just in-case needed factor) and "B" is BLS "Hot" no ALS and "A" is BLS "Cold". But, "C" and "B" are reduced in priority based on local protocols or medical control which every EMD has to have to operate. It is safe to say that EMD has it's purposes and can work in most situations, especially in pre-hospital instructions to callers on the phone with the calltaker. Also, keep in mind, the EMD is increasingly usefull and benificial to response grids and regions that are not anywhere near a hospital or the nearest emergency responder is possibly 20 minutes out.
Well said.
***
For more on the dispatch perspective check out Nee Naw a blog by an EMS dispatcher in London that is great reading.
(Oddly, while working together dispatch sent us to a quiet location where we sat for the last six hours of our shift without a call).
I didn't mean to be totally trashing EMD in recent posts. I recognize while I may get frustrated with the overtriage of lights and sirens, EMD and the EMD dispatchers are a valuable part of our EMS system. I'd like to post a great comment I got on a recent post from a dispatcher:
As an EMD dispatcher, it is safe to acknowlege that EMD is not only to slow units responding down for the non-emergent calls. EMD also provides callers with post dispatch instructions and this ranges from CPR, Choking, Maternity, bleeding control and much more. In a sense the 911 call taker is the virtual first responder. As we are unable to see the patient, as we are trained to treat a patient as an EMT-B & EMT-P, we rely on the callers information. Getting an out-of-control caller to calm down is difficult even for the experienced dispatchers, but non-the-less needs to happen in order to improve the quality of life for the patient. EMD provides a set of protocols that allows the call taker to reduce the agitation or excitment of a caller much easier. Yes, in the past it was "winged" but as Medics & EMT's alike know it is risky to provide pre-hospital instructions to a caller with out being able to see the patient. Also, in the excitment of the call and reducing the callers "freaking" a call taker, even medically trained, may miss important questions that is nessecary to assit that patient. A caller may give information that the patient is not breathing. A call taker, not using protocols may get tunnel vision and start working the patient over the phone, but fail to ask the pertinent questions that EMD will make you ask. Now you find out, using EMD, the patient fell down a flight of stairs and is not breathing. There is instructions for the caller to use jaw thrust to protect the patients c-spine. In the delivery of a baby over the phone, as a call taker even trained medically, you do not want to miss ANYTHING. One missed step could mean life or death for the infant or mother. As EMD may not work for the response level of the responding units all the time, in my view I have seen a reduction in the amount of calls that are being sent on a priority one. It also does not help when a company deviates from the response algirthym such as making all "E", "D", "C", "B" responses priority responses, when EMD protocol states that only "E" & "D" are Hot responses all the time. The protocol states that "C" response is BLS "Hot" with ALS "Cold" (The just in-case needed factor) and "B" is BLS "Hot" no ALS and "A" is BLS "Cold". But, "C" and "B" are reduced in priority based on local protocols or medical control which every EMD has to have to operate. It is safe to say that EMD has it's purposes and can work in most situations, especially in pre-hospital instructions to callers on the phone with the calltaker. Also, keep in mind, the EMD is increasingly usefull and benificial to response grids and regions that are not anywhere near a hospital or the nearest emergency responder is possibly 20 minutes out.
Well said.
***
For more on the dispatch perspective check out Nee Naw a blog by an EMS dispatcher in London that is great reading.
Thursday, September 14, 2006
Words
Last night I gave my capnography CME. There was about thirty people there. I think it went over okay. It is hard to tell when you are standing up behind a podium and giving a presentation for the first time how well it is being recieved. Our medical control physician thought it was very good and that I was changing his thinking on capnography. He also mentioned he thought it would be a good presentation for the ED docs, although he said they wouldn't sit for more than an hour. The presentation currently runs about an hour and a half. I don't think I would be comfortable doing the presentation in front of them. I just don't explain the science part well enough. While I understand ventilation/perfusion mismatch, I don't explain it well in detail, not that the physicians would need that, but they might ask me a question that would tongue-tie me and expose me as a little deficient on the science side of things. I am glad the presentation is over and I can set it aside for awhile. It took up much of my summer. For those interested, here again is my capnography blog.
Capnography for Paramedics
I will continue updating it as I learn more about capnography.
**
On Tuesday at my monthly regional medical advisory meeting, we passed in principle, a protocol allowing us to give up to .15 mg/kg of Morphine for pain on standing orders,(the current protocol allows .1 mg/kg before having to call for medical control). We also expanded it to include back pain on standing orders, as well as abdominal pain, although the abdominal pain will be limited to .05 mg/kg before calling for medical control.
I have been strongly pushing for increased emphasis on pain management and have been pleased with the gradual prgress we have been making in our region. It occurred to me when I was making my case for the increased pain meds that we overtriage everything in EMS -- whether it is c-spining or sending ambulances lights and sirens, but in one area where we can make a big difference - pain management -- we undertreat.
***
I worked with my preceptee in the city and while there were two traumatic arrests today, we missed both of them. On one, a BLS crew was sent as the first car in (a medic supervisor and a medic car were called to aid them once it was clear there was CPR in progress). Shortly after at the hospital, I saw one of our best medics -- a guy who helped me out on what turned out to be a double fatality MVA when I first started over a decade ago -- coming out of the hospital with a BLS transfer with a vase of flowers in his hand as he pushed the stretcher. If I was in a bad wreck I would have wanted him first on the scene, not being tied up duing a transfer.
***
At an Alzheimer's home today where we were sent for a patient not feeling well, we found ten old people sitting out in the common area watching the big screen TV with an aide who looked to be about 19. It was the Maury Povitch show, and someone on the show was calling his girlfiend a "Bitch and a Hoe!" and there was all this yelling and shoving going on back and forth and someone doing a booty dance, and I looked at all the old people on the couch and they were all staring at the TV with this look on their faces like they didn't understand what they were watching and whatever it was, they had no words for it.
Capnography for Paramedics
I will continue updating it as I learn more about capnography.
**
On Tuesday at my monthly regional medical advisory meeting, we passed in principle, a protocol allowing us to give up to .15 mg/kg of Morphine for pain on standing orders,(the current protocol allows .1 mg/kg before having to call for medical control). We also expanded it to include back pain on standing orders, as well as abdominal pain, although the abdominal pain will be limited to .05 mg/kg before calling for medical control.
I have been strongly pushing for increased emphasis on pain management and have been pleased with the gradual prgress we have been making in our region. It occurred to me when I was making my case for the increased pain meds that we overtriage everything in EMS -- whether it is c-spining or sending ambulances lights and sirens, but in one area where we can make a big difference - pain management -- we undertreat.
***
I worked with my preceptee in the city and while there were two traumatic arrests today, we missed both of them. On one, a BLS crew was sent as the first car in (a medic supervisor and a medic car were called to aid them once it was clear there was CPR in progress). Shortly after at the hospital, I saw one of our best medics -- a guy who helped me out on what turned out to be a double fatality MVA when I first started over a decade ago -- coming out of the hospital with a BLS transfer with a vase of flowers in his hand as he pushed the stretcher. If I was in a bad wreck I would have wanted him first on the scene, not being tied up duing a transfer.
***
At an Alzheimer's home today where we were sent for a patient not feeling well, we found ten old people sitting out in the common area watching the big screen TV with an aide who looked to be about 19. It was the Maury Povitch show, and someone on the show was calling his girlfiend a "Bitch and a Hoe!" and there was all this yelling and shoving going on back and forth and someone doing a booty dance, and I looked at all the old people on the couch and they were all staring at the TV with this look on their faces like they didn't understand what they were watching and whatever it was, they had no words for it.
Sunday, September 10, 2006
Size Up
This is a call I did a few months back. I wrote about it then, but didn't post the story. Part of the reason I didn't is because while I want to write honestly about being a medic, I have some restrictions. I can't trash the company I work for or anybody who works for it, and I guess I also can't really trash myself. I can point out my failings, but sometimes it takes a little while to see the failings.
The call and my feelings about it are not straight forward, but since I have been writing about lights and sirens, I want to address it now. There is not a simple moral here because there is a fair amount of gray involved, although some of it, is fairly straight forward. Enough with the rambling, here's what happened:
***
We were sent lights and sirens for a five car MVA. Our staring point was a distant hospital so it took us a good fifteen minutes to get there. I pride myself on being cool on a scene, quickly sizing up what needs to be done, and allocating the proper resources. When we get there it is dark and rainy. There were a number of cars in the road. It is a good bangup, but one car has no injuries, there is no fifth car, and the other three looks managable. A man holding his chest with a nonrebreather on, but alert seems to be the most seriously injured. Another man wanders about with general body pain. The woman who apparently lost control and came across the median stands by her car claiming she is a diabetic and that she is about to pass out. She has a baby in the backseat in a car seat and the baby is fine. A second ambulance -- a BLS ambulance -- is already on the way. I decide to take the guy with chest pain and the other guy, while leaving the woman and the baby for the BLS crew. I tell an officer we should be all set, and have my partner let dispatch know we're all set. We c-spine the two men and get them in the ambulance. It is then, as I climb in the back that I hear on the radio another medic signing on to head to the five car crash. I can hear his siren in the background of the radio transmission. I tell my partner we don't need a medic, we are all set as soon as the BLS crew got there. He comes back and says the PD is requesting another medic. I tell him to tell the other car not to kill itself getting there, everything is in hand.
The BLS car finally arrives and we take off -- not on a priority because by now I realize the guy with chest pain, while hurt is not as seriously hurt as I first thought. He just seems bruised. The trauma center is about eight minutes away so there is clearly no need for lights and sirens. Everyone is stable. Plus I am standing in the back with two boarded patients and I don't want get throw all over the place.
We get to the hospital, unload our patients. I keep waiting for the other car to show up to see what the deal is -- why the cop wanted the medic. I find out later that the BLS crew waits for the medic, and then the medic goes lights and sirens to the further trauma hospital on the far side of town.
This all annoys me because A) I didn't request another medic, B) I said he didn't need to come on a hard priority and (C) he ended up transporting on a priority.
A good part of this is my ego. I am supposed to manage the scene, but it didn't go like I say it should.
I get some of the story later. The cop called for the medic because the woman said she thought she was going to black out. When I saw the basic crew I told them I didn't ask for a medic. They said, well, it was good one came because the woman had an irregular heart beat. Irregular heart beat? I'm thinking com'on. That's some BS. This woman completely struck me as someone trying to get out of a ticket. I asked for more details. They couldn't explain the irregular heart beat, but they said the medic had to run two large bore IVs wide open, but they say all she had otherwise was shoulder pain, and the baby didn't even get transported. The father showed up at the scene and took him home. The female patient's vitals were fine and she was alert the whole way. When I saw the medic later he told me she had a funky heart rythmn that was going from 40 to 90 and back(on the monitor which records in very brief intervals). A Sinus Arrythmia with all kind of blocks. He showed me a strip, but it was not very convincing. I didn't see any blocks and I didn't see any long periods without a beat, enough to make someone pass out. And why go on a lights and sirens priority to the distant trauma hospital if he was so concerned? Why not the closest hospital? And what was up with the two large bore IVs wide open. Shoulder pain with stable vitals?
BS, I think, a load of BS. I think a lot of times how a medic is sent to a call determines how they handle the call. Being sent lights and sirens We Need a Medic Now for a Five Car MVA seems to make a medic more inclined to go lights and sirens two Large Bore IVs Wide Open We Need the Trauma Room where if you just look around and settle down, you see things really aren't that bad. I know when I first started I went lights and siren two Large Bore IVs Wide Open for lots of stuff that today I would go on a non-priority, and certainly not Two Large Bore IVs Wide Open.
I am annoyed by this five car crash call. Annoyed as I said before and for all the reasons I listed above. But I am also annoyed because I didn't do my job properly. I just eyeballed the lady -- a decade of being a medic told me it was BS. But after all she did cross over the median. Was she going to fast and lost control? Did she skid on the wet pavement? Or did she pass out because of a heart rythmn? That's her story now.
Nobody died. Everybody got to the hospital. But I was too quick to size things up. I could have gotten burned.
Experience can enable you to cut through everything and see the immediate need, the truth at the center of a call, but it can also make you miss. I am not because of this going back to doing everything by the book. Now I do much of my work by the book, but not everything because the book is made for the class, made for when you need a map to see your way through, which I often do. But I do need to be more careful.
**
Reviewing what I have written now months later, two things strike me, both involving the other medic's two large bore IVs wide open treatment for a patient with stable vitals and only shoulder pain, and no significant trauma?
1. Conditioned Response: I wish you could do an controlled experiment where medics were sent to the same call. Half the medics are sent lights and sirens and told it is a really bad crash, the other half are sent nonlights and sirens. Same crash, same patients, same injuries. My guess is that the medics sent lights and sirens will be more aggresive in their treatment, will put in more IVs, run more fluid, and go to the hospital on a priority more than the medics sent on a non-priority. I say this because in the past and maybe even sometimes now, how I get sent ramps me up, and I let it affect my treatment. I can think of several times I was sent lights and sirens to a crash, did the rapid extrication, short scene time drill, only to realize half way to the hospital that my patient really wasn't hurt very badly at all.
2. Old Dogs(mas): I recently overheard an experienced medic tell a paramedic student that he always establishes two large bore IVs and start running fluid on all trauma patients to "stay ahead of the game." That's what we were taught ten years ago. Not today. All the studies show aggressive fluid management may not be the best thing for trauma patients, it may in fact be harmful. The AHA 2005 Guidelines for trauma say:
Aggressive fluid resuscitation is not required for trauma patients who have no evidence of hemodynamic compromise. Recommendations for volume resuscitation in trauma patients with signs of hypovolemic shock are determined by the type of trauma (penetrating vs blunt) and the setting (urban vs rural). A high rate of volume infusion with the therapeutic goal of a systolic blood pressure 100 mm Hg is now recommended only for patients with isolated head or extremity trauma, either blunt or penetrating. In the urban setting, aggressive prehospital volume resuscitation for penetrating trauma is no longer recommended because it is likely to increase blood pressure and consequently accelerate the rate of blood loss, delay arrival at the trauma center, and delay surgical intervention to repair or ligate bleeding vessels.4,14,22 Such delay cannot be justified when the patient can be delivered to a trauma center within a few minutes. In rural settings, transport times to trauma centers will be longer, so volume resuscitation for blunt or penetrating trauma is provided during transport to maintain a systolic blood pressure of 90 mm Hg.
-AHA 2005, Part 10:7
And the other day a medic student told me about a code he had just done where they tried pacing the patient in asystole. The new AHA guidelines, which are already protocol in our region, have eliminated pacing in asystole. Don't do it, it doesn't work.
Pacing in Arrest
Several randomized controlled trials (LOE 2)99–101 failed to show benefit from attempted pacing for asystole. At this time use of pacing for patients with asystolic cardiac arrest is not recommended.
-AHA 2005, Part 7.2
Three randomized controlled trials (LOE 2)140–142 of fair quality and additional studies (LOE 3 to 7)143–149 indicate no improvement in the rate of admission to hospital or survival to hospital discharge when paramedics or physicians attempted to provide pacing in asystolic patients in the prehospital or hospital (emergency department) setting. Given the recent recognition of the importance of maximizing chest compressions as well as the lack of demonstrated benefit of pacing for asystole, withholding chest compressions to attempt pacing for patients with asystole is not recommended (Class III).
-AHA 2005, Part 5
I have heard many older medics badmouth the new AHA guidleines. What's wrong with the old way? they say. These new guidlines are a bunch of BS by people who have never worked the street, the medics say. And these "medics" are passing on their knowledge to new medics.
What kind of system are we perpetuating?
I think as medics we need to approach each call fresh and we need to approach each new development fresh.
No preconcieved notions.
Assess and evaluate - size up - everything with an open mind.
Whether it is a woman at a scene who says she is going to pass out or new research that says we need to do some things differently.
We have to always ask ourselves: What is the right thing to do?
Yes, this patient needs to be taken seriously -- fully assessed -- even if our gut tells us she isn't really sick.
But no, she doesn't need 2 large bore IVs.
We don't need to go lights and sirens.
The call and my feelings about it are not straight forward, but since I have been writing about lights and sirens, I want to address it now. There is not a simple moral here because there is a fair amount of gray involved, although some of it, is fairly straight forward. Enough with the rambling, here's what happened:
***
We were sent lights and sirens for a five car MVA. Our staring point was a distant hospital so it took us a good fifteen minutes to get there. I pride myself on being cool on a scene, quickly sizing up what needs to be done, and allocating the proper resources. When we get there it is dark and rainy. There were a number of cars in the road. It is a good bangup, but one car has no injuries, there is no fifth car, and the other three looks managable. A man holding his chest with a nonrebreather on, but alert seems to be the most seriously injured. Another man wanders about with general body pain. The woman who apparently lost control and came across the median stands by her car claiming she is a diabetic and that she is about to pass out. She has a baby in the backseat in a car seat and the baby is fine. A second ambulance -- a BLS ambulance -- is already on the way. I decide to take the guy with chest pain and the other guy, while leaving the woman and the baby for the BLS crew. I tell an officer we should be all set, and have my partner let dispatch know we're all set. We c-spine the two men and get them in the ambulance. It is then, as I climb in the back that I hear on the radio another medic signing on to head to the five car crash. I can hear his siren in the background of the radio transmission. I tell my partner we don't need a medic, we are all set as soon as the BLS crew got there. He comes back and says the PD is requesting another medic. I tell him to tell the other car not to kill itself getting there, everything is in hand.
The BLS car finally arrives and we take off -- not on a priority because by now I realize the guy with chest pain, while hurt is not as seriously hurt as I first thought. He just seems bruised. The trauma center is about eight minutes away so there is clearly no need for lights and sirens. Everyone is stable. Plus I am standing in the back with two boarded patients and I don't want get throw all over the place.
We get to the hospital, unload our patients. I keep waiting for the other car to show up to see what the deal is -- why the cop wanted the medic. I find out later that the BLS crew waits for the medic, and then the medic goes lights and sirens to the further trauma hospital on the far side of town.
This all annoys me because A) I didn't request another medic, B) I said he didn't need to come on a hard priority and (C) he ended up transporting on a priority.
A good part of this is my ego. I am supposed to manage the scene, but it didn't go like I say it should.
I get some of the story later. The cop called for the medic because the woman said she thought she was going to black out. When I saw the basic crew I told them I didn't ask for a medic. They said, well, it was good one came because the woman had an irregular heart beat. Irregular heart beat? I'm thinking com'on. That's some BS. This woman completely struck me as someone trying to get out of a ticket. I asked for more details. They couldn't explain the irregular heart beat, but they said the medic had to run two large bore IVs wide open, but they say all she had otherwise was shoulder pain, and the baby didn't even get transported. The father showed up at the scene and took him home. The female patient's vitals were fine and she was alert the whole way. When I saw the medic later he told me she had a funky heart rythmn that was going from 40 to 90 and back(on the monitor which records in very brief intervals). A Sinus Arrythmia with all kind of blocks. He showed me a strip, but it was not very convincing. I didn't see any blocks and I didn't see any long periods without a beat, enough to make someone pass out. And why go on a lights and sirens priority to the distant trauma hospital if he was so concerned? Why not the closest hospital? And what was up with the two large bore IVs wide open. Shoulder pain with stable vitals?
BS, I think, a load of BS. I think a lot of times how a medic is sent to a call determines how they handle the call. Being sent lights and sirens We Need a Medic Now for a Five Car MVA seems to make a medic more inclined to go lights and sirens two Large Bore IVs Wide Open We Need the Trauma Room where if you just look around and settle down, you see things really aren't that bad. I know when I first started I went lights and siren two Large Bore IVs Wide Open for lots of stuff that today I would go on a non-priority, and certainly not Two Large Bore IVs Wide Open.
I am annoyed by this five car crash call. Annoyed as I said before and for all the reasons I listed above. But I am also annoyed because I didn't do my job properly. I just eyeballed the lady -- a decade of being a medic told me it was BS. But after all she did cross over the median. Was she going to fast and lost control? Did she skid on the wet pavement? Or did she pass out because of a heart rythmn? That's her story now.
Nobody died. Everybody got to the hospital. But I was too quick to size things up. I could have gotten burned.
Experience can enable you to cut through everything and see the immediate need, the truth at the center of a call, but it can also make you miss. I am not because of this going back to doing everything by the book. Now I do much of my work by the book, but not everything because the book is made for the class, made for when you need a map to see your way through, which I often do. But I do need to be more careful.
**
Reviewing what I have written now months later, two things strike me, both involving the other medic's two large bore IVs wide open treatment for a patient with stable vitals and only shoulder pain, and no significant trauma?
1. Conditioned Response: I wish you could do an controlled experiment where medics were sent to the same call. Half the medics are sent lights and sirens and told it is a really bad crash, the other half are sent nonlights and sirens. Same crash, same patients, same injuries. My guess is that the medics sent lights and sirens will be more aggresive in their treatment, will put in more IVs, run more fluid, and go to the hospital on a priority more than the medics sent on a non-priority. I say this because in the past and maybe even sometimes now, how I get sent ramps me up, and I let it affect my treatment. I can think of several times I was sent lights and sirens to a crash, did the rapid extrication, short scene time drill, only to realize half way to the hospital that my patient really wasn't hurt very badly at all.
2. Old Dogs(mas): I recently overheard an experienced medic tell a paramedic student that he always establishes two large bore IVs and start running fluid on all trauma patients to "stay ahead of the game." That's what we were taught ten years ago. Not today. All the studies show aggressive fluid management may not be the best thing for trauma patients, it may in fact be harmful. The AHA 2005 Guidelines for trauma say:
Aggressive fluid resuscitation is not required for trauma patients who have no evidence of hemodynamic compromise. Recommendations for volume resuscitation in trauma patients with signs of hypovolemic shock are determined by the type of trauma (penetrating vs blunt) and the setting (urban vs rural). A high rate of volume infusion with the therapeutic goal of a systolic blood pressure 100 mm Hg is now recommended only for patients with isolated head or extremity trauma, either blunt or penetrating. In the urban setting, aggressive prehospital volume resuscitation for penetrating trauma is no longer recommended because it is likely to increase blood pressure and consequently accelerate the rate of blood loss, delay arrival at the trauma center, and delay surgical intervention to repair or ligate bleeding vessels.4,14,22 Such delay cannot be justified when the patient can be delivered to a trauma center within a few minutes. In rural settings, transport times to trauma centers will be longer, so volume resuscitation for blunt or penetrating trauma is provided during transport to maintain a systolic blood pressure of 90 mm Hg.
-AHA 2005, Part 10:7
And the other day a medic student told me about a code he had just done where they tried pacing the patient in asystole. The new AHA guidelines, which are already protocol in our region, have eliminated pacing in asystole. Don't do it, it doesn't work.
Pacing in Arrest
Several randomized controlled trials (LOE 2)99–101 failed to show benefit from attempted pacing for asystole. At this time use of pacing for patients with asystolic cardiac arrest is not recommended.
-AHA 2005, Part 7.2
Three randomized controlled trials (LOE 2)140–142 of fair quality and additional studies (LOE 3 to 7)143–149 indicate no improvement in the rate of admission to hospital or survival to hospital discharge when paramedics or physicians attempted to provide pacing in asystolic patients in the prehospital or hospital (emergency department) setting. Given the recent recognition of the importance of maximizing chest compressions as well as the lack of demonstrated benefit of pacing for asystole, withholding chest compressions to attempt pacing for patients with asystole is not recommended (Class III).
-AHA 2005, Part 5
I have heard many older medics badmouth the new AHA guidleines. What's wrong with the old way? they say. These new guidlines are a bunch of BS by people who have never worked the street, the medics say. And these "medics" are passing on their knowledge to new medics.
What kind of system are we perpetuating?
I think as medics we need to approach each call fresh and we need to approach each new development fresh.
No preconcieved notions.
Assess and evaluate - size up - everything with an open mind.
Whether it is a woman at a scene who says she is going to pass out or new research that says we need to do some things differently.
We have to always ask ourselves: What is the right thing to do?
Yes, this patient needs to be taken seriously -- fully assessed -- even if our gut tells us she isn't really sick.
But no, she doesn't need 2 large bore IVs.
We don't need to go lights and sirens.
Saturday, September 09, 2006
Fair Enough
A few days ago I promised I would try to write something true about lights and sirens response in EMS. I believe I have come up with something, but first I want to outline a call this morning.
The horn goes off. The call is for an unresponsive at a nursing home, history of diabetes. Code 3 response, which in our town is lights and sirens. The dispatcher tells us it is a pass from the commercial company. As I head out to the ambulance, I hear the same call go out to two police units. Code 3.
Our driver today hasn’t worked for awhile and is excited about the call. I caution her that passes from the commercial company are rarely as serious as they sound. I explain that the fact the nursing home called the commercial company and not 911 is a good indicator that the call is not serious. I also tell her that the call takers are not medically trained, and are taught to simply follow a medical dispatch algorithm. Sometimes the wrong choice of words will initiate an emergency response. I cite the recent example of the psychiatric patients who got in a verbal dispute with a nurse over watching television, triggering a difficulty breathing code three response because the nurse’s answer to the question whether or not the patient was breathing normally was that the patient was not breathing normally because she was agitated. We arrived to find the patient smoking a cigarette.
Two police cars are parked outside the home. We unload our stretcher with equipment piled on it and enter the lobby. There is no one there to direct us to the proper wing. We were given no patient name or wing, just the nursing home address. “Which way did they go?” I ask an old man in a wheelchair. He points to the right and also to the left. “They split up,” he says.
Then a nurse arrives looking quite puzzled. She asks us who we are here for. I say we don’t know. She says the only one going out is Mr. Brown. She leads us down the hall to the left, and to a room where an elderly man is sitting on the side of his bed laughing with a visitor. “This can’t be him,” I say, “Our patient is supposed to be unresponsive. Plus there should be officers here.”
“I don’t know then," she said, “We can ask at the nurse’s station.”
We wheel our stretcher further down the wing and ahead I now see two officers standing at the desk in a very heated argument with a nurse who is looking at them like they are from outer space.
The gist of the matter is they are angry that they came lights and sirens and no one was there to direct them to the room. Plus the patient was obviously not unresponsive. The man we saw laughing evidently is our patient. The nurse just shakes her head and says she didn’t call 911. She called the commercial company and told them it was not an emergency. The man had had a brief hypoglycemic episode four hours earlier and come around after drinking orange juice. She had put a call in to the doctor and he had called back four hours later to tell her to send the man to the ED to look into why his sugar has been on the low side in recent days.
This mismatch between the patient acuity and dispatch response obviously happens in our town all the time, and it is a disaster waiting to happen. Some day someone is going to get killed in a wreck because public response vehicles – two police cars and an ambulance are being sent lights and sirens to a non-emergency. How did it happen and how can we prevent that fatal accident from happening?
This is all about liability.
The nurse calls the doctor to report the episode. The man’s sugar only went down to 78, but he was a little woozy from it, and it has happened a couple times lately. Fair enough.
The doctor who is probably at home or perhaps playing golf, says oh, hell, send him to the ER. He probably figures to cover his butt in case the man has any problem. Pawn it off to the ER. Fair enough, I guess.
The nurse calls the commercial service for transport. It is after all four hours after the incident and it is just for an evalve. The commercial service call taker is trained to follow an algorithm. When the nurse says the words altered mental status to describe what happened, the call becomes a priority, which by state ruling has to be passed to the local 911 holder. The commercial service by using EMD and employing a strictly algorithm controlled response protects itself from liability. The company is in business, and this is clearly a smart business practice. Fair enough.
I should add to our list of players and factors the EMD algorithm and the science or lack of science behind it, as well as the companies profiting or not profiting from its use and proliferation. Let’s believe everybody is trying to do what is right. Fair enough.
The 911 police receive that call and dispatch two police cars along with the ambulance because the police are the first responders and have to go to all the calls because it is a state regulation, and because the town doesn’t do its own EMD, it has to go to all the calls, even ones at nursing homes and doctor’s offices where the personnel there have more medical training than they do. Regulations are regulations. They were written with good meaning, but clearly not with anticipation of scenarios like this. Fair enough.
So here we are. We started with “This is not an emergency...” and ended up with two police officers and an ambulance crew going lights and sirens and ending up shouting at a disbelieving nurse.
I promised I would write one true thing about lights and sirens.
Here it is:
If the system is going to pass the liability down to the cops and EMS field people, then I guess we’ll have to take it on our backs.
Therefore:
It is our job, duty and responsibility to exercise all due regard to arrive at the scene safely, and to not endanger other people with our response.
Like they teach us in class. Our safety comes first. And we can’t let contracted response times, misguided EMD protocols or our own desire to do good, get in the way of that principle.
Fair enough.
***
Ambulance Crash Log
"Sixteen of the 32 protocols performed no better than chance alone at identifying high-acuity patients."-Comparison of the medical priority dispatch system to an out-of-hospital patient acuity score.
Acad Emerg Med. 2006 Sep;13(9):954-60.
Feldman MJ, Verbeek PR, Lyons DG, Chad SJ, Craig AM, Schwartz B.
The horn goes off. The call is for an unresponsive at a nursing home, history of diabetes. Code 3 response, which in our town is lights and sirens. The dispatcher tells us it is a pass from the commercial company. As I head out to the ambulance, I hear the same call go out to two police units. Code 3.
Our driver today hasn’t worked for awhile and is excited about the call. I caution her that passes from the commercial company are rarely as serious as they sound. I explain that the fact the nursing home called the commercial company and not 911 is a good indicator that the call is not serious. I also tell her that the call takers are not medically trained, and are taught to simply follow a medical dispatch algorithm. Sometimes the wrong choice of words will initiate an emergency response. I cite the recent example of the psychiatric patients who got in a verbal dispute with a nurse over watching television, triggering a difficulty breathing code three response because the nurse’s answer to the question whether or not the patient was breathing normally was that the patient was not breathing normally because she was agitated. We arrived to find the patient smoking a cigarette.
Two police cars are parked outside the home. We unload our stretcher with equipment piled on it and enter the lobby. There is no one there to direct us to the proper wing. We were given no patient name or wing, just the nursing home address. “Which way did they go?” I ask an old man in a wheelchair. He points to the right and also to the left. “They split up,” he says.
Then a nurse arrives looking quite puzzled. She asks us who we are here for. I say we don’t know. She says the only one going out is Mr. Brown. She leads us down the hall to the left, and to a room where an elderly man is sitting on the side of his bed laughing with a visitor. “This can’t be him,” I say, “Our patient is supposed to be unresponsive. Plus there should be officers here.”
“I don’t know then," she said, “We can ask at the nurse’s station.”
We wheel our stretcher further down the wing and ahead I now see two officers standing at the desk in a very heated argument with a nurse who is looking at them like they are from outer space.
The gist of the matter is they are angry that they came lights and sirens and no one was there to direct them to the room. Plus the patient was obviously not unresponsive. The man we saw laughing evidently is our patient. The nurse just shakes her head and says she didn’t call 911. She called the commercial company and told them it was not an emergency. The man had had a brief hypoglycemic episode four hours earlier and come around after drinking orange juice. She had put a call in to the doctor and he had called back four hours later to tell her to send the man to the ED to look into why his sugar has been on the low side in recent days.
This mismatch between the patient acuity and dispatch response obviously happens in our town all the time, and it is a disaster waiting to happen. Some day someone is going to get killed in a wreck because public response vehicles – two police cars and an ambulance are being sent lights and sirens to a non-emergency. How did it happen and how can we prevent that fatal accident from happening?
This is all about liability.
The nurse calls the doctor to report the episode. The man’s sugar only went down to 78, but he was a little woozy from it, and it has happened a couple times lately. Fair enough.
The doctor who is probably at home or perhaps playing golf, says oh, hell, send him to the ER. He probably figures to cover his butt in case the man has any problem. Pawn it off to the ER. Fair enough, I guess.
The nurse calls the commercial service for transport. It is after all four hours after the incident and it is just for an evalve. The commercial service call taker is trained to follow an algorithm. When the nurse says the words altered mental status to describe what happened, the call becomes a priority, which by state ruling has to be passed to the local 911 holder. The commercial service by using EMD and employing a strictly algorithm controlled response protects itself from liability. The company is in business, and this is clearly a smart business practice. Fair enough.
I should add to our list of players and factors the EMD algorithm and the science or lack of science behind it, as well as the companies profiting or not profiting from its use and proliferation. Let’s believe everybody is trying to do what is right. Fair enough.
The 911 police receive that call and dispatch two police cars along with the ambulance because the police are the first responders and have to go to all the calls because it is a state regulation, and because the town doesn’t do its own EMD, it has to go to all the calls, even ones at nursing homes and doctor’s offices where the personnel there have more medical training than they do. Regulations are regulations. They were written with good meaning, but clearly not with anticipation of scenarios like this. Fair enough.
So here we are. We started with “This is not an emergency...” and ended up with two police officers and an ambulance crew going lights and sirens and ending up shouting at a disbelieving nurse.
I promised I would write one true thing about lights and sirens.
Here it is:
If the system is going to pass the liability down to the cops and EMS field people, then I guess we’ll have to take it on our backs.
Therefore:
It is our job, duty and responsibility to exercise all due regard to arrive at the scene safely, and to not endanger other people with our response.
Like they teach us in class. Our safety comes first. And we can’t let contracted response times, misguided EMD protocols or our own desire to do good, get in the way of that principle.
Fair enough.
***
Ambulance Crash Log
"Sixteen of the 32 protocols performed no better than chance alone at identifying high-acuity patients."-Comparison of the medical priority dispatch system to an out-of-hospital patient acuity score.
Acad Emerg Med. 2006 Sep;13(9):954-60.
Feldman MJ, Verbeek PR, Lyons DG, Chad SJ, Craig AM, Schwartz B.
Thursday, September 07, 2006
Troublesome, Unformed Idea
Since I closed down my daily blog I have been trying to increase the number of posts to Street Watch, which I have always thought of as my weekly blog. I am hoping to post at least three or four times a week. Since I will not always be able to write the type of extended life of a paramedic story I like best, I am going to also try to do posts a variety of post types, including research, news story type updates, and a general miscellaneous type post which I will try to do tonight. I am going to try to respond to comments more.
**
I rode today with another paramedic and her preceptee. I had called in looking for a shift, and hers was open. They didn’t tell me she had a preceptee with her. That was all right. I just drove, and let them do the calls. The preceptee is a bright articulate young man, who I think will be an excellent medic. We had no real challenging calls, but I could see he had a good head and common sense. We were in one of the newer ambulance, where the emergency lights are in the ceiling above you head. Supposedly, you just reach up and hit emergency master and they all light up. We got a call to intercept with a basic car that needed a medic, so I looked up, hit the emergency master and off we went. I drove a little faster than normal because I wanted to be able to hit the intercept point before the other ambulance, which was already enroute passed it. We made it fine. Later, the driver of the other ambulance mentioned I had had my siren on, but no lights. I guess, whoever was in the car before me had turned the individual emergency lights off, so you had to not only hit the emergency master, you had to then hit each of the lights. D’ooh! Oh, well.
**
Consider the following merely an idea brewing in my head, a troublesome unformed idea:
The other day I had an interesting talk with an EMT, who used to work in the dispatch center, which is located in another city from us. He works the road, but still keeps his feet in various dispatch centers. While like many road people, I find dispatchers annoying and easy to blame, they do have their side to tell. While I may suspect them of sending me on a priority one for something I don't think should be lights and sirens only because they want to clear their screens( by getting us to the call quicker to get us to the hospital sooner, and clear for the next call sooner) there may in fact be more to it.
We used to have dispatch right in our same building, and we all knew and saw each other everyday, and the dispatchers often knew the streets better than we did, so for the most part we got along. For the most part, they were good to us, we were good to them. It was also in the days before EMD, when dispatchers could use their common sense in selecting how to send us to the call. Now, we hire non-medically trained people to EMD the calls, which I understand is what the EMD company prefers so that the call takers won’t deviate from the algorithm. The ambulance company I guess gets a better insurance rate as long as they stick to the algorithm – the EMD company will defend them in court. The problem is, the dispatchers, whose hands I guess are tired by the call-takers work (And the call-takers side may simply be we're just doing our jobs as we have been trained), end up sending us priority one all the time for difficulty breathings simply because the patient is not breathing normally, but there is no context. Maybe they are COPDers and this is their baseline, and their problem today is a skin tear. Maybe they have had pneumonia for a few days and the doctor has finally decided to send them in for hydration and antibiotics. An glaring example the other day we were sent priority one for difficulty breathing only to find the call was for a psych who was breathing rapidly because she was agitated because the nurse wouldn’t let her watch the show she wanted on the common TV. We found her with a cigarette in her mouth. I could go on. The calls are all appropriate per EMD, but inappropriate for a lights and sirens response per common sense.
I am a big fan of Bryan Bledsoe, an EMS physciaian and writer, who has made a name for himself, among other things exploding EMS myths. I believe I heard him once and another time read him making a reference to their being no science behind EMD – nothing that provided that it in fact made a difference in a measurable way. I eagerly wait for him or someone else to truly tackle the topic. In the meantime a few days ago I was browsing around on a site called Pub Med where you can look up research articles and I found some very recent ones, which I will write about soon in more detail, which showed how poorly many of the calls correlate to the EMD protocols they are assigned by the dispatcher. For instance, something like only 26% of calls given the chest pain protocol, are actually cardiac related, and I read another that I believe said only 1 out of 18 cardiac-related calls is a true MI. I seem to remember reading something that in many cases random chance did a better job of picking the appropriate response than EMD (I hope this isn’t so). Now, keep in mind these numbers are just out of my memory now, and I promise a deeper look into them. The bottom line tonight for me is that while we may all think of EMD as motherhood and apple pie, and may it protect us from liability, it may also not be doing the patients much good and may be putting us in harm’s way.
I’m going to look into this further, and promise to post my findings here, as well as the relevant research. I may in fact be wrong, but I also may be right.
Earlier today we were sent on a priority one by a town police department for a psych and arrived to find the man in handcuffs with about seven cops surrounding him, and the man was quite calm. While this call was not EMDed it came as a request from an officer, I would argue that our going lights and sirens did not contribute to saving anyone’s life and may in fact have endangered someone’s – ours and the public’s.
So here is the deal, I want to put all these things in a pot:
EMS
Evidence-based medicine
Research
Ambulance personnel
Ambulance Companies
Ambulance crashes
Unions
OSHA
Dispatchers
Police and fire requests for ambulance to their scenes
The public in their cars
The public who is sick
EMD
Lights and sirens policies
Safety equipment
First responders
Whatever else I think of
Mix it all up and see if I can come up with a statement about responding lights and sirens that is true.
Here's an abstract from one of the studies that just came out:
1: Acad Emerg Med. 2006 Sep;13(9):954-60. Epub 2006 Aug 7. Links
Comparison of the medical priority dispatch system to an out-of-hospital patient acuity score.Feldman MJ, Verbeek PR, Lyons DG, Chad SJ, Craig AM, Schwartz B.
Sunnybrook-Osler Center for Prehospital Care, 10 Carlson Court, Suite 640, Toronto, Ontario, Canada. mfeldman@socpc.ca
BACKGROUND: Although the Medical Priority Dispatch System (MPDS) is widely used by emergency medical services (EMS) dispatchers to determine dispatch priority, there is little evidence that it reflects patient acuity. The Canadian Triage and Acuity Scale (CTAS) is a standard patient acuity scale widely used by Canadian emergency departments and EMS systems to prioritize patient care requirements. OBJECTIVES: To determine the relationship between MPDS dispatch priority and out-of-hospital CTAS. METHODS: All emergency calls on a large urban EMS communications database for a one-year period were obtained. Duplicate calls, nonemergency transfers, and canceled calls were excluded. Sensitivity and specificity to detect high-acuity illness, as well as positive predictive value (PPV) and negative predictive value (NPV), were calculated for all protocols. RESULTS: Of 197,882 calls, 102,582 met inclusion criteria. The overall sensitivity of MPDS was 68.2% (95% confidence interval [CI] = 67.8% to 68.5%), with a specificity of 66.2% (95% CI = 65.7% to 66.7%). The most sensitive protocol for detecting high acuity of illness was the breathing-problem protocol, with a sensitivity of 100.0% (95% CI = 99.9% to 100.0%), whereas the most specific protocol was the one for psychiatric problems, with a specificity of 98.1% (95% CI = 97.5% to 98.7%). The cardiac-arrest protocol had the highest PPV (92.6%, 95% CI = 90.3% to 94.3%), whereas the convulsions protocol had the highest NPV (85.9%, 95% CI = 84.5% to 87.2%). The best-performing protocol overall was the cardiac-arrest protocol, and the protocol with the overall poorest performance was the one for unknown problems. Sixteen of the 32 protocols performed no better than chance alone at identifying high-acuity patients. CONCLUSIONS: The Medical Priority Dispatch System exhibits at least moderate sensitivity and specificity for detecting high acuity of illness or injury. This performance analysis may be used to identify target protocols for future improvements.
**
Speaking of lights and sirens and ambulance crashes, I was disappointed with the final episode of SAVED. In the end, the medic takes the ambulance lights and sirens to see his girl hoping to catch her before she can leave town with the man she doesn’t love. He is distracted to find his partner in the back who has possibly ODed due to domestic unhappiness. He runs the red light and they are t-boned by a semi-truck.
Now despite all the inaccuracies and quibbles here and there seen though a medic’s eyes, I still really enjoyed the season, and hope it gets renewed. In the end, I think it does raise our profile in the public eye, conveys some of the feeling of what it is like to be a medic, and portrays us as carrying, and at times, heroic people. For TV, that’s doing well. And frankly we need all the help we can, so I send them out a nod of appreciation.
**
Here's a story about an interesting study that shows there is no correlation between pain and vital signs.
Correlating Self-Reported Pain and Vital Signs
Here are his concluding remarks:
I have also heard health-care providers say, "Well, he can't be in much pain because he isn't even tachycardic." This study is a milestone in my book to the fact that every patient's pain is theirs and theirs alone. We have created so many myths and personal biases regarding pain that it gets in the way of caring for our patients. Our traditional teaching has been so ingrained in us with these myths that when we don't see the expected changes in vital signs, we assume the patient is simply not in as much pain as they profess.
It may be true that if your patient is tachycardic, tachypneic or hypertensive that it could be a reflection of his or her degree of pain. This is useful when you have the stoic patient who refuses to confess how much it hurts. However, the converse is not true, as it was eloquently demonstrated in this study.
Remember: Our job is not to keep the patients from becoming junkies. It's to provide compassionate care and relieve pain and suffering. Leave the prejudice to someone less enlightened than you.
**
I rode today with another paramedic and her preceptee. I had called in looking for a shift, and hers was open. They didn’t tell me she had a preceptee with her. That was all right. I just drove, and let them do the calls. The preceptee is a bright articulate young man, who I think will be an excellent medic. We had no real challenging calls, but I could see he had a good head and common sense. We were in one of the newer ambulance, where the emergency lights are in the ceiling above you head. Supposedly, you just reach up and hit emergency master and they all light up. We got a call to intercept with a basic car that needed a medic, so I looked up, hit the emergency master and off we went. I drove a little faster than normal because I wanted to be able to hit the intercept point before the other ambulance, which was already enroute passed it. We made it fine. Later, the driver of the other ambulance mentioned I had had my siren on, but no lights. I guess, whoever was in the car before me had turned the individual emergency lights off, so you had to not only hit the emergency master, you had to then hit each of the lights. D’ooh! Oh, well.
**
Consider the following merely an idea brewing in my head, a troublesome unformed idea:
The other day I had an interesting talk with an EMT, who used to work in the dispatch center, which is located in another city from us. He works the road, but still keeps his feet in various dispatch centers. While like many road people, I find dispatchers annoying and easy to blame, they do have their side to tell. While I may suspect them of sending me on a priority one for something I don't think should be lights and sirens only because they want to clear their screens( by getting us to the call quicker to get us to the hospital sooner, and clear for the next call sooner) there may in fact be more to it.
We used to have dispatch right in our same building, and we all knew and saw each other everyday, and the dispatchers often knew the streets better than we did, so for the most part we got along. For the most part, they were good to us, we were good to them. It was also in the days before EMD, when dispatchers could use their common sense in selecting how to send us to the call. Now, we hire non-medically trained people to EMD the calls, which I understand is what the EMD company prefers so that the call takers won’t deviate from the algorithm. The ambulance company I guess gets a better insurance rate as long as they stick to the algorithm – the EMD company will defend them in court. The problem is, the dispatchers, whose hands I guess are tired by the call-takers work (And the call-takers side may simply be we're just doing our jobs as we have been trained), end up sending us priority one all the time for difficulty breathings simply because the patient is not breathing normally, but there is no context. Maybe they are COPDers and this is their baseline, and their problem today is a skin tear. Maybe they have had pneumonia for a few days and the doctor has finally decided to send them in for hydration and antibiotics. An glaring example the other day we were sent priority one for difficulty breathing only to find the call was for a psych who was breathing rapidly because she was agitated because the nurse wouldn’t let her watch the show she wanted on the common TV. We found her with a cigarette in her mouth. I could go on. The calls are all appropriate per EMD, but inappropriate for a lights and sirens response per common sense.
I am a big fan of Bryan Bledsoe, an EMS physciaian and writer, who has made a name for himself, among other things exploding EMS myths. I believe I heard him once and another time read him making a reference to their being no science behind EMD – nothing that provided that it in fact made a difference in a measurable way. I eagerly wait for him or someone else to truly tackle the topic. In the meantime a few days ago I was browsing around on a site called Pub Med where you can look up research articles and I found some very recent ones, which I will write about soon in more detail, which showed how poorly many of the calls correlate to the EMD protocols they are assigned by the dispatcher. For instance, something like only 26% of calls given the chest pain protocol, are actually cardiac related, and I read another that I believe said only 1 out of 18 cardiac-related calls is a true MI. I seem to remember reading something that in many cases random chance did a better job of picking the appropriate response than EMD (I hope this isn’t so). Now, keep in mind these numbers are just out of my memory now, and I promise a deeper look into them. The bottom line tonight for me is that while we may all think of EMD as motherhood and apple pie, and may it protect us from liability, it may also not be doing the patients much good and may be putting us in harm’s way.
I’m going to look into this further, and promise to post my findings here, as well as the relevant research. I may in fact be wrong, but I also may be right.
Earlier today we were sent on a priority one by a town police department for a psych and arrived to find the man in handcuffs with about seven cops surrounding him, and the man was quite calm. While this call was not EMDed it came as a request from an officer, I would argue that our going lights and sirens did not contribute to saving anyone’s life and may in fact have endangered someone’s – ours and the public’s.
So here is the deal, I want to put all these things in a pot:
EMS
Evidence-based medicine
Research
Ambulance personnel
Ambulance Companies
Ambulance crashes
Unions
OSHA
Dispatchers
Police and fire requests for ambulance to their scenes
The public in their cars
The public who is sick
EMD
Lights and sirens policies
Safety equipment
First responders
Whatever else I think of
Mix it all up and see if I can come up with a statement about responding lights and sirens that is true.
Here's an abstract from one of the studies that just came out:
1: Acad Emerg Med. 2006 Sep;13(9):954-60. Epub 2006 Aug 7. Links
Comparison of the medical priority dispatch system to an out-of-hospital patient acuity score.Feldman MJ, Verbeek PR, Lyons DG, Chad SJ, Craig AM, Schwartz B.
Sunnybrook-Osler Center for Prehospital Care, 10 Carlson Court, Suite 640, Toronto, Ontario, Canada. mfeldman@socpc.ca
BACKGROUND: Although the Medical Priority Dispatch System (MPDS) is widely used by emergency medical services (EMS) dispatchers to determine dispatch priority, there is little evidence that it reflects patient acuity. The Canadian Triage and Acuity Scale (CTAS) is a standard patient acuity scale widely used by Canadian emergency departments and EMS systems to prioritize patient care requirements. OBJECTIVES: To determine the relationship between MPDS dispatch priority and out-of-hospital CTAS. METHODS: All emergency calls on a large urban EMS communications database for a one-year period were obtained. Duplicate calls, nonemergency transfers, and canceled calls were excluded. Sensitivity and specificity to detect high-acuity illness, as well as positive predictive value (PPV) and negative predictive value (NPV), were calculated for all protocols. RESULTS: Of 197,882 calls, 102,582 met inclusion criteria. The overall sensitivity of MPDS was 68.2% (95% confidence interval [CI] = 67.8% to 68.5%), with a specificity of 66.2% (95% CI = 65.7% to 66.7%). The most sensitive protocol for detecting high acuity of illness was the breathing-problem protocol, with a sensitivity of 100.0% (95% CI = 99.9% to 100.0%), whereas the most specific protocol was the one for psychiatric problems, with a specificity of 98.1% (95% CI = 97.5% to 98.7%). The cardiac-arrest protocol had the highest PPV (92.6%, 95% CI = 90.3% to 94.3%), whereas the convulsions protocol had the highest NPV (85.9%, 95% CI = 84.5% to 87.2%). The best-performing protocol overall was the cardiac-arrest protocol, and the protocol with the overall poorest performance was the one for unknown problems. Sixteen of the 32 protocols performed no better than chance alone at identifying high-acuity patients. CONCLUSIONS: The Medical Priority Dispatch System exhibits at least moderate sensitivity and specificity for detecting high acuity of illness or injury. This performance analysis may be used to identify target protocols for future improvements.
**
Speaking of lights and sirens and ambulance crashes, I was disappointed with the final episode of SAVED. In the end, the medic takes the ambulance lights and sirens to see his girl hoping to catch her before she can leave town with the man she doesn’t love. He is distracted to find his partner in the back who has possibly ODed due to domestic unhappiness. He runs the red light and they are t-boned by a semi-truck.
Now despite all the inaccuracies and quibbles here and there seen though a medic’s eyes, I still really enjoyed the season, and hope it gets renewed. In the end, I think it does raise our profile in the public eye, conveys some of the feeling of what it is like to be a medic, and portrays us as carrying, and at times, heroic people. For TV, that’s doing well. And frankly we need all the help we can, so I send them out a nod of appreciation.
**
Here's a story about an interesting study that shows there is no correlation between pain and vital signs.
Correlating Self-Reported Pain and Vital Signs
Here are his concluding remarks:
I have also heard health-care providers say, "Well, he can't be in much pain because he isn't even tachycardic." This study is a milestone in my book to the fact that every patient's pain is theirs and theirs alone. We have created so many myths and personal biases regarding pain that it gets in the way of caring for our patients. Our traditional teaching has been so ingrained in us with these myths that when we don't see the expected changes in vital signs, we assume the patient is simply not in as much pain as they profess.
It may be true that if your patient is tachycardic, tachypneic or hypertensive that it could be a reflection of his or her degree of pain. This is useful when you have the stoic patient who refuses to confess how much it hurts. However, the converse is not true, as it was eloquently demonstrated in this study.
Remember: Our job is not to keep the patients from becoming junkies. It's to provide compassionate care and relieve pain and suffering. Leave the prejudice to someone less enlightened than you.
Tuesday, September 05, 2006
Patience
Preceptees come in all types, ranging from those who are so smart you have to reread your books at night just to keep up with them to those who think the excuse “well, we didn’t go over that in class” covers them from any need to improve further. I’ve had preceptees for whom, on arriving at a scene, I had to open the back of the ambulance, and say, “Are you planning on getting out anytime soon?” to those who were already in the house with the patient intubated, a IV in their necks, and were whirling the defib paddles like numb-chucks before I could even make it in the door.
Some preceptees are dark clouds – I had one who got a tube on her first call, and who it seemed we went to so many multiple shootings, I actually considered buying a bullet-proof vest. And I had others who were white clouds, people who towns wanted to hire out because when they were on duty trauma and disease took the hours off.
When I first started as a preceptor I think I was much more accepting of a new medic’s ignorance because I was so close to my own precepting period where I frankly didn’t know much and felt it a miracle that I passed. Now I am less understanding of gaps in learning. But also back then I was not as forgiving if they missed an IV or their first shot at a tube. I’d push them right out of the way. I’m much more laid back now. I’ll be right at their side, schooling them in how to tube, manipulating the neck for them, coaching them through it or letting them go for the IV on the third try, if I think they will get it this time.
My new preceptee is a man just a few years younger than myself. I believe he will be the kind of paramedic the company needs. He is kind to the patients, intelligent, and not at all rash. Unfortunately, as far as his precepting goes, he is a white cloud. We have only been together a couple weeks, but we aren’t getting much. The one morning there was a code, it came in just before our shift, and hearing it on the radio, I responded right to the scene and met the night medic there, and we worked it together. My preceptee was waiting at the barn when we got back. “Fifteen minutes later and you would have had the call,” I said.
“Oh, well,” he said.
I consider patience one of my better qualities. My preceptee is patient too. The knock on him has been that he might be too slow on scene. I’m supposed to evaluate him on that. We haven’t really had a bad call yet to test how quick he can move when he has too. It's true he moves a little on the slow side on the calls we’ve been on, but not in a bad way. He reminds me somewhat of Columbo, the TV detective. He has a slow manner, but he is bright, and he ends up with the patient’s full attention. They feel he cares about them, that he listens.
Several of the calls we have had have tried my patience. I guess I am anxious because I want to get good calls for my preceptee. Here’s some of the ones we’ve had this week. The 80 year old man, fully dressed, who called because his home BP cuff gave him a reading of 106/72 and his pressure is usually 120/80, and he is concerned and believes he should go to the hospital because he felt slightly lightheaded when he stood up. The man is upset we brought the stretcher in, he can walk, he says, and no he hasn’t called his doctor. The woman who has a knot in her back and instead of driving to the hospital, drove back to her retirement community because they always call an ambulance for her and she could park her car, and then have the retirement community send their courtesy van when she is done seeing the doctor in the ER. The nursing home patient discharged a few days ago with pneumonia who is requesting to go to the hospital because he is worried his pneumonia is acting up, not because the staff has thought he should go.
And then there is Hazel. Hazel is a skinny old woman with a wig, who looks like a scrawny bird. She lives alone, and always wears a yellow bathroom that is faded and stained. Her house stinks of cigarette smoke. She has early dementia and calls us several times a week for nonspecific complaints. She’s constipated, she wants her blood pressure checked, and she didn’t sleep a wink all night. Sometimes her neighbor is there when we get there – her neighbor said Hazel once called her twenty-two times in one day. Lately, my approach to Hazel has been, you want to go to the hospital, get your coat, let’s go. I can’t take the smell in her apartment. It’s like she has smoked three packs a day for fifty years and has never once opened a window. When I first started getting called there, I tried to get social services involved believing she needed to be in a nursing home because of her increasing dementia. One day I gave her a HIPPA form. She started reading it, and then got bored and put it down. Then she discovered it again and started reading it again, and then got bored and put it down, only to discover it in her hand, and start reading again. I saw her in the hallway five hours later and she was still reading the HIPPA form like it was a racy novel.
The hospital has stopped working her up, and now she just goes to the waiting room. She isn’t demented enough I guess for a nursing home. Still she keeps calling. My preceptee has been with me to her house three times already. He’s very patient with her. I end up standing outside, breathing the fresh air, while he helps her lock up her house and get her things.
Yesterday was a slow day. We sat around a long time until we finally got a call. It was at an elderly apartment complex that just opened in a renovated building that used to be a nursing home. The call was for a medic alarm. A red light was flashing on the alarm board by the front door. The neighbors, seeing the flashing light, called 911. The night medic had warned me about the new place. The night before he’d talked to a commercial crew who had responded there, and taken the patient in. No one answered the apartment door, but before the policeman tried to kick the door in, I had him call dispatch and check and see if it was the same apartment as the one the crew went to the night before. It was, and dispatch now told us they had transported the resident. It seems no one had reset the button. So we cleared. One call, no patients.
We were so bored by then, I suggested we stop at Hazel’s house, walk in and say, “What’s wrong today? You called for an ambulance?” just to see what she would do. Whether she would be upset that she didn’t remember she had called for an ambulance or whether she would think that she had.
I know that wouldn’t have been very nice, but hey we were just cracking jokes, trying to pass the time. We spent much of the day watching the news coverage of the death of the crocodile hunter. What a bummer that was. At least he died doing something he loved. We joked that we were surprised it wasn’t a crocodile that had gotten him. Instead, it was a sting ray. Maybe it was an out-of-town job, we guessed. The crocks got together and called in a hired tail to do the job. Stingy. Made it look like a freak accident. But it was a hit. The word would get around the outback. Teach anyone else to mess with the crocks.
I know it’s not politically correct to make fun of an old lady with dementia or someone so recently tragically killed. Poor taste. But that’s how it is sometimes, particularly when you are bored. Paramedics with time on their hands.
Nothing for the rest of the day. At least it was a holiday. Double time and a half pay. Still I felt like a bad host. Instead of being out there being big bad paramedics – doing codes and MIs and rollovers and pushing all kinds of drugs, showing my preceptee the street life, we were sitting in the base living room, bored, reading the newspaper over and over, watching the same clips on TV. I was feeling restless. My preceptee sat in the arm chair, mouth open, snoring.
This morning, while we were talking about how today would be the day we’d get the good calls he needs before getting cut loose, the tones on the radio went off.
“Unit One!” the dispatcher called.
“Note the urgent quality to the dispatcher’s voice,” I said to my preceptee. “This is going to be good.”
“Unit One,” I answered.
“Female. Constipation.” He gave the familiar address. My preceptee started laughing.
“Hazel,” he said.
My preceptee does his usual stellar job with Hazel. She is all agitated. “I didn’t sleep a lick last night. I’m constipated. I feel horrible all over. I’m a wreck. I didn’t sleep at all. Close the door, you're letting the cold air in.”
"I need to hold the door open," I say, "Because there is no air in here. I can't breathe."
"Close the door. My, what a draft. I feel terrible. I hardly slept a lick," she says.
"Fine," I say. "I'm waiting outside."
"Don't mind him," my preceptee says, "He has a respiratory problem."
They come out of the house fifteen minutes later. She’s wearing her yellow stained bathrobe and tennis shoes and carrying her little purse, her wig slightly off kilter on her head.
The ED is not too busy today and the triage nurse assigns Hazel a bed in the non-urgent wing.
My preceptee gives the room nurse a report. I hand Hazel her HIPPA form.
Some preceptees are dark clouds – I had one who got a tube on her first call, and who it seemed we went to so many multiple shootings, I actually considered buying a bullet-proof vest. And I had others who were white clouds, people who towns wanted to hire out because when they were on duty trauma and disease took the hours off.
When I first started as a preceptor I think I was much more accepting of a new medic’s ignorance because I was so close to my own precepting period where I frankly didn’t know much and felt it a miracle that I passed. Now I am less understanding of gaps in learning. But also back then I was not as forgiving if they missed an IV or their first shot at a tube. I’d push them right out of the way. I’m much more laid back now. I’ll be right at their side, schooling them in how to tube, manipulating the neck for them, coaching them through it or letting them go for the IV on the third try, if I think they will get it this time.
My new preceptee is a man just a few years younger than myself. I believe he will be the kind of paramedic the company needs. He is kind to the patients, intelligent, and not at all rash. Unfortunately, as far as his precepting goes, he is a white cloud. We have only been together a couple weeks, but we aren’t getting much. The one morning there was a code, it came in just before our shift, and hearing it on the radio, I responded right to the scene and met the night medic there, and we worked it together. My preceptee was waiting at the barn when we got back. “Fifteen minutes later and you would have had the call,” I said.
“Oh, well,” he said.
I consider patience one of my better qualities. My preceptee is patient too. The knock on him has been that he might be too slow on scene. I’m supposed to evaluate him on that. We haven’t really had a bad call yet to test how quick he can move when he has too. It's true he moves a little on the slow side on the calls we’ve been on, but not in a bad way. He reminds me somewhat of Columbo, the TV detective. He has a slow manner, but he is bright, and he ends up with the patient’s full attention. They feel he cares about them, that he listens.
Several of the calls we have had have tried my patience. I guess I am anxious because I want to get good calls for my preceptee. Here’s some of the ones we’ve had this week. The 80 year old man, fully dressed, who called because his home BP cuff gave him a reading of 106/72 and his pressure is usually 120/80, and he is concerned and believes he should go to the hospital because he felt slightly lightheaded when he stood up. The man is upset we brought the stretcher in, he can walk, he says, and no he hasn’t called his doctor. The woman who has a knot in her back and instead of driving to the hospital, drove back to her retirement community because they always call an ambulance for her and she could park her car, and then have the retirement community send their courtesy van when she is done seeing the doctor in the ER. The nursing home patient discharged a few days ago with pneumonia who is requesting to go to the hospital because he is worried his pneumonia is acting up, not because the staff has thought he should go.
And then there is Hazel. Hazel is a skinny old woman with a wig, who looks like a scrawny bird. She lives alone, and always wears a yellow bathroom that is faded and stained. Her house stinks of cigarette smoke. She has early dementia and calls us several times a week for nonspecific complaints. She’s constipated, she wants her blood pressure checked, and she didn’t sleep a wink all night. Sometimes her neighbor is there when we get there – her neighbor said Hazel once called her twenty-two times in one day. Lately, my approach to Hazel has been, you want to go to the hospital, get your coat, let’s go. I can’t take the smell in her apartment. It’s like she has smoked three packs a day for fifty years and has never once opened a window. When I first started getting called there, I tried to get social services involved believing she needed to be in a nursing home because of her increasing dementia. One day I gave her a HIPPA form. She started reading it, and then got bored and put it down. Then she discovered it again and started reading it again, and then got bored and put it down, only to discover it in her hand, and start reading again. I saw her in the hallway five hours later and she was still reading the HIPPA form like it was a racy novel.
The hospital has stopped working her up, and now she just goes to the waiting room. She isn’t demented enough I guess for a nursing home. Still she keeps calling. My preceptee has been with me to her house three times already. He’s very patient with her. I end up standing outside, breathing the fresh air, while he helps her lock up her house and get her things.
Yesterday was a slow day. We sat around a long time until we finally got a call. It was at an elderly apartment complex that just opened in a renovated building that used to be a nursing home. The call was for a medic alarm. A red light was flashing on the alarm board by the front door. The neighbors, seeing the flashing light, called 911. The night medic had warned me about the new place. The night before he’d talked to a commercial crew who had responded there, and taken the patient in. No one answered the apartment door, but before the policeman tried to kick the door in, I had him call dispatch and check and see if it was the same apartment as the one the crew went to the night before. It was, and dispatch now told us they had transported the resident. It seems no one had reset the button. So we cleared. One call, no patients.
We were so bored by then, I suggested we stop at Hazel’s house, walk in and say, “What’s wrong today? You called for an ambulance?” just to see what she would do. Whether she would be upset that she didn’t remember she had called for an ambulance or whether she would think that she had.
I know that wouldn’t have been very nice, but hey we were just cracking jokes, trying to pass the time. We spent much of the day watching the news coverage of the death of the crocodile hunter. What a bummer that was. At least he died doing something he loved. We joked that we were surprised it wasn’t a crocodile that had gotten him. Instead, it was a sting ray. Maybe it was an out-of-town job, we guessed. The crocks got together and called in a hired tail to do the job. Stingy. Made it look like a freak accident. But it was a hit. The word would get around the outback. Teach anyone else to mess with the crocks.
I know it’s not politically correct to make fun of an old lady with dementia or someone so recently tragically killed. Poor taste. But that’s how it is sometimes, particularly when you are bored. Paramedics with time on their hands.
Nothing for the rest of the day. At least it was a holiday. Double time and a half pay. Still I felt like a bad host. Instead of being out there being big bad paramedics – doing codes and MIs and rollovers and pushing all kinds of drugs, showing my preceptee the street life, we were sitting in the base living room, bored, reading the newspaper over and over, watching the same clips on TV. I was feeling restless. My preceptee sat in the arm chair, mouth open, snoring.
This morning, while we were talking about how today would be the day we’d get the good calls he needs before getting cut loose, the tones on the radio went off.
“Unit One!” the dispatcher called.
“Note the urgent quality to the dispatcher’s voice,” I said to my preceptee. “This is going to be good.”
“Unit One,” I answered.
“Female. Constipation.” He gave the familiar address. My preceptee started laughing.
“Hazel,” he said.
My preceptee does his usual stellar job with Hazel. She is all agitated. “I didn’t sleep a lick last night. I’m constipated. I feel horrible all over. I’m a wreck. I didn’t sleep at all. Close the door, you're letting the cold air in.”
"I need to hold the door open," I say, "Because there is no air in here. I can't breathe."
"Close the door. My, what a draft. I feel terrible. I hardly slept a lick," she says.
"Fine," I say. "I'm waiting outside."
"Don't mind him," my preceptee says, "He has a respiratory problem."
They come out of the house fifteen minutes later. She’s wearing her yellow stained bathrobe and tennis shoes and carrying her little purse, her wig slightly off kilter on her head.
The ED is not too busy today and the triage nurse assigns Hazel a bed in the non-urgent wing.
My preceptee gives the room nurse a report. I hand Hazel her HIPPA form.
Sunday, September 03, 2006
Note to Fellow Bloggers
I have added a blogroll. If you have an EMS related blog and want it to be listed in the column on the bottom right(or delisted if I have already added you), post a comment here listing the http of your blog or send me an email at: peter@petercanning.org
Thanks.
Thanks.
Saturday, September 02, 2006
Waiting
I go back to work tomorrow morning at six. I last worked the Wednesday overnight in the suburbs, which really wasn’t like working because I slept all night in a bed, and only did one call at five-thirty in the morning, and I didn’t even have to tech that one. I was planning to work on Friday and Saturday, but there were no shifts open. Lately all I’ve had to do was call in to get a shift, but I guess they’ve hired more people or maybe it’s the college students wanting to score a last pay-day before hitting the books. At any rate, I found myself with some unplanned free time.
Thursday I sat on the couch all day and watched the entire 12 episodes of The Wire: The Complete Season Three. If you have never watched it, it is the best show on cable TV. I don’t have HBO, but I liked to buy or rent the series when they come out on DVD. The wire is about cops, drug dealers and politicians in Baltimore. Each episode involves a “wire” where the special police unit listens in on the drug dealers. What is great about the series is the quality of writing and acting. Phenomenal dialogue. The stories are very realistic, and the personalities are complex. Lots of shades of gray. The cops and politicians and drug dealers are all very similar in their approaches. One of the main protagonists is a cop, who is all about the case. He’ll disobey superiors to do what is necessary to solve the case. He is “good police” but being “good police” is always getting him in trouble with his superiors. Plus his personal life is screwed up. He’s divorced, he’s broke, he drinks too much.
He gets in an argument with his buddy about how all that matters is getting the case solved, and his buddy asks him what he’s going to do with his life if he ever does get the case solved, if he will feel fulfilled or will he be just as empty the next morning after the night’s celebratory drinking, as he is now, and when will it end. He tells him life is what is happening to him while he's too busy with the case to notice.
There is another character who is a police major who grew up on the streets and decides to try an innovative strategy to solve the horrible crime rate -— he pushes the drug trade in his district into an abandoned section where he tells the dealers he will leave them alone as long as they stay in the special zones. It works great for awhile, the street corners are safe for people to walk on again, crime is way down, they are even sending health people in to do needle exchange, health and intervention programs, but he knows it won’t last, that when it is discovered that he has basically legalized drugs, there will be a shitstorm, and he’ll be on the wrong end of it, and then the streets will go back to what they were and he’ll have lost his command, but he does it anyway. He's glad he's at least doing something.
And there are two drug dealers who have come up together from the streets, and while one is in prison the other sets up these elaborate private and legitimate businesses – basically insulating them from the street, which they still control but are removed from the violence and the reach of police. They have more money than they could ever spend. But when the guy gets out of prison, he can’t deal with the fact that someone else is on his corners or that his rep suffers because the higher interests of business say don’t retaliate to a small slight, keep the streets quiet, the business going, the profits coming in. His friend asks him “Is it about the money or your rep?”
I was doing a lot of thinking that day. Good story-telling will do that to you.
I thought about the great Karl Wallenda, the guy who walked on the high wire. He said he was only alive when he was on the wire, everything else was waiting. He of course plunged to his death when a gust of wind swept him into the void.
Who are we? How do we see ourselves? What matters most about our time on earth? I can toss out the stock answers: family, God for some, the community, peace on earth. I don’t know. Everyone has their own inner fire, their inner drives, their lonesome valleys – their walks to make.
So, Friday I go to the gym. Pump the iron. I’m starting to get back into some shape after slacking off for awhile. I need the gym today. I’m a little out of sorts. My friend who has cancer emailed me that after her treatment her physical exam that day showed no signs of her tumor. There was some transmission problem with the CAT SCAN, so she didn’t have those results, but it all sounded like great news. I emailed back a Whoo-Hoo! but then I was bothered by the Cat Scan line. I had a growing bad feeling and when I called her that night, it was confirmed – there was a lesion in a new area. They have to do more tests, but still, it just sounded like the weight of the world was back on her, the big shadow approaching again. I didn't know what to say to her. I felt helpless.
I did some errands, went out to Best Buy and bought a CD for the first time in a long time. The new Bob Dylan - Modern Times. I listened to it while I drank beer and played on-line poker. When it comes to poker, I’m a grinder not a gambler. I only play limits I can beat. I’m patient; I sit and wait, bet when the odds are in my favor, fold if there is any doubt. I’m a steady winner, but you won’t see me on TV, I’ll have no big cashes. Just slow and steady. I don’t win every session – I am as subject to fate and the standard deviation as the next man, but I’m better than most at the tables I play. I don’t sit down with the sharks. I just wait. Discipline is key. I like to drink beer when I play so there is another battle going on – the battle between the beer and the sense, but lately it doesn’t matter. I can sit down with a cooler full and I don’t loose my control. Fold, fold, over and over, waiting my moment to raise, my moment to go all-in. Every month I tabulate my modest earnings. Not anything to retire on -- no new car this year. Still every little bit helps.
I’m not always like that in real life – not always in control. Maybe that’s why I try so hard to master it at the poker table. They say poker reveals your true character. It may be so, but life is where your character counts.
Dylan’s album is the third in a trilogy. It’s really good. The last album had a song called "Mississippi" about a guy whose ship has been " splint to splinters" that has another great line in it that goes “The only thing I did wrong, I stayed in Mississippi a day too long.” I remember playing it for my friend. It was a good drinking song. It’s the kind of song you sing with a beer in your hand(and empties on the table)-- and you sing it aloud and give a joyous finger to the fates all waiting for you again outside the barroom.
The new album has a song about a guy who says, “They burnt my barn and stole my horse.” But he’s still strong enough to sing about it.
I guess that’s the important thing – to be strong enough to recognize that everything is little shit compared to the important shit and the important shit is the ability to sing your songs -- to try to be good police or a good paramedic – to solve the case, to do what you feel you need to even if its going to come back and burn you, to care in your heart about something -- family, god, the job --whatever, as long as you give a damn.
I slept till I got up this morning. It was a cold day, raining off and on and I used that as an excuse not to mow my overgrown lawn. I worked some on my novel, and then took my girlfriend’s eleven-year-old to a big agricultural fair. It was a long drive to get there most of it on empty wooded country roads. Over an hour trip. For awhile there I thought I was lost, thought I had taken a wrong turn, cursing myself for leaving the directions at home, trying to rely on my memory. But then there ahead was the Ferris wheel.
My young traveling friend wasn’t feeling too well so we just walked around for awhile. It was cold and windy and the rain was threatening again. She wasn’t up to going on any rides and the barker’s come-ons didn’t interest her. She didn't like the smell of the animals in the barns. I bought her some cotton candy and fried dough with powdered sugar on it. We had an artist draw a portrait of her that came out okay. We only stayed an hour. She thanked me when I dropped her off back at home and asked if I was working tomorrow. I said I was. She said okay, and asked if I could take her swimming at the indoor pool the next time I had a day off. I said I would.
Now I’m listening to Dylan again, playing poker -- I'm up $27 -- and hoping to get to bed at a reasonable hour. No beer tonight. I’ve already got my uniform laid out for tomorrow, my backpack in the car.
I’ll punch in about ten minutes before six, although they won’t start paying me until six. I’ll check my gear out, check the rig, and then I’ll wait.
Wait to see what the day, what the job brings, what life has out there waiting me.
Thursday I sat on the couch all day and watched the entire 12 episodes of The Wire: The Complete Season Three. If you have never watched it, it is the best show on cable TV. I don’t have HBO, but I liked to buy or rent the series when they come out on DVD. The wire is about cops, drug dealers and politicians in Baltimore. Each episode involves a “wire” where the special police unit listens in on the drug dealers. What is great about the series is the quality of writing and acting. Phenomenal dialogue. The stories are very realistic, and the personalities are complex. Lots of shades of gray. The cops and politicians and drug dealers are all very similar in their approaches. One of the main protagonists is a cop, who is all about the case. He’ll disobey superiors to do what is necessary to solve the case. He is “good police” but being “good police” is always getting him in trouble with his superiors. Plus his personal life is screwed up. He’s divorced, he’s broke, he drinks too much.
He gets in an argument with his buddy about how all that matters is getting the case solved, and his buddy asks him what he’s going to do with his life if he ever does get the case solved, if he will feel fulfilled or will he be just as empty the next morning after the night’s celebratory drinking, as he is now, and when will it end. He tells him life is what is happening to him while he's too busy with the case to notice.
There is another character who is a police major who grew up on the streets and decides to try an innovative strategy to solve the horrible crime rate -— he pushes the drug trade in his district into an abandoned section where he tells the dealers he will leave them alone as long as they stay in the special zones. It works great for awhile, the street corners are safe for people to walk on again, crime is way down, they are even sending health people in to do needle exchange, health and intervention programs, but he knows it won’t last, that when it is discovered that he has basically legalized drugs, there will be a shitstorm, and he’ll be on the wrong end of it, and then the streets will go back to what they were and he’ll have lost his command, but he does it anyway. He's glad he's at least doing something.
And there are two drug dealers who have come up together from the streets, and while one is in prison the other sets up these elaborate private and legitimate businesses – basically insulating them from the street, which they still control but are removed from the violence and the reach of police. They have more money than they could ever spend. But when the guy gets out of prison, he can’t deal with the fact that someone else is on his corners or that his rep suffers because the higher interests of business say don’t retaliate to a small slight, keep the streets quiet, the business going, the profits coming in. His friend asks him “Is it about the money or your rep?”
I was doing a lot of thinking that day. Good story-telling will do that to you.
I thought about the great Karl Wallenda, the guy who walked on the high wire. He said he was only alive when he was on the wire, everything else was waiting. He of course plunged to his death when a gust of wind swept him into the void.
Who are we? How do we see ourselves? What matters most about our time on earth? I can toss out the stock answers: family, God for some, the community, peace on earth. I don’t know. Everyone has their own inner fire, their inner drives, their lonesome valleys – their walks to make.
So, Friday I go to the gym. Pump the iron. I’m starting to get back into some shape after slacking off for awhile. I need the gym today. I’m a little out of sorts. My friend who has cancer emailed me that after her treatment her physical exam that day showed no signs of her tumor. There was some transmission problem with the CAT SCAN, so she didn’t have those results, but it all sounded like great news. I emailed back a Whoo-Hoo! but then I was bothered by the Cat Scan line. I had a growing bad feeling and when I called her that night, it was confirmed – there was a lesion in a new area. They have to do more tests, but still, it just sounded like the weight of the world was back on her, the big shadow approaching again. I didn't know what to say to her. I felt helpless.
I did some errands, went out to Best Buy and bought a CD for the first time in a long time. The new Bob Dylan - Modern Times. I listened to it while I drank beer and played on-line poker. When it comes to poker, I’m a grinder not a gambler. I only play limits I can beat. I’m patient; I sit and wait, bet when the odds are in my favor, fold if there is any doubt. I’m a steady winner, but you won’t see me on TV, I’ll have no big cashes. Just slow and steady. I don’t win every session – I am as subject to fate and the standard deviation as the next man, but I’m better than most at the tables I play. I don’t sit down with the sharks. I just wait. Discipline is key. I like to drink beer when I play so there is another battle going on – the battle between the beer and the sense, but lately it doesn’t matter. I can sit down with a cooler full and I don’t loose my control. Fold, fold, over and over, waiting my moment to raise, my moment to go all-in. Every month I tabulate my modest earnings. Not anything to retire on -- no new car this year. Still every little bit helps.
I’m not always like that in real life – not always in control. Maybe that’s why I try so hard to master it at the poker table. They say poker reveals your true character. It may be so, but life is where your character counts.
Dylan’s album is the third in a trilogy. It’s really good. The last album had a song called "Mississippi" about a guy whose ship has been " splint to splinters" that has another great line in it that goes “The only thing I did wrong, I stayed in Mississippi a day too long.” I remember playing it for my friend. It was a good drinking song. It’s the kind of song you sing with a beer in your hand(and empties on the table)-- and you sing it aloud and give a joyous finger to the fates all waiting for you again outside the barroom.
The new album has a song about a guy who says, “They burnt my barn and stole my horse.” But he’s still strong enough to sing about it.
I guess that’s the important thing – to be strong enough to recognize that everything is little shit compared to the important shit and the important shit is the ability to sing your songs -- to try to be good police or a good paramedic – to solve the case, to do what you feel you need to even if its going to come back and burn you, to care in your heart about something -- family, god, the job --whatever, as long as you give a damn.
I slept till I got up this morning. It was a cold day, raining off and on and I used that as an excuse not to mow my overgrown lawn. I worked some on my novel, and then took my girlfriend’s eleven-year-old to a big agricultural fair. It was a long drive to get there most of it on empty wooded country roads. Over an hour trip. For awhile there I thought I was lost, thought I had taken a wrong turn, cursing myself for leaving the directions at home, trying to rely on my memory. But then there ahead was the Ferris wheel.
My young traveling friend wasn’t feeling too well so we just walked around for awhile. It was cold and windy and the rain was threatening again. She wasn’t up to going on any rides and the barker’s come-ons didn’t interest her. She didn't like the smell of the animals in the barns. I bought her some cotton candy and fried dough with powdered sugar on it. We had an artist draw a portrait of her that came out okay. We only stayed an hour. She thanked me when I dropped her off back at home and asked if I was working tomorrow. I said I was. She said okay, and asked if I could take her swimming at the indoor pool the next time I had a day off. I said I would.
Now I’m listening to Dylan again, playing poker -- I'm up $27 -- and hoping to get to bed at a reasonable hour. No beer tonight. I’ve already got my uniform laid out for tomorrow, my backpack in the car.
I’ll punch in about ten minutes before six, although they won’t start paying me until six. I’ll check my gear out, check the rig, and then I’ll wait.
Wait to see what the day, what the job brings, what life has out there waiting me.
Friday, September 01, 2006
Blood Sweat and Tea
I've been reading (and enjoying) Blood Sweat and Tea by U.K. blogger Tom Reynolds. The book contains excerpts from his blog Random Acts of Reality. He has been blogging since 2003 about his life and work as an EMT in inner city London. He writes five times a week, and from his posts EMS in London isn't much different than here in the United States.
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