A patient with Alzheimer’s and an unsteady gait falls and has a small bruise on her nose. The doctor wants her evaluated even though there doesn’t seem to be anything wrong. A 21 year old woman at a minimum wage assembly plant feels dizzy and has a headache – a common complaint at this plant. The nurse calls 911. A mother says her infant is having trouble breathing, and has been for the last two weeks. It has a runny nose.
I just say, “What hospital do you want to go to?” I put them on the stretcher and take them. I try to do it with a smile, and without conveying the slightest "You called an ambulance 911 for this!" irritation.
I came to work this morning, slept for two hours until the tones woke me up. Later, I cooked some coconut chicken, and got to eat half of it at the table, and the other half as we drove lights and sirens to a chest pain – our one real call of the day. In between calls I also got to catch up on my email, work on my novel and play some poker on my computer simulator.
I have it pretty easy. No lash marks on my back.
The least I can do is smile and be nice.
Tuesday, October 31, 2006
Sunday, October 29, 2006
Saturday, October 28, 2006
Routine
Routine. Routine. Routine. Twice in just a couple weeks I have been saved by routine.
Here’s what happened this time.
First, a little background. The first responders in one of the towns I work in have decided they will no longer respond to lift assists without injury. It was argued to the high-ups that well, you never really know until you get there, but to no avail. The first responders have other priorities and the ambulance can do the lift assist if no one is injury. I just found out about the policy. I didn’t even know it was in effect. We have such a good relationship with the first responders. It seems they are always there helping us.
Anyway, so we get sent to the “lift assist, no injuries,” and are told there will be no first responder. I explain the policy to my partner, who hadn’t heard of either.
The call is at an elderly apartment complex. A neighbor meets us at the door and leads us into a bedroom, where we find an obese sixty-year-old woman laying flat on the bed, unable to sit up. She is alert and oriented. I touch her forehead it is warm and dry. She says she is weak, and while she normally could get up, she can’t. I ask her if she is a diabetic. She says she is. I ask if she checked her sugar. She said she did earlier and it was fine. Her speech is clear, but when I test handgrips, her left side is weaker. I do the arm drift test and she can’t hold her left arm up. She looks like she might have slight facial droop, but I’m not sure of it. She says she was up around four to have breakfast, and was walking fine, and then she went back to bed, and couldn’t get up when she heard her neighbor knocking at seven.
“This may be a priority after all,” I tell my partner. “We may be on the clock.”
The woman is a difficult lift – it would help to have the first responders there, but we don’t have time. She is already close to the three hour prehospital stroke window. With her neighbor’s help – holding the woman’s feet, we are able to spin her around from the far side of the bed to the closer side, and then lift her on the bed sheet onto our stretcher.
Out in the ambulance, as we race to the hospital lights and sirens, I ask the woman if she has ever had a stroke or a TIA before.
“Is that what I’m having now?” she asks, “A stroke?” Her eyes tear up.
“It could be. You’re left side is weak. We’ll let the hospital decide.”
I search for a vein. She says they need to use a butterfly on her. I take a stab at the AC, but come up with nothing. When I pull the needle out of her arm, there is just a small dab of blood from the hole I made. I take out the glucometer and do a sugar check off of it. Just to cover all my bases.
LO
LO means less than 20.
“This might be good news. You’re sugar is low.”
“That can cause a stroke?”
“Not a stroke, but it can make you look like you are having a stroke. I’m not saying that’s the problem, but I’m going to give you some sugar and we’ll see.”
I’m wondering what she is doing talking to me if her sugar is less than 20. In most people she would be unconscious.
I renew my search for a vein, and find a tiny one on her right arm – enough to fit a 24 in. I recheck the sugar again – just to be sure in case my first reading was contaminated.
It still reads LO.
I then push the sugar – it actually flows quite well.
“Squeeze my hands.”
Equal grips.
“Hold your hands up in the air.”
They both stay up.
I unbuckle her strap. “Can you sit up for me?”
She sits bold upright.
“I think you’re fixed,” I say. To my partner, I say, “Slow it down and cut off the lights.”
**
I check a sugar on just about everyone – and of course it is part of the stroke protocol to check the sugar just in case it is the sugar causing the problem, but the key part is your routine just makes you used to doing it so you don’t forget, so you don’t end up at the hospital with a stroke protocol only to have the doctor say, “ah, did you check the sugar? It’s less than 20.”
**
Maybe that’s why first responders shouldn’t pick and chose calls. Sometimes “unable to get up – not injured” means a stroke or hypoglycemia. Sometimes it means cardiac arrest. I’ve had that happen before. A woman says, “My husband can’t get up...He’s cold.”
Sometimes there's nothing routine about routine.
Here’s what happened this time.
First, a little background. The first responders in one of the towns I work in have decided they will no longer respond to lift assists without injury. It was argued to the high-ups that well, you never really know until you get there, but to no avail. The first responders have other priorities and the ambulance can do the lift assist if no one is injury. I just found out about the policy. I didn’t even know it was in effect. We have such a good relationship with the first responders. It seems they are always there helping us.
Anyway, so we get sent to the “lift assist, no injuries,” and are told there will be no first responder. I explain the policy to my partner, who hadn’t heard of either.
The call is at an elderly apartment complex. A neighbor meets us at the door and leads us into a bedroom, where we find an obese sixty-year-old woman laying flat on the bed, unable to sit up. She is alert and oriented. I touch her forehead it is warm and dry. She says she is weak, and while she normally could get up, she can’t. I ask her if she is a diabetic. She says she is. I ask if she checked her sugar. She said she did earlier and it was fine. Her speech is clear, but when I test handgrips, her left side is weaker. I do the arm drift test and she can’t hold her left arm up. She looks like she might have slight facial droop, but I’m not sure of it. She says she was up around four to have breakfast, and was walking fine, and then she went back to bed, and couldn’t get up when she heard her neighbor knocking at seven.
“This may be a priority after all,” I tell my partner. “We may be on the clock.”
The woman is a difficult lift – it would help to have the first responders there, but we don’t have time. She is already close to the three hour prehospital stroke window. With her neighbor’s help – holding the woman’s feet, we are able to spin her around from the far side of the bed to the closer side, and then lift her on the bed sheet onto our stretcher.
Out in the ambulance, as we race to the hospital lights and sirens, I ask the woman if she has ever had a stroke or a TIA before.
“Is that what I’m having now?” she asks, “A stroke?” Her eyes tear up.
“It could be. You’re left side is weak. We’ll let the hospital decide.”
I search for a vein. She says they need to use a butterfly on her. I take a stab at the AC, but come up with nothing. When I pull the needle out of her arm, there is just a small dab of blood from the hole I made. I take out the glucometer and do a sugar check off of it. Just to cover all my bases.
LO
LO means less than 20.
“This might be good news. You’re sugar is low.”
“That can cause a stroke?”
“Not a stroke, but it can make you look like you are having a stroke. I’m not saying that’s the problem, but I’m going to give you some sugar and we’ll see.”
I’m wondering what she is doing talking to me if her sugar is less than 20. In most people she would be unconscious.
I renew my search for a vein, and find a tiny one on her right arm – enough to fit a 24 in. I recheck the sugar again – just to be sure in case my first reading was contaminated.
It still reads LO.
I then push the sugar – it actually flows quite well.
“Squeeze my hands.”
Equal grips.
“Hold your hands up in the air.”
They both stay up.
I unbuckle her strap. “Can you sit up for me?”
She sits bold upright.
“I think you’re fixed,” I say. To my partner, I say, “Slow it down and cut off the lights.”
**
I check a sugar on just about everyone – and of course it is part of the stroke protocol to check the sugar just in case it is the sugar causing the problem, but the key part is your routine just makes you used to doing it so you don’t forget, so you don’t end up at the hospital with a stroke protocol only to have the doctor say, “ah, did you check the sugar? It’s less than 20.”
**
Maybe that’s why first responders shouldn’t pick and chose calls. Sometimes “unable to get up – not injured” means a stroke or hypoglycemia. Sometimes it means cardiac arrest. I’ve had that happen before. A woman says, “My husband can’t get up...He’s cold.”
Sometimes there's nothing routine about routine.
Thursday, October 26, 2006
The Field, not the Class
Monday and Tuesday I spent in field training officer/preceptor classroom training. We all thought the meetings were going to be about going over the nuts and bolts of the job, but it was instead more of a focus on safety issues and adult learning.
I hate meetings, particularly mandated day long meetings that cover material required to be taught by either some law or policy. During Hurricane Katrina, some of us were sent down to Mississippi. Because we were a private company, our employees were “on the ground” and helping almost immediately. I later heard stories of fire departments that went down as part of the federal effort and were required to spend days in classrooms getting sexual harassment and other training before they could start. Which doesn’t mean, our company doesn’t subject its employees to long meetings. To comply with our national training officer standard we had to sit through these two days or we would no longer be able to train other people. We got paid for it, but still it was painful.
The first day was about safety and we had to watch these homemade films about accidents and poor management styles. It either starred employee volunteers or some pretty bad actors playing employees. At one point I said the problem was no longer the employee it was the company’s for not firing the one guy who in nearly every scene was doing something stupid.
While the teacher was a good guy and there is no denying the need to emphasize safety, keeping 30 EMTs and medics in a class for eight hours is a hard task. We are all let’s get out there and do it types. Me, I can’t sit for more than an hour or two without going nuts. I was trying not to be rude, while surreptitiously doing the crossword puzzle in the daily paper. I needed to keep my mind busy.
The 2nd day focused on adult learning. The teacher was pretty good, but still it was a long day. The one cool part was we got to take a variety of personality tests, including the Myers-Briggs Personality Indicator and a left-brain, right-brain test. On the Myers-Briggs test, I came out an INFJ, which means I would be a good writer/editor or a nurse, which I will take to count as a paramedic also. On the right brain left brain I was 2/3 right-brain to 1/3 left brain. On the control test, I came out believing strongly in my own skills as opposed to luck or fate. On a management test I did really well except in one category about the setting of goals or standards for employees, where I came out worse than entry level managers. I went back and looked at the scoring and saw where I lost points. Here’s the one question where I lost major points.
“New supervisors may think they are going to make a big hit by holding their personnel to high standards, but they soon learn that doing so does not work.”
I wrote “strongly agree” when the more correct answer was “strongly disagree.”
Maybe I misread the question. What I was reacting to was the tendency of new supervisors to come in and say I expect the best blah blah blah. They believe that giving a talk and setting a standard is like the magic wand and the expression “Make it be so.” Life doesn’t work like that. Getting things done involves truly managing the resources you have and the situations. Hard working laborers with no skills can’t build the Taj Mahal out of sticks, not to mention the government bureaucrat who won’t give you the permits to build. You need to use coaxing, political persuasion, creative thinking, training, everything in your bag of tricks to gradually build the resources you need to get the job done. I most admire the managers who everyone likes, even if they disagree with them because those managers listen and make you feel important and see you as a person. They are the managers you will do anything for. Of course those managers also need the vision to see the big picture.
Supervising isn’t ordering, it truly is managing. It’s the vision to see the big picture, and then putting pieces of a puzzle together while anticipating problems.
Anyway, enough of that. The tests, for whatever they are worth made me feel I am truly in the right field, and that this is my place.
The field, not the class.
I hate meetings, particularly mandated day long meetings that cover material required to be taught by either some law or policy. During Hurricane Katrina, some of us were sent down to Mississippi. Because we were a private company, our employees were “on the ground” and helping almost immediately. I later heard stories of fire departments that went down as part of the federal effort and were required to spend days in classrooms getting sexual harassment and other training before they could start. Which doesn’t mean, our company doesn’t subject its employees to long meetings. To comply with our national training officer standard we had to sit through these two days or we would no longer be able to train other people. We got paid for it, but still it was painful.
The first day was about safety and we had to watch these homemade films about accidents and poor management styles. It either starred employee volunteers or some pretty bad actors playing employees. At one point I said the problem was no longer the employee it was the company’s for not firing the one guy who in nearly every scene was doing something stupid.
While the teacher was a good guy and there is no denying the need to emphasize safety, keeping 30 EMTs and medics in a class for eight hours is a hard task. We are all let’s get out there and do it types. Me, I can’t sit for more than an hour or two without going nuts. I was trying not to be rude, while surreptitiously doing the crossword puzzle in the daily paper. I needed to keep my mind busy.
The 2nd day focused on adult learning. The teacher was pretty good, but still it was a long day. The one cool part was we got to take a variety of personality tests, including the Myers-Briggs Personality Indicator and a left-brain, right-brain test. On the Myers-Briggs test, I came out an INFJ, which means I would be a good writer/editor or a nurse, which I will take to count as a paramedic also. On the right brain left brain I was 2/3 right-brain to 1/3 left brain. On the control test, I came out believing strongly in my own skills as opposed to luck or fate. On a management test I did really well except in one category about the setting of goals or standards for employees, where I came out worse than entry level managers. I went back and looked at the scoring and saw where I lost points. Here’s the one question where I lost major points.
“New supervisors may think they are going to make a big hit by holding their personnel to high standards, but they soon learn that doing so does not work.”
I wrote “strongly agree” when the more correct answer was “strongly disagree.”
Maybe I misread the question. What I was reacting to was the tendency of new supervisors to come in and say I expect the best blah blah blah. They believe that giving a talk and setting a standard is like the magic wand and the expression “Make it be so.” Life doesn’t work like that. Getting things done involves truly managing the resources you have and the situations. Hard working laborers with no skills can’t build the Taj Mahal out of sticks, not to mention the government bureaucrat who won’t give you the permits to build. You need to use coaxing, political persuasion, creative thinking, training, everything in your bag of tricks to gradually build the resources you need to get the job done. I most admire the managers who everyone likes, even if they disagree with them because those managers listen and make you feel important and see you as a person. They are the managers you will do anything for. Of course those managers also need the vision to see the big picture.
Supervising isn’t ordering, it truly is managing. It’s the vision to see the big picture, and then putting pieces of a puzzle together while anticipating problems.
Anyway, enough of that. The tests, for whatever they are worth made me feel I am truly in the right field, and that this is my place.
The field, not the class.
Sunday, October 22, 2006
What Harm?
Four more chapters of the novel Mortal Men are posted at the following site:
Mortal Men
***
It's been a typical day in the suburbs. A nursing home rectal bleed, an elderly man from home with pneumonia, a lady with hypertension and a nose bleed, and a call from our most frequent flyer -- Hazel, the old woman with dementia, who I have written about in Patience and a couple other posts.
Today she was laying in bed and said she just wanted her heart checked. She didn't sleep a wink last night, she said. I told her we didn't check hearts. I could either take her to the ER where she could see a cardiologist or ED doctor, who could evaluate her.
"But how will I get home?" she asked.
"How have you gotten home the other two hundred times we've taken you to the hospital?"
"They make me take a taxi."
"Well, then you'll have to take a taxi?"
"But I just want my heart checked."
"Well, we need to take you down to the ER for that."
"But I don't want to go."
"You called us. We're here to take you?"
"But how will I get back?"
"You'll probably have to take a cab."
"But I just want my heart checked."
"Listen, I've taken your pulse and your blood pressure and they are both good, but I can't tell you your heart is good based on that, other than its still working. If you want a full heart check, they can do that at the ER. What have they told you when we've taken you in on the other two hundred occasions?"
"They told me it was anxiety and my heart was good."
"Well, we can take you down there and they can check it out one more time."
"But how will I get back?"
This went on and on, until she finaly signed a refusal. She had a neighbor with her, and I told the neighbor to call us if anything changed. The neighbor just rolled her eyes. "It never does," she said.
I suppose at the beginning I could have just put my stethoscope on her chest, listened awhile and pronounced her heart fine. What harm would that have really done?
Mortal Men
***
It's been a typical day in the suburbs. A nursing home rectal bleed, an elderly man from home with pneumonia, a lady with hypertension and a nose bleed, and a call from our most frequent flyer -- Hazel, the old woman with dementia, who I have written about in Patience and a couple other posts.
Today she was laying in bed and said she just wanted her heart checked. She didn't sleep a wink last night, she said. I told her we didn't check hearts. I could either take her to the ER where she could see a cardiologist or ED doctor, who could evaluate her.
"But how will I get home?" she asked.
"How have you gotten home the other two hundred times we've taken you to the hospital?"
"They make me take a taxi."
"Well, then you'll have to take a taxi?"
"But I just want my heart checked."
"Well, we need to take you down to the ER for that."
"But I don't want to go."
"You called us. We're here to take you?"
"But how will I get back?"
"You'll probably have to take a cab."
"But I just want my heart checked."
"Listen, I've taken your pulse and your blood pressure and they are both good, but I can't tell you your heart is good based on that, other than its still working. If you want a full heart check, they can do that at the ER. What have they told you when we've taken you in on the other two hundred occasions?"
"They told me it was anxiety and my heart was good."
"Well, we can take you down there and they can check it out one more time."
"But how will I get back?"
This went on and on, until she finaly signed a refusal. She had a neighbor with her, and I told the neighbor to call us if anything changed. The neighbor just rolled her eyes. "It never does," she said.
I suppose at the beginning I could have just put my stethoscope on her chest, listened awhile and pronounced her heart fine. What harm would that have really done?
Thursday, October 19, 2006
Yes
Back many months ago I wrote in Scenario about a call where I intubated a patient who was a DNR, but not a DNI. In the comments section there was discussion about the categories of DNR. In this state we have several different forms. The other day from the same nursing home where the DNR, but not DNI occurred, I had a patient with an advance directives sheet that listed Do CPR, Hospitalize, artificial nutrition, medicine, but Do NOT intubate. I think often people don’t know what they are signing. On one hand you have the intubate but no compressions, on the other, do compressions but don’t intubate.
**
I gave morphine twice in a row the other day. One to an eighty year old with a possible broken hip, who fell right to sleep. The other a seventeen year old football player with a possible dislocated shoulder. It knocked his pain down from an 8 to a 3. The x-rays showed no break or dislocation and he was sent home with Motrin. Should I have given him the morphine even though he had no eventual break or dislocation. Yes. He was in pain.
**
I was driving back from a call in the rain. I came up over a rose, and there was a line of cars stopped in the road. I hit the brakes and went into a controlled skid. I kept getting closer to the car in front of me. I tried to steer to avoid it, and fortunately after about a five second skid, stopped ten feet short. I looked in the rear-view mirror and saw the car behind me go skidding off the road to avoid me. No impacts thankfully.
**
I didn’t write about it at the time, but a week ago Tuesday at our monthly MAC meeting, the issue of morphine for abdominal pain came up again, and even though we had already passed it, we backed off. We are still permitting it specifically in the protocols, but are requiring medical control. We try to operate by consensus so if even one doctor insisits, we tend to back off. One of the arguments against morphine was that because ERs are so busy, and the loudest most complaining patients often get the most attention, calming down a patient with abdominal pain prehospitally may enable them to slip through the cracks in the ED. I didn’t say at the time because I was argued out about how there was never any research in the first place that morphine hindered diagnosis along with all the damage pain can to do a person, but what I wished I’d said was paramedics shouldn’t have to lower their standard of care just because the ED can’t provide it.
**
The new issue of JEMS has some good articles, including one that relates to the story Understand. It describes a county in Washington that came up with a “Compelling Reasons” guideline to prevent futile resuscitations.
The “Compelling Reasons” guidelines allow both EMTs and paramedics to withhold resuscitation if a patient has a preexisting terminal condition and the patient, family or caregivers indicate, in writing or verbally, that the patient did not want resuscitation. - October 2006 JEMS
Here’s the link to the article:
Futile Rescusitations
**
I gave morphine twice in a row the other day. One to an eighty year old with a possible broken hip, who fell right to sleep. The other a seventeen year old football player with a possible dislocated shoulder. It knocked his pain down from an 8 to a 3. The x-rays showed no break or dislocation and he was sent home with Motrin. Should I have given him the morphine even though he had no eventual break or dislocation. Yes. He was in pain.
**
I was driving back from a call in the rain. I came up over a rose, and there was a line of cars stopped in the road. I hit the brakes and went into a controlled skid. I kept getting closer to the car in front of me. I tried to steer to avoid it, and fortunately after about a five second skid, stopped ten feet short. I looked in the rear-view mirror and saw the car behind me go skidding off the road to avoid me. No impacts thankfully.
**
I didn’t write about it at the time, but a week ago Tuesday at our monthly MAC meeting, the issue of morphine for abdominal pain came up again, and even though we had already passed it, we backed off. We are still permitting it specifically in the protocols, but are requiring medical control. We try to operate by consensus so if even one doctor insisits, we tend to back off. One of the arguments against morphine was that because ERs are so busy, and the loudest most complaining patients often get the most attention, calming down a patient with abdominal pain prehospitally may enable them to slip through the cracks in the ED. I didn’t say at the time because I was argued out about how there was never any research in the first place that morphine hindered diagnosis along with all the damage pain can to do a person, but what I wished I’d said was paramedics shouldn’t have to lower their standard of care just because the ED can’t provide it.
**
The new issue of JEMS has some good articles, including one that relates to the story Understand. It describes a county in Washington that came up with a “Compelling Reasons” guideline to prevent futile resuscitations.
The “Compelling Reasons” guidelines allow both EMTs and paramedics to withhold resuscitation if a patient has a preexisting terminal condition and the patient, family or caregivers indicate, in writing or verbally, that the patient did not want resuscitation. - October 2006 JEMS
Here’s the link to the article:
Futile Rescusitations
Wednesday, October 18, 2006
Understand
The call is for a sudden death; mother took her last breaths according to the son, and does not wish to be resuscitated. They send us in a non-emergency mode. I tell my partner we should probably be going lights and sirens until we know what is going on. He radios dispatch and they say okay.
I know that something is going to be funky when we get there, and when we come down the street and I see no police cars out front, I let out my breath and say to myself, here goes.
I go up the steps carrying the monitor and house bag with my meds and intubation equipment. A large man with tears in his eyes meets us at the door. He is talking on his cell phone. “She stopped breathing about ten minutes ago,” he says to whoever is on the other end, “the police have just gotten here.”
“What’s going on?” I say, trying to get him to focus on me because I know I am going to have to make some split second decisions.” He doesn’t even know I am a paramedic and not the law officers he was expecting.
“My mother-in-law stopped breathing. It was her time. She hasn’t been well, but she went peacefully.”
“Is she a DNR?”
“Huh?”
“Is she a do not resuscitate?”
“Yes, I was talking to her yesterday, the visiting nurse was here and she was having trouble with breathing and the nurse wanted her to go to the hospital, but she said no more, she wouldn’t go. She said it was her time to go. She was ready.”
“Papers.” I said, “Do you have DNR paperwork for her?”
“Yes, they are in the safe.”
“Can you get them for me?”
“It’s locked. I don’t have the combination. My wife is coming. She’ll be here in about ten minutes.”
I know that he has no idea of the dilemma I am facing. We are taught that without the signed Do Not Resuscitate (DNR) paperwork, we have to try to resuscitate the patient.
“This is a legal thing,” I say. “We need the paperwork or else we’re obligated to try to revive her.”
“No, no, don’t put her through that that. Don’t do that to her. She was ready to die. It wouldn’t be right. She doesn’t want it.”
“I don’t want to do it either. I’m just trying to explain, there are some cases where one family member might say one thing and another something different.”
“This isn’t one. Don’t do it.”
“Where is she?
“In the bedroom.”
“Tell me more about her history,” as I start toward the bedroom. “Does she have cancer?”
“She had breast cancer, but she’s been getting fluid in her lungs. She said yesterday she didn’t want to go to the hospital. I was talking to her like I’m talking to you.”
The woman lies on the bed in pajamas. She looks dead, still, her face drained of color. I touch her forehead. It is hot – not cold or cool – hot like a fever. She isn’t breathing. She looks peaceful – looks well cared for – loved. There is a small glass of orange juice by the bedside.
I don’t want to work her, and I already know I’m not going to work her – I’m just not, but still I need to work through the legal morass.
“I’m going to have to call my medical control to get permission not to try to resuscitate her,” I tell the man as I place the leads on her.
“She doesn’t want anything done.”
“I don’t have the authority,” I say. “I have to call unless you have those papers.”
“My wife is on the way.”
I look at the monitor. I see a rhythm that startles me until I recognize it is a pacemaker. It is not as easy a sight as asystole.
I hear the police officers coming in. The man turns to talk with them. I hear them commiserating with him, saying they are sorry for his loss.
For the first time I put capnography on patient I am considering presuming to document the apnea and just to do something else while I formulate what I am going to say to my medical control physician. The capnography shows a flat line – apnea. There is no number reading, and then all of a sudden I see the number 7 pop up on the screen. It again startles me. It’s not a great number, but any number is a sign of life. It puzzles me as there is no wave form. It is not until later that I guess that it represented some gas passively escaping from the stomach.
I go out to the living room where the police and man are now talking. “Here’s what’s going to happen,” I say. I’m going out to the ambulance to call the ED doctor and get permission to presume. If they say its okay, then I don’t have to do anything.”
“Why do you have to do that?” the man says. “You didn’t do that when my father-in law died. You just called him dead.”
“Well we can do that is they are cold and stiff -- not if they are warm. There are legal criteria we have to follow."
“So I am supposed to sit her with her and wait for her to get cold before I call?”
“I don’t think it is going to be a problem,” I say, “It’s just something I need to do legally. I’m with you I don’t want to work her.”
“No one is going to do anything to her,” he says now, a hint of anger in his voice.
“I’ll be back,” I say.
Out in the rig, I call the hospital. I ask for the doctor’s medical control number and the nurse says I can get it when I get to the hospital. I was there earlier today and I saw two new doctors I had never seen before. This is not a good omen.
“I’m on scene with a 95-year old female, history of cancer, pulseless and apneic, who took her last breaths about fifteen minutes ago according to her son-in-law, who says she did not want to be resuscitated. They have DNR papers, but they are locked in a safe and the person with the combination won’t be here for another fifteen minutes. I would like permission to withhold resuscitation.”
There is a short silence, and then a question. “What is your ETA?”
“ETA? I’m on scene with a 95 year old pulseless apneic patient with a history of cancer. The family says the patient is a DNR, but the papers are locked in a safe. They will be able to open the safe in about ten minutes. I’m requesting permission to presume the patient, to not start CPR.”
There is a long silence.
My partner has come out. He says, “The man just told the cops he will fight anyone who tries to resuscitate her.”
Finally the hospital comes back on. “Are the papers legally signed?”
“They are locked in a safe,” I say, and then repeat what are usually the magic words, “This is a 95 year old with cancer. The family says she is a DNR, but the papers are in the safe and the person coming with the combination won’t be here for another ten minutes to open the safe. The family says she did not want to be resuscitated and now the son is threatening to attack anyone who tries. I’d like permission to presume.”
More silence, and they, “Okay, provided you stay until you can verify the papers.”
I repeat the order and then go back in the house.
The man looks at me in the way a man in a bar might look at another man with whom he has just had a serious confrontation, looking at me to see if it is over or if we will have to take it outside.
“I got permission,” I say, “But I can’t presume until I see the papers.”
“She’s on her way,” he says.
I hear a commotion at the back door and a crying woman comes in. The man talks with her and then he says to me, give me a minute and he and the woman go into the bedroom. I wait a moment and they come back. He has some papers in his hands. He hands me the papers. Dated almost ten years ago, it is a signed superior court paper – the jist of it says “ I, (blank) of sound mind and health, request that no heroic measures by taken should I fall ill…I do not wish to have CPR, etc.” It isn’t the official DNR, but it meets its purpose in my book.
I nod. “Okay.”
I go back in the room and look at the patient. The pacemaker has stopped now. It is flat line.
“A peaceful way to go,” my partner say. He holds a flowered sheet that he spreads over the patient up to her neck.
Out in the living room I tell the cops the time of presumption and give them my name and date of birth per protocol. I then approach the man, and say, “I’m sorry for your loss, and sorry for any apprehension I may have caused.”
We shake hands. “Thank you, that’s all right. I know you are just doing your job, but….” He looks me dead in the eye, my hand still gripped firmly in his. “You and I would have been wrestling.”
“I understand,” I say.
I walk out of the house, the monitor over my shoulder, in my hand the house bag with unopened intubation and med kits.
If he had fought, I would have let him pin me.
***
Postscript: Two days later, I read her obituary. It says she died "peacefully at home."
I know that something is going to be funky when we get there, and when we come down the street and I see no police cars out front, I let out my breath and say to myself, here goes.
I go up the steps carrying the monitor and house bag with my meds and intubation equipment. A large man with tears in his eyes meets us at the door. He is talking on his cell phone. “She stopped breathing about ten minutes ago,” he says to whoever is on the other end, “the police have just gotten here.”
“What’s going on?” I say, trying to get him to focus on me because I know I am going to have to make some split second decisions.” He doesn’t even know I am a paramedic and not the law officers he was expecting.
“My mother-in-law stopped breathing. It was her time. She hasn’t been well, but she went peacefully.”
“Is she a DNR?”
“Huh?”
“Is she a do not resuscitate?”
“Yes, I was talking to her yesterday, the visiting nurse was here and she was having trouble with breathing and the nurse wanted her to go to the hospital, but she said no more, she wouldn’t go. She said it was her time to go. She was ready.”
“Papers.” I said, “Do you have DNR paperwork for her?”
“Yes, they are in the safe.”
“Can you get them for me?”
“It’s locked. I don’t have the combination. My wife is coming. She’ll be here in about ten minutes.”
I know that he has no idea of the dilemma I am facing. We are taught that without the signed Do Not Resuscitate (DNR) paperwork, we have to try to resuscitate the patient.
“This is a legal thing,” I say. “We need the paperwork or else we’re obligated to try to revive her.”
“No, no, don’t put her through that that. Don’t do that to her. She was ready to die. It wouldn’t be right. She doesn’t want it.”
“I don’t want to do it either. I’m just trying to explain, there are some cases where one family member might say one thing and another something different.”
“This isn’t one. Don’t do it.”
“Where is she?
“In the bedroom.”
“Tell me more about her history,” as I start toward the bedroom. “Does she have cancer?”
“She had breast cancer, but she’s been getting fluid in her lungs. She said yesterday she didn’t want to go to the hospital. I was talking to her like I’m talking to you.”
The woman lies on the bed in pajamas. She looks dead, still, her face drained of color. I touch her forehead. It is hot – not cold or cool – hot like a fever. She isn’t breathing. She looks peaceful – looks well cared for – loved. There is a small glass of orange juice by the bedside.
I don’t want to work her, and I already know I’m not going to work her – I’m just not, but still I need to work through the legal morass.
“I’m going to have to call my medical control to get permission not to try to resuscitate her,” I tell the man as I place the leads on her.
“She doesn’t want anything done.”
“I don’t have the authority,” I say. “I have to call unless you have those papers.”
“My wife is on the way.”
I look at the monitor. I see a rhythm that startles me until I recognize it is a pacemaker. It is not as easy a sight as asystole.
I hear the police officers coming in. The man turns to talk with them. I hear them commiserating with him, saying they are sorry for his loss.
For the first time I put capnography on patient I am considering presuming to document the apnea and just to do something else while I formulate what I am going to say to my medical control physician. The capnography shows a flat line – apnea. There is no number reading, and then all of a sudden I see the number 7 pop up on the screen. It again startles me. It’s not a great number, but any number is a sign of life. It puzzles me as there is no wave form. It is not until later that I guess that it represented some gas passively escaping from the stomach.
I go out to the living room where the police and man are now talking. “Here’s what’s going to happen,” I say. I’m going out to the ambulance to call the ED doctor and get permission to presume. If they say its okay, then I don’t have to do anything.”
“Why do you have to do that?” the man says. “You didn’t do that when my father-in law died. You just called him dead.”
“Well we can do that is they are cold and stiff -- not if they are warm. There are legal criteria we have to follow."
“So I am supposed to sit her with her and wait for her to get cold before I call?”
“I don’t think it is going to be a problem,” I say, “It’s just something I need to do legally. I’m with you I don’t want to work her.”
“No one is going to do anything to her,” he says now, a hint of anger in his voice.
“I’ll be back,” I say.
Out in the rig, I call the hospital. I ask for the doctor’s medical control number and the nurse says I can get it when I get to the hospital. I was there earlier today and I saw two new doctors I had never seen before. This is not a good omen.
“I’m on scene with a 95-year old female, history of cancer, pulseless and apneic, who took her last breaths about fifteen minutes ago according to her son-in-law, who says she did not want to be resuscitated. They have DNR papers, but they are locked in a safe and the person with the combination won’t be here for another fifteen minutes. I would like permission to withhold resuscitation.”
There is a short silence, and then a question. “What is your ETA?”
“ETA? I’m on scene with a 95 year old pulseless apneic patient with a history of cancer. The family says the patient is a DNR, but the papers are locked in a safe. They will be able to open the safe in about ten minutes. I’m requesting permission to presume the patient, to not start CPR.”
There is a long silence.
My partner has come out. He says, “The man just told the cops he will fight anyone who tries to resuscitate her.”
Finally the hospital comes back on. “Are the papers legally signed?”
“They are locked in a safe,” I say, and then repeat what are usually the magic words, “This is a 95 year old with cancer. The family says she is a DNR, but the papers are in the safe and the person coming with the combination won’t be here for another ten minutes to open the safe. The family says she did not want to be resuscitated and now the son is threatening to attack anyone who tries. I’d like permission to presume.”
More silence, and they, “Okay, provided you stay until you can verify the papers.”
I repeat the order and then go back in the house.
The man looks at me in the way a man in a bar might look at another man with whom he has just had a serious confrontation, looking at me to see if it is over or if we will have to take it outside.
“I got permission,” I say, “But I can’t presume until I see the papers.”
“She’s on her way,” he says.
I hear a commotion at the back door and a crying woman comes in. The man talks with her and then he says to me, give me a minute and he and the woman go into the bedroom. I wait a moment and they come back. He has some papers in his hands. He hands me the papers. Dated almost ten years ago, it is a signed superior court paper – the jist of it says “ I, (blank) of sound mind and health, request that no heroic measures by taken should I fall ill…I do not wish to have CPR, etc.” It isn’t the official DNR, but it meets its purpose in my book.
I nod. “Okay.”
I go back in the room and look at the patient. The pacemaker has stopped now. It is flat line.
“A peaceful way to go,” my partner say. He holds a flowered sheet that he spreads over the patient up to her neck.
Out in the living room I tell the cops the time of presumption and give them my name and date of birth per protocol. I then approach the man, and say, “I’m sorry for your loss, and sorry for any apprehension I may have caused.”
We shake hands. “Thank you, that’s all right. I know you are just doing your job, but….” He looks me dead in the eye, my hand still gripped firmly in his. “You and I would have been wrestling.”
“I understand,” I say.
I walk out of the house, the monitor over my shoulder, in my hand the house bag with unopened intubation and med kits.
If he had fought, I would have let him pin me.
***
Postscript: Two days later, I read her obituary. It says she died "peacefully at home."
Monday, October 16, 2006
Cognac
This weekend I went down to Foxwoods for my annual poker excursion at an event called FARGO, which stands for Foxwoods Annual Recreational Gambling Outing. Every year since 1997 a group of poker players who discuss strategy on the internet have been meeting for several days to play poker and earn bragging rights amongst themselves. Our group has included many players who have gone on to win world championships, including Greg "Fossilman" Raymer, who played with us again this year, and other notables such as Andy Block, who finished second this year in the WSOP $50,000 H.O.R.S.E. tournament buy-in winning himself a nifty million plus and Gavin Smith, the 2006 WPT Player of the Year, as well as many ordinary players such as myself.
We get a reduced hotel room rate, a free dinner at Custy's all-you-can-eat-lobster buffet, and play three tournaments together. There is an also a nationwide outing every August in Las Vegas and similar regional poker outings at casinos in Atlantic City, Mississippi, California. Of those, I've only been to the Vegas outing once. Some in the group go to all events. Since the advent of online poker rooms, which make playing not only easier, but more profitable, the online casino takes a much smaller portion of the pot for their take than the brick and mortar casinos, I limit my trips to Foxwoods to once a year.
Poker players talking about poker is very similar to EMTs talking about EMS. In poker, it is the bad beat story. "I had all my chips in preflop with ace-ace, and get cracked by a joker with jack-jack when a jack lands on the river." In EMS, it is usually stupid calls. “We go lights and siren for a difficulty breathing and it turns out the guy is only having trouble breathing because he got in a yelling match with the nurse at the home over how many cigarettes he could smoke.” After awhile you can get tired of hearing the same old thing. Whine whine whine.
So I won’t tell you how I did, how I lost. I budgeted for three tournaments and some cash game play. I did not win, but I also didn’t have to hit the ATM in order to keep playing or to pay for gas home. i stayed on budget. Chalk it up as entertainment.
Before the last tournament, instead of eating at the breakfast buffet, I went down to the gym and took a steam bath. It is an annual ritual. I pretend I am the traveling poker pro, and this is my life, steam baths, carpeted locker room, complimentary juice bar, tooth brush and razor, and then I head out to do battle.
Two hours later, my last hand is beat. I stand and leave the table while my opponent rakes in the chips, the dealer shuffles and deals a new hand to the remaining players, and I am forgotten until next year.
It was a beautiful day to drive back, the leaves orange and yellow. I got back in plenty of time to clean the house, do laundry, watch some football, cook a steak, and lay out my working clothes for the next day’s predawn rise.
**
People say I work too much, and sometimes I think that is true, but I do have some escapes and poker is one of them. I forget about work and just get lost in the cards, in the challenge of the plays and situations. It was good to play in a real casino again, and hold the chips in my hand, and joke with the others at the table. One of the big topics of conversation was the new law banning online poker which late one night in the final days of the session was snuck onto a bill dealing with port security without ever being debated. I heard someone say now Osama Bin Laden sitting in his cave in Pakistan can play Texas Hold'em on Party Poker on his laptop, while we in America, where poker is a national pastime – a game played by Presidents and factory workers alike -- are now banned from pushing our chips in.
In EMS, you see how life beats people down – they get old, their backs hurt, their joints ache, their eyes dim, their houses fall into disrepair, just getting out of bed and walking to the bathroom becomes a chore, their mates die, their children don’t visit. EMS teaches you to enjoy life while you have it. What really pisses me off is a government that tries to tell people what they can’t do with their own lives in their own houses. You’re dying of cancer; you can’t smoke marijuana to relieve your constant nausea and pain. All of your old poker buddies are dead or in nursing homes, but you can’t play poker anymore because the government won’t let you play a nickel and dime poker game on the internet, all the while they will take your lottery money and of course you can bet on the horses because the Senators from those states were able to carve out an exemption for internet betting on horses, probably by trading their votes on issues like lavish pork spending for other Senator’s states. And they spend their time on this stuff instead of addressing the real issues of poverty, health care, and education, not to mention the war.
In any time and age or country, people should have a right to enjoy themselves. My girlfriend works even longer hours than I do. She came down to Foxwoods to join me for two days. While I played poker she spent an afternoon at the spa. When the hospital called her cell phone to see if she could come in to work overtime, she told them, “I’m sitting by the pool drinking cognac.” “That would be a no then,” the caller correctly assumed.
We get a reduced hotel room rate, a free dinner at Custy's all-you-can-eat-lobster buffet, and play three tournaments together. There is an also a nationwide outing every August in Las Vegas and similar regional poker outings at casinos in Atlantic City, Mississippi, California. Of those, I've only been to the Vegas outing once. Some in the group go to all events. Since the advent of online poker rooms, which make playing not only easier, but more profitable, the online casino takes a much smaller portion of the pot for their take than the brick and mortar casinos, I limit my trips to Foxwoods to once a year.
Poker players talking about poker is very similar to EMTs talking about EMS. In poker, it is the bad beat story. "I had all my chips in preflop with ace-ace, and get cracked by a joker with jack-jack when a jack lands on the river." In EMS, it is usually stupid calls. “We go lights and siren for a difficulty breathing and it turns out the guy is only having trouble breathing because he got in a yelling match with the nurse at the home over how many cigarettes he could smoke.” After awhile you can get tired of hearing the same old thing. Whine whine whine.
So I won’t tell you how I did, how I lost. I budgeted for three tournaments and some cash game play. I did not win, but I also didn’t have to hit the ATM in order to keep playing or to pay for gas home. i stayed on budget. Chalk it up as entertainment.
Before the last tournament, instead of eating at the breakfast buffet, I went down to the gym and took a steam bath. It is an annual ritual. I pretend I am the traveling poker pro, and this is my life, steam baths, carpeted locker room, complimentary juice bar, tooth brush and razor, and then I head out to do battle.
Two hours later, my last hand is beat. I stand and leave the table while my opponent rakes in the chips, the dealer shuffles and deals a new hand to the remaining players, and I am forgotten until next year.
It was a beautiful day to drive back, the leaves orange and yellow. I got back in plenty of time to clean the house, do laundry, watch some football, cook a steak, and lay out my working clothes for the next day’s predawn rise.
**
People say I work too much, and sometimes I think that is true, but I do have some escapes and poker is one of them. I forget about work and just get lost in the cards, in the challenge of the plays and situations. It was good to play in a real casino again, and hold the chips in my hand, and joke with the others at the table. One of the big topics of conversation was the new law banning online poker which late one night in the final days of the session was snuck onto a bill dealing with port security without ever being debated. I heard someone say now Osama Bin Laden sitting in his cave in Pakistan can play Texas Hold'em on Party Poker on his laptop, while we in America, where poker is a national pastime – a game played by Presidents and factory workers alike -- are now banned from pushing our chips in.
In EMS, you see how life beats people down – they get old, their backs hurt, their joints ache, their eyes dim, their houses fall into disrepair, just getting out of bed and walking to the bathroom becomes a chore, their mates die, their children don’t visit. EMS teaches you to enjoy life while you have it. What really pisses me off is a government that tries to tell people what they can’t do with their own lives in their own houses. You’re dying of cancer; you can’t smoke marijuana to relieve your constant nausea and pain. All of your old poker buddies are dead or in nursing homes, but you can’t play poker anymore because the government won’t let you play a nickel and dime poker game on the internet, all the while they will take your lottery money and of course you can bet on the horses because the Senators from those states were able to carve out an exemption for internet betting on horses, probably by trading their votes on issues like lavish pork spending for other Senator’s states. And they spend their time on this stuff instead of addressing the real issues of poverty, health care, and education, not to mention the war.
In any time and age or country, people should have a right to enjoy themselves. My girlfriend works even longer hours than I do. She came down to Foxwoods to join me for two days. While I played poker she spent an afternoon at the spa. When the hospital called her cell phone to see if she could come in to work overtime, she told them, “I’m sitting by the pool drinking cognac.” “That would be a no then,” the caller correctly assumed.
Thursday, October 12, 2006
Gassed
We’re called for a woman feeling faint after accidently leaving the stove on. Low priority response. We pull up to the house and see only a police car out in front. No fire department. A woman waves me in the front door. She is smiling and seems perfectly healthy. I ask her if she is the patient at the same time I get a powerful whiff of gas. No, she says, it's my mother, she’s in the kitchen. Already I am feeling light-headed so I follow her in and find her mother laying against the stove with a nonrebreather on and a police officer kneeling by her. I ask what happened. She says she isn’t certain. I touch her forehead. It is cool and clammy. The gas smell is overwhelming. You need to go to the hospital, I say, and uh, maybe we should go outside, I say.
We get her up, she seems a little groggy. I tell my partner who has followed me in to set the stretcher up outside.
The officer and I help the woman walk out to the porch. On one hand, she just had some kind of syncopal episode, on the other, the gas smell is not a hint of gas, it is an atomic bomb of gas -- I feel like I am inside a gas balloon, my head feels so big. I’m worried I will bump it against the ceiling. We get her on the stretcher and out to the ambulance. We have a hard time getting the stretcher in the back, and getting it to latch. My partner who has been driving an ambulance for thirty years, gets in front and takes off. The problem is the back doors are wide open. I shout hey, man! He apologizes and I shut the doors without managing to fall out.
I am doing all my care on the go because the hospital we are going to is far enough away that I will have time to do it all. I put in an IV, put her on the monitor, put her back on the 02 just to clear her out. That gas smell was strong! Before we left my partner told the officer to call the fire department, told him that a couple times because the officer seemed a little spacy. The ride to the hospital is rough, but I try not to yell at my partner because he is my friend and I don’t want him to know that I think he is driving like a lunatic. Each bump jostles me. The monitor comes off the bench, IV supplies fall out of the open cabinent.
But I manage. I have my routine. I am use to bumps. I check the woman’s sugar because that is just part of my routine.
38.
Well, there you go. I give her some D50 and suddenly instead of a slowspeaking clammy old woman she is cracking jokes with me, although she does still admit to a headache and feels tipsy. The two of us are laughing hysterically. We both shout at the driver. Hey buddy, you missed a bump.
When my partner opens the back door at the hospital, I look down as he does and sees we are about six feet short of the landing. Back it up some more, I say. He closes the door, and then the next thing I know I hear a scraping, and then he opens the door again, and looks a little sheepish. I get out and see he has hit a pole holding up the ED overhang.
Good one, I say.
He hangs his head. Don't tell on me now, he says. I won't hear the end of it.
While waiting in the triage line, another crew comes in and looks at us. Which one of you was driving? Not me. Not him. Our driver, he’s -- he’s not here. We fired him. He’s dead. We’re cracking ourselves up. They look at us like we are high or something.
We are joking with the woman about the gas in the house, how if she lit a match, there would be no more house. Yeah, that’d be a blast, my partner says. He tries to keep a straight face waiting for everyone to get his double meaning. You’re killing me, I say. We both laugh some more. You should be on Johnny Carson, I say.
He makes me drive back. I ask if he will blame it on me if the ER overhang collapses when I pull out. He gets out of the ambulance and goes and stands on a corner to make it look like he has nothing to do with me or the crookedly parked ambulance. I pull out with no problem. I never hit the pole, he says getting back in. There was microscopic air between the car and the pole – that’s why the roof is still standing.
Yeah, right, I say, as I head toward the highway.
That call was a gas, he says.
Roll down the windows, I say, you're killing me.
We get her up, she seems a little groggy. I tell my partner who has followed me in to set the stretcher up outside.
The officer and I help the woman walk out to the porch. On one hand, she just had some kind of syncopal episode, on the other, the gas smell is not a hint of gas, it is an atomic bomb of gas -- I feel like I am inside a gas balloon, my head feels so big. I’m worried I will bump it against the ceiling. We get her on the stretcher and out to the ambulance. We have a hard time getting the stretcher in the back, and getting it to latch. My partner who has been driving an ambulance for thirty years, gets in front and takes off. The problem is the back doors are wide open. I shout hey, man! He apologizes and I shut the doors without managing to fall out.
I am doing all my care on the go because the hospital we are going to is far enough away that I will have time to do it all. I put in an IV, put her on the monitor, put her back on the 02 just to clear her out. That gas smell was strong! Before we left my partner told the officer to call the fire department, told him that a couple times because the officer seemed a little spacy. The ride to the hospital is rough, but I try not to yell at my partner because he is my friend and I don’t want him to know that I think he is driving like a lunatic. Each bump jostles me. The monitor comes off the bench, IV supplies fall out of the open cabinent.
But I manage. I have my routine. I am use to bumps. I check the woman’s sugar because that is just part of my routine.
38.
Well, there you go. I give her some D50 and suddenly instead of a slowspeaking clammy old woman she is cracking jokes with me, although she does still admit to a headache and feels tipsy. The two of us are laughing hysterically. We both shout at the driver. Hey buddy, you missed a bump.
When my partner opens the back door at the hospital, I look down as he does and sees we are about six feet short of the landing. Back it up some more, I say. He closes the door, and then the next thing I know I hear a scraping, and then he opens the door again, and looks a little sheepish. I get out and see he has hit a pole holding up the ED overhang.
Good one, I say.
He hangs his head. Don't tell on me now, he says. I won't hear the end of it.
While waiting in the triage line, another crew comes in and looks at us. Which one of you was driving? Not me. Not him. Our driver, he’s -- he’s not here. We fired him. He’s dead. We’re cracking ourselves up. They look at us like we are high or something.
We are joking with the woman about the gas in the house, how if she lit a match, there would be no more house. Yeah, that’d be a blast, my partner says. He tries to keep a straight face waiting for everyone to get his double meaning. You’re killing me, I say. We both laugh some more. You should be on Johnny Carson, I say.
He makes me drive back. I ask if he will blame it on me if the ER overhang collapses when I pull out. He gets out of the ambulance and goes and stands on a corner to make it look like he has nothing to do with me or the crookedly parked ambulance. I pull out with no problem. I never hit the pole, he says getting back in. There was microscopic air between the car and the pole – that’s why the roof is still standing.
Yeah, right, I say, as I head toward the highway.
That call was a gas, he says.
Roll down the windows, I say, you're killing me.
Tuesday, October 10, 2006
Pain Manifesto
I give a lot of pain medicine to my patients, but from everything I am reading I am not giving enough. In the last week I gave pain medicine to the following:
1. An 80 year old man with a compression fracture of the lower back. He slept all the way to the hospital.
2. A 69 year old woman with sciatica. Her 10 out of 10 pain and inability to get out of bed went down to a 5 and she was able to stand and pivot onto the stretcher, but still grimaced throughout the ride.
3. An 86 year old man with the worst abdominal pain of his life. He was still in pain, but perhaps no longer in agony. Pain went down to an 8
4. An 11 year old girl with a possibly fractured ankle. She stopped crying, and seemed sad, but calm.
I did not give morphine to:
1. A 62 year old woman in a minor motor vehicle, who claimed shoulder pain. I saw no deformity, but she seemed to have trouble moving her arm over her shoulder. She cried when we moved her off our stretcher onto the hospital’s bed.
2. A 37 year old woman with knee pain (no deformity) from a minor motor vehicle who looked me cold in the eye and told me her pain was “A ten.”
In retrospect, I should have given more to the 69 year old with sciatica, and I should have given it to the woman with shoulder pain.
My preceptee, who rode with me on a couple of these calls, when he started riding with me, was at first shocked, and then gradually came to accept and understand the need to properly medicate patients. After a call in which he failed to give pain meds to another elderly man with a compression fracture, telling me he was more conservative than me, and that the man’s pain was not that bad, and that the man did not seem to be in agony (So we now have an agony scale? I questioned later), I had him read the following powerpoint bt Dr. Bryan Bledsoe.
Why We Don't Do a Better Job of Treating Pain
Note: It is a long download.
Fortunately our next call was the 80 year old man who also had a compression fracture, and my preceptee was able to compare the two calls and 1) the relief the patient recieved and 2) the satisfaction he recieved knowing he made the patient feel better.
I have been reading an excellent book called Pain Management and Sedation: Emergency Department Management.
It is a book intended for ER Docs, but I think any book written for an ER doc can only benefit a medic. It has some fascinating information about the damage acute pain can do to a patient.
“In addition to the obvious moral, ethical, and legal/regulatory reasons to treat pain adequately and expeditiously, failure to properly treat may make it much more difficult to treat future pain and may increase the likelihood of developing chronic pain...There is evidence that inadequate analgesia and /or sedation leads to worse clinical outcomes and more complications. A possible pathophysiologic mechanism for the negative effects of inadequate analgesia/sedation may be an excess of stress hormones causing catabolism, immunosuppression, and hemodynamic instability.”
“...Early and aggressive therapy for acute pain holds the promise of preventing or ameliorating physiologic changes that may set the stage for prolonged or chronic pain states. A great deal of work remains to be done in this area and despite these considerations, the treatment of acute pain and suffering is justified in and of itself.”
There are also chapters on opiod dependent patients and sickle cell anemia patients that will make you think twice about withholding meds on suspicion on their being drug seekers, which I will address is later postings.
I’ve been really involved in capnography lately; I think my next teaching/learning project will be pain management. I owe it to all the patients I let suffer in the past, not knowing any better.
1. An 80 year old man with a compression fracture of the lower back. He slept all the way to the hospital.
2. A 69 year old woman with sciatica. Her 10 out of 10 pain and inability to get out of bed went down to a 5 and she was able to stand and pivot onto the stretcher, but still grimaced throughout the ride.
3. An 86 year old man with the worst abdominal pain of his life. He was still in pain, but perhaps no longer in agony. Pain went down to an 8
4. An 11 year old girl with a possibly fractured ankle. She stopped crying, and seemed sad, but calm.
I did not give morphine to:
1. A 62 year old woman in a minor motor vehicle, who claimed shoulder pain. I saw no deformity, but she seemed to have trouble moving her arm over her shoulder. She cried when we moved her off our stretcher onto the hospital’s bed.
2. A 37 year old woman with knee pain (no deformity) from a minor motor vehicle who looked me cold in the eye and told me her pain was “A ten.”
In retrospect, I should have given more to the 69 year old with sciatica, and I should have given it to the woman with shoulder pain.
My preceptee, who rode with me on a couple of these calls, when he started riding with me, was at first shocked, and then gradually came to accept and understand the need to properly medicate patients. After a call in which he failed to give pain meds to another elderly man with a compression fracture, telling me he was more conservative than me, and that the man’s pain was not that bad, and that the man did not seem to be in agony (So we now have an agony scale? I questioned later), I had him read the following powerpoint bt Dr. Bryan Bledsoe.
Why We Don't Do a Better Job of Treating Pain
Note: It is a long download.
Fortunately our next call was the 80 year old man who also had a compression fracture, and my preceptee was able to compare the two calls and 1) the relief the patient recieved and 2) the satisfaction he recieved knowing he made the patient feel better.
I have been reading an excellent book called Pain Management and Sedation: Emergency Department Management.
It is a book intended for ER Docs, but I think any book written for an ER doc can only benefit a medic. It has some fascinating information about the damage acute pain can do to a patient.
“In addition to the obvious moral, ethical, and legal/regulatory reasons to treat pain adequately and expeditiously, failure to properly treat may make it much more difficult to treat future pain and may increase the likelihood of developing chronic pain...There is evidence that inadequate analgesia and /or sedation leads to worse clinical outcomes and more complications. A possible pathophysiologic mechanism for the negative effects of inadequate analgesia/sedation may be an excess of stress hormones causing catabolism, immunosuppression, and hemodynamic instability.”
“...Early and aggressive therapy for acute pain holds the promise of preventing or ameliorating physiologic changes that may set the stage for prolonged or chronic pain states. A great deal of work remains to be done in this area and despite these considerations, the treatment of acute pain and suffering is justified in and of itself.”
There are also chapters on opiod dependent patients and sickle cell anemia patients that will make you think twice about withholding meds on suspicion on their being drug seekers, which I will address is later postings.
I’ve been really involved in capnography lately; I think my next teaching/learning project will be pain management. I owe it to all the patients I let suffer in the past, not knowing any better.
Monday, October 09, 2006
Bagdad
We are sent for a man with lung cancer difficulty breathing. Visiting nurse on scene. We’ve been going to this house a lot recently. Small one story house in a lower middle class neighborhood. The grass in the yard is mostly dead, the driveway cracked. The house needs painting.
The stink hits you from the door. It is one of the commonest EMS smells. It is the smell of the unbathed. Not the BO smell of a high school locker room, but the smell of people for whom washing and cleaning themselves has become an impossible task when just getting up to go to the kitchen brings on shortness of breath. The smell is in the carpets, in the walls. Some day an out-of-state family member or relator will have to tear out the carpets, strip the walls, and give the house a professional cleaning and airing out if they ever hope to sell it, after its decades old occupants are passed on.
But for now, the husband sits in the old armchair, an oxygen cannula in his nose. From his build he looks like he was once a large powerful man. Now speaking more than a few words at a time leaves him weak. His tee-shirt is stained yellow. I can see fungus growing on his feet.
The visiting nurse sits at the kitchen table looking at her lap top computer. She is on the phone talking to the ER, telling them how she is sending the patient in because he has become increasingly short of breath. She tries to tell the person on the other end of the phone the names of the patient’s medications, but the person on the other end of the phone has other patients to attend to, and has probably just scrawled "74 year old male, cancer, dsypnea" on a pad, and that suffices.
I want my partner to hurry up and get the stretcher set, so we can get this man on it, and out into the fresh air. We get the clean white sheet spread out, and while the man wants to stand and take a step to the stretcher, I say no. I remember how short of breath he became the last time. I tell my partner we have to lift him. I reach in from behind, giving him a bear hug, my arms under his, grasping him by the crossed forearms, while my partner, with now gloved hands, picks up from under the knees, and we lift him over. Both of us trying not to breathe more than we can help for fear we will gag.
The man’s wife, using her walker, comes over and kisses him goodbye. She is crying.
"I'm not dead yet," he jokes.
We switch the cannula to an oxygen mask.
On the TV the newscaster reports another 60 people are found dead in Bagdad.
The stink hits you from the door. It is one of the commonest EMS smells. It is the smell of the unbathed. Not the BO smell of a high school locker room, but the smell of people for whom washing and cleaning themselves has become an impossible task when just getting up to go to the kitchen brings on shortness of breath. The smell is in the carpets, in the walls. Some day an out-of-state family member or relator will have to tear out the carpets, strip the walls, and give the house a professional cleaning and airing out if they ever hope to sell it, after its decades old occupants are passed on.
But for now, the husband sits in the old armchair, an oxygen cannula in his nose. From his build he looks like he was once a large powerful man. Now speaking more than a few words at a time leaves him weak. His tee-shirt is stained yellow. I can see fungus growing on his feet.
The visiting nurse sits at the kitchen table looking at her lap top computer. She is on the phone talking to the ER, telling them how she is sending the patient in because he has become increasingly short of breath. She tries to tell the person on the other end of the phone the names of the patient’s medications, but the person on the other end of the phone has other patients to attend to, and has probably just scrawled "74 year old male, cancer, dsypnea" on a pad, and that suffices.
I want my partner to hurry up and get the stretcher set, so we can get this man on it, and out into the fresh air. We get the clean white sheet spread out, and while the man wants to stand and take a step to the stretcher, I say no. I remember how short of breath he became the last time. I tell my partner we have to lift him. I reach in from behind, giving him a bear hug, my arms under his, grasping him by the crossed forearms, while my partner, with now gloved hands, picks up from under the knees, and we lift him over. Both of us trying not to breathe more than we can help for fear we will gag.
The man’s wife, using her walker, comes over and kisses him goodbye. She is crying.
"I'm not dead yet," he jokes.
We switch the cannula to an oxygen mask.
On the TV the newscaster reports another 60 people are found dead in Bagdad.
Thursday, October 05, 2006
Ambulance Driver
With apologies to Steve Berry’s "I am Not an Ambulance Driver," here’s a story from Las Vegas.
It’s Friday, my friend and I go down to the pool to have a few beers and take in some sun before going out to the Jeff Beck concert, and then heading home the next day. I bring my backpack with me, and place my wallet in the backpack rather than leave it in the room. I was at the pool the day before and was able to secure a lounge chair in the first row along the pool so I could always see my backpack when I was in the water or over at the bar line. But when we get down there all the chairs in the first line are taken, so we have to grab two from the second line. The problem is of course, I won’t be able to see my backpack if I go in the water. It will be ripe for getting lifted. So while my friend watches the backpack, I go and get us some beers, and then we sit back and get some sun. Then I see two people get up from some front line chairs and leave, so we grab our stuff and quickly claim the chairs. To our right are two women vacationing we soon learn from from Green Bay. They each have two drinks in large coconut shaped souvenir holders, that are reminiscent from a scene from Austin Powers. They immediately notice our presence and perhaps believing we have been scooping them out, turn their attention to us. My friend, who is very personable, immediately gets involved in a discussion with them, and soon they are chatting away about the great weather, the shows in town, the best buffets, the night life. The women mention their desire to going to a club called Tabbo that night. Now my friend is happily married and I am in a committed relationship. But I am getting the strong sense these two women, each a definite candidate for the bariatric ambulance, are in to the “What Happens in Vegas Stays in Vegas” scene. Then they ask us what we are doing in town. My friend mentions the EMS convention. Really? Emergency Medical Services? Are you doctors?
“No,” I say. “He’s an EMT and I’m an Ambulance Driver. He does all the blood and guts and gore stuff, and me I drive like wind. I hit those sirens on and the traffic parts like the Red Sea. Like I'm Moses himself. Yee-Haw! It’s the life for me!”
Two minutes later they excuse themselves. Nice talking to you.
“Well, you blew it with those chicks,” my friend jokes. “Should have told them we were trauma surgeons.”
Ahh, no.
**
As I mentioned the Jeff Beck concert that night was great. I found this video clip of Beck playing a “Day in the Life” which was the highlight of the show for me.
Jeff Beck: A Day in the Life
It’s Friday, my friend and I go down to the pool to have a few beers and take in some sun before going out to the Jeff Beck concert, and then heading home the next day. I bring my backpack with me, and place my wallet in the backpack rather than leave it in the room. I was at the pool the day before and was able to secure a lounge chair in the first row along the pool so I could always see my backpack when I was in the water or over at the bar line. But when we get down there all the chairs in the first line are taken, so we have to grab two from the second line. The problem is of course, I won’t be able to see my backpack if I go in the water. It will be ripe for getting lifted. So while my friend watches the backpack, I go and get us some beers, and then we sit back and get some sun. Then I see two people get up from some front line chairs and leave, so we grab our stuff and quickly claim the chairs. To our right are two women vacationing we soon learn from from Green Bay. They each have two drinks in large coconut shaped souvenir holders, that are reminiscent from a scene from Austin Powers. They immediately notice our presence and perhaps believing we have been scooping them out, turn their attention to us. My friend, who is very personable, immediately gets involved in a discussion with them, and soon they are chatting away about the great weather, the shows in town, the best buffets, the night life. The women mention their desire to going to a club called Tabbo that night. Now my friend is happily married and I am in a committed relationship. But I am getting the strong sense these two women, each a definite candidate for the bariatric ambulance, are in to the “What Happens in Vegas Stays in Vegas” scene. Then they ask us what we are doing in town. My friend mentions the EMS convention. Really? Emergency Medical Services? Are you doctors?
“No,” I say. “He’s an EMT and I’m an Ambulance Driver. He does all the blood and guts and gore stuff, and me I drive like wind. I hit those sirens on and the traffic parts like the Red Sea. Like I'm Moses himself. Yee-Haw! It’s the life for me!”
Two minutes later they excuse themselves. Nice talking to you.
“Well, you blew it with those chicks,” my friend jokes. “Should have told them we were trauma surgeons.”
Ahh, no.
**
As I mentioned the Jeff Beck concert that night was great. I found this video clip of Beck playing a “Day in the Life” which was the highlight of the show for me.
Jeff Beck: A Day in the Life
Wednesday, October 04, 2006
Go Ahead
Morphine for undifferentiated abdominal pain. I’ve written about it. I’ve advocated for it. But until yesterday, I hadn’t ever given it. At our last regional council meeting we approved the use of .05 mg/kg for undifferentiated abdominal pain on standing orders. .05 mg/kg is half the regular morphine for pain dose. It is a “judicious amount” in the new terminology that advocates relief of suffering. The literature on the issue is clear. Morphine does not hinder the diagnosis of abdominal pain. To quote the conclusion of the most recent study:
“Although administration of intravenous morphine to adult ED patients with acute abdominal pain could lead to as much as a 12% difference in diagnostic accuracy, equally favoring opioid or placebo, our findings are most consistent with the inference that morphine safely provides analgesia without eroding clinically important diagnostic accuracy. These data are congruent with the aggregate weight of evidence accumulated from previous studies examining this question during the past 20 years.”
-Randomized Clinical Trial of Morphine in Acute Abdominal Pain
Gallagher, Esses, Lee, Lahn, Bijur
Annals of Emergency Medicine
August 2006
When I read that at the MAC meeting, it was a slam dunk. Who can speak against such a statement?
Still, the old ways are hard to change. It was grilled in us 15 years ago. NEVER give Morphine for abdominal pain, unless you can make a clear case that the pain is caused by kidney stones. Never. Every now and then you would hear of someone calling in and asking to give it. Such a beating they received. People would talk behind their backs for years. There’s the moron who tried to give a patient morphine for abdominal pain.
For months I have been anticipating giving it. Until our protocols are rolled out, I am required to call for orders if I want to give it for abdominal pain. I have played out the scenario in my head. I call and am denied. The doctor says on the radio. See me when you get here. He says it in the way a principle says "To my office." To my office back in the days of corporal punishment. I imagine everyone staring at me when I come in. People looking at me in amazement. All this time they all thought I knew what I was doing and here I have gone and asked for morphine for abdominal pain. Scandal. Gossip. But in my imagination I am prepared. I go toe to toe with the MD. You need to read the literature, I say. I start spouting. Annals of Emergency Medicine. Latest edition of Cope’s Early Diagnosis of the Acute Abdominal. Aggregate evidence of the last twenty years. Get with the program. I slap down the studies on the tray by the bedside. The doctor is flustered. The staff looks at me. Well, all right then. A new sheriff in town.
So here’s what happened. 86 year old male, pale as a sheet, comes walking out the front door, holding his stomach. While we spread a clean sheet on the stretcher; he says he has had the pain for four hours. He has vomited twice. There is in fact dried vomit on his shirt. No diarrhea. Once we get him on the stretcher I examine his abdomen. Soft, non-tender. No pulsing masses. His pressure is 200/100. Heart rate in the 80’s inching up to the nineties. I put in a line and hang a bag of fluid. He looks really uncomfortable. He is irritated at me when I ask questions. The pain is dull and diffusive and goes into the back. No, it is not tearing. He says he has never had pain like this before.
I’m not certain what is going on. Maybe an ischemic bowel? I don't know. I think about morphine, but I also think, maybe I don’t want to mask the diagnosis. I know, I know. I’ve read the studies. Everything for the last twenty years. Still. It is deeply ingrained. We are enroute now. My partner is taking the long way – a way he thinks is the shortest, but I know to be at least ten minutes linger, particularly at this time of day – afternoon rush hour. We aren’t going lights and sirens. The patient looks really, really uncomfortable. I am thinking this is no normal belly ache. We are at least twenty minutes from the hospital. I ask him how bad his pain is. He is annoyed by the question. He finally snaps, “I’ve never had pain this bad.” "That would be a ten then, “I say. “Ten,” he says through gritting teeth.
He is in pain. He is suffering. He needs something. Okay. I pump out my chest, run my hand through my hair. Here goes. I make the call. I give as detailed a patch as I have given for years, and then I say, “I’d like to give a judicious amount of morphine for pain relief – 3 mg IV.” I say.
“Go ahead, 3 mg MS IV,” the doctor says. Since the radio is scratchy I can’t pick up the tone, but it clear. I got the go ahead. They said yes.
Easy enough. I give the patient the morphine, and while it only makes the pain go down to an 8, he seems much more comfortable. His heart rate goes down to the 60’s.
At the ED, they put him in a medical alert room so he gets immediate treatment by two doctors. They order a stat ultrasound. I ask the doctor to sign my narcotics sheet. He does so without a problem. “Excellent job,” he says.
All right then.
“Although administration of intravenous morphine to adult ED patients with acute abdominal pain could lead to as much as a 12% difference in diagnostic accuracy, equally favoring opioid or placebo, our findings are most consistent with the inference that morphine safely provides analgesia without eroding clinically important diagnostic accuracy. These data are congruent with the aggregate weight of evidence accumulated from previous studies examining this question during the past 20 years.”
-Randomized Clinical Trial of Morphine in Acute Abdominal Pain
Gallagher, Esses, Lee, Lahn, Bijur
Annals of Emergency Medicine
August 2006
When I read that at the MAC meeting, it was a slam dunk. Who can speak against such a statement?
Still, the old ways are hard to change. It was grilled in us 15 years ago. NEVER give Morphine for abdominal pain, unless you can make a clear case that the pain is caused by kidney stones. Never. Every now and then you would hear of someone calling in and asking to give it. Such a beating they received. People would talk behind their backs for years. There’s the moron who tried to give a patient morphine for abdominal pain.
For months I have been anticipating giving it. Until our protocols are rolled out, I am required to call for orders if I want to give it for abdominal pain. I have played out the scenario in my head. I call and am denied. The doctor says on the radio. See me when you get here. He says it in the way a principle says "To my office." To my office back in the days of corporal punishment. I imagine everyone staring at me when I come in. People looking at me in amazement. All this time they all thought I knew what I was doing and here I have gone and asked for morphine for abdominal pain. Scandal. Gossip. But in my imagination I am prepared. I go toe to toe with the MD. You need to read the literature, I say. I start spouting. Annals of Emergency Medicine. Latest edition of Cope’s Early Diagnosis of the Acute Abdominal. Aggregate evidence of the last twenty years. Get with the program. I slap down the studies on the tray by the bedside. The doctor is flustered. The staff looks at me. Well, all right then. A new sheriff in town.
So here’s what happened. 86 year old male, pale as a sheet, comes walking out the front door, holding his stomach. While we spread a clean sheet on the stretcher; he says he has had the pain for four hours. He has vomited twice. There is in fact dried vomit on his shirt. No diarrhea. Once we get him on the stretcher I examine his abdomen. Soft, non-tender. No pulsing masses. His pressure is 200/100. Heart rate in the 80’s inching up to the nineties. I put in a line and hang a bag of fluid. He looks really uncomfortable. He is irritated at me when I ask questions. The pain is dull and diffusive and goes into the back. No, it is not tearing. He says he has never had pain like this before.
I’m not certain what is going on. Maybe an ischemic bowel? I don't know. I think about morphine, but I also think, maybe I don’t want to mask the diagnosis. I know, I know. I’ve read the studies. Everything for the last twenty years. Still. It is deeply ingrained. We are enroute now. My partner is taking the long way – a way he thinks is the shortest, but I know to be at least ten minutes linger, particularly at this time of day – afternoon rush hour. We aren’t going lights and sirens. The patient looks really, really uncomfortable. I am thinking this is no normal belly ache. We are at least twenty minutes from the hospital. I ask him how bad his pain is. He is annoyed by the question. He finally snaps, “I’ve never had pain this bad.” "That would be a ten then, “I say. “Ten,” he says through gritting teeth.
He is in pain. He is suffering. He needs something. Okay. I pump out my chest, run my hand through my hair. Here goes. I make the call. I give as detailed a patch as I have given for years, and then I say, “I’d like to give a judicious amount of morphine for pain relief – 3 mg IV.” I say.
“Go ahead, 3 mg MS IV,” the doctor says. Since the radio is scratchy I can’t pick up the tone, but it clear. I got the go ahead. They said yes.
Easy enough. I give the patient the morphine, and while it only makes the pain go down to an 8, he seems much more comfortable. His heart rate goes down to the 60’s.
At the ED, they put him in a medical alert room so he gets immediate treatment by two doctors. They order a stat ultrasound. I ask the doctor to sign my narcotics sheet. He does so without a problem. “Excellent job,” he says.
All right then.
Tuesday, October 03, 2006
Too Busy
Writing about the daily life of EMS always creates a tension for me. On one hand I want to write about the nobler aspects of the job, on the other, much of the job is so frustrating you just want to scream. I try to avoid whining so most of the time I ignore it. I just came back from the EMS EXPO -- all fired up as always to go out and do great calls -- and as always happens instead of coming back to use your new skills in airway management or cardiac arrests, you get crapped on.
Yesterday was abuse EMS day. Most of the time when we think about EMS abusers it is the poor people who call for an ambulance because they have no primary care doctor and no ride to the hospital. Yesterday was two different, but in my opinion, worse offenders.
Call number one was for "high blood pressure." An ambulatory, working patient with mental retardation, who takes his blood pressure twice a day with one of those drug store home automatic BP cuffs, had a pressure of 150/100 while at his job. Since this exceeds his parameters -- 140/90, his case worker's "protocol" is to have him transported to the ED, and of course that means calling 911. She said to my partner, the ambulance and the hospital seem to always get upset when she calls, but "I'm are just following our protocol." My partner said maybe your need a new protocol.
The other call ticked me off even more. A doctor's office calls 911 for "heart failure." The patient at the office for a scheduled stress test has been gaining fluid in recent days. Her respiratory rate is 20, her SAT on room air is 95%, her end tidal is 35, her heart rate is 60, her pressure is 150/90. She is a direct admit to one of the floors. The office says they will fax her info to the floor and they get upset when I ask for a report. Why do I need her information when I am just taking her to a floor where they have already talked to the people who will be taking care of her? I ask them why they called 911 for a direct admit, they said when they call the commercial ambulance it takes an hour and they are "too bust to wait that long" at their office. It takes an hour of course because for direct admits the ambulance company has to get the patient's insurance company to approve the transport since it is not an "emergency." I am supposed to call the commercial ambulance to come and take the direct admits because as the town 911 ambulance, we don't do direct admits, which often take a great deal of time because the hospital is not ready for the patient - we only go to the ER. What I end up doing is taking the patient to the ER anyway, and then telling the triage nurse the patient may be a direct admit, and if the room is ready, then I take them up to the floor. If the room isn't ready, I leave the patient in the ER. That way, my run form shows I took them to the ER, which means their insurance will likely pay for the ride, instead of jobbing them with a $300 plus unapproved bill. I just resent the attitude we're too busy to wait for a commercial ambulance. We get better service with 911. On the one hand, you want to say to the office, we're not taking her. You're going to have to call the commercial. On the other hand, you have an innocent old woman sitting there and you don't want to put her in the middle.
And we also did a bunch of fender bender MVAs my neck hurts.
The only good thing about the day was we had an unresponsive diabetic at a nursing home. I brought her around with some D50, had them call her doctor back. The patient had been given insulin that morning, but had not eaten and the home's glucometer was off. They had a reading of 78. Ours was less than 20. The doctor canceled the transport.
Yesterday was abuse EMS day. Most of the time when we think about EMS abusers it is the poor people who call for an ambulance because they have no primary care doctor and no ride to the hospital. Yesterday was two different, but in my opinion, worse offenders.
Call number one was for "high blood pressure." An ambulatory, working patient with mental retardation, who takes his blood pressure twice a day with one of those drug store home automatic BP cuffs, had a pressure of 150/100 while at his job. Since this exceeds his parameters -- 140/90, his case worker's "protocol" is to have him transported to the ED, and of course that means calling 911. She said to my partner, the ambulance and the hospital seem to always get upset when she calls, but "I'm are just following our protocol." My partner said maybe your need a new protocol.
The other call ticked me off even more. A doctor's office calls 911 for "heart failure." The patient at the office for a scheduled stress test has been gaining fluid in recent days. Her respiratory rate is 20, her SAT on room air is 95%, her end tidal is 35, her heart rate is 60, her pressure is 150/90. She is a direct admit to one of the floors. The office says they will fax her info to the floor and they get upset when I ask for a report. Why do I need her information when I am just taking her to a floor where they have already talked to the people who will be taking care of her? I ask them why they called 911 for a direct admit, they said when they call the commercial ambulance it takes an hour and they are "too bust to wait that long" at their office. It takes an hour of course because for direct admits the ambulance company has to get the patient's insurance company to approve the transport since it is not an "emergency." I am supposed to call the commercial ambulance to come and take the direct admits because as the town 911 ambulance, we don't do direct admits, which often take a great deal of time because the hospital is not ready for the patient - we only go to the ER. What I end up doing is taking the patient to the ER anyway, and then telling the triage nurse the patient may be a direct admit, and if the room is ready, then I take them up to the floor. If the room isn't ready, I leave the patient in the ER. That way, my run form shows I took them to the ER, which means their insurance will likely pay for the ride, instead of jobbing them with a $300 plus unapproved bill. I just resent the attitude we're too busy to wait for a commercial ambulance. We get better service with 911. On the one hand, you want to say to the office, we're not taking her. You're going to have to call the commercial. On the other hand, you have an innocent old woman sitting there and you don't want to put her in the middle.
And we also did a bunch of fender bender MVAs my neck hurts.
The only good thing about the day was we had an unresponsive diabetic at a nursing home. I brought her around with some D50, had them call her doctor back. The patient had been given insulin that morning, but had not eaten and the home's glucometer was off. They had a reading of 78. Ours was less than 20. The doctor canceled the transport.
Sunday, October 01, 2006
EMS EXPO Report
I returned last night from the EMS EXPO in Las Vegas. I love going to these EMS conventions. The classes are great. You meet new friends and get reacquainted with old ones. You get to hear the best speakers and get updated on all the latest research and ideas, and you can wander the convention floor and see all the new products. Also, as far as convention cities, Las Vegas obviously doesn’t lack for diversions.
Here are some of my trip highlights:
1. Dinner with Thom Dick. I was able to have dinner with one of my heroes, Thom Dick, the author of Street Talk and People Care. As I wrote about in this blog several months ago, Thom Dick's writings have been very influential in my career, particularly as a new EMT. He set the example of the need to focus on the person.
2. Capnography Classes with Baruch Krauss and Bob Page. This was why I went out to Vegas. Baruch Krauss, a physician from Harvard, is the leading proponent of capnography in EMS. He has conducted research, written articles and given lectures on the subject. His class was packed to capacity, and was very informative.
Bob Page is a paramedic from Missouri, and one of the best lecturers I’ve seen. Many years ago I took a great 12 lead class from him. I wasn’t expecting to hear him, but one afternoon while wandering through the convention hall, I went by the Zoll booth and saw him as he was getting ready to give a 30 minute mini-class on capnography. I was one of five people who sat in on the class.
Both lecturers were excellent. I spoke to each of them very briefly after their talks and discovered they are both writing textbooks on capnography. Finally! I will be posting my notes on the lectures on my blog, Capnography for Paramedics. If you ever get a chance to hear either of these fine teachers, don’t miss the opportunity.
3. Drinking beers by the pool on the last day and then going to the Jeff Beck concert at the House of Blues. I stayed with an old friend of mine, who has worked in EMS at all levels from paramedic to clinical coordinator to state administrator. It was good hanging out with him – he introduced me to Thom Dick and some other interesting EMS people who I had read about but never met, and he got the best seats for the show. Jeff Beck is an enigmatic guitarist, who instead of pursuing fame, although he has plenty, has always chosen to play just what he wants regardless of commercial success. A peer of Clapton and Hendrix, a former member of the Yardbirds and The Jeff Beck group featuring Rod Stewart, he barely said a word to the crowd, just played his blazing guitar. He did an amazing version of the Beatles “A Day in the Life.” I always admire people, who do what they love, who pursue their own excellence regardless of what others think they should do.
Other notes:
I took a class called "What’s New in EMS," which was a review of the latest research: According to the lecturer, capnography, pain relief, particularly fentanyl, CPAP and nitro for pulmonary edema, permissive hypotension for trauma, 12 lead ECGs, are all proving their worth. On the downside, lasix and Morphine for pulmonary edema, intubation for head injured patients, and amiodarone are not faring well in research.
As I mentioned the EXPO floor was akin to a Tijuana market with so many vendors competing for your attention.
There were a multitude of ambulances and rescue vehicles, hundreds of different mannequins, including a dog mannequin for animal CPR, training and data software vendors, all kinds of monitors and other gizmos. Here were my non-commercial favorites:
1. Safety Ambulance – a prototype with ideas from EMTs and medics on how to make the ambulance safer.
2. The National Association of Emergency Medical Technicians (NAEMT) booth. – I’ve been in EMS for 18 years now and have never joined a national association. They signed me up and I am now a member.
3. The National EMS Museum – I gave them the requested $5 donation. The museum is just an idea now, but a needed one. I’m posting their web site, although it is still under construction. They plan to start with a virtual museum, and maybe one day get to the brick and mortal.
The next EMS EXPO is scheduled for Orlando in 2007. The next JEMS EMS Todayconference will be in Baltimore on March 6-10, 2007.
Here are some of my trip highlights:
1. Dinner with Thom Dick. I was able to have dinner with one of my heroes, Thom Dick, the author of Street Talk and People Care. As I wrote about in this blog several months ago, Thom Dick's writings have been very influential in my career, particularly as a new EMT. He set the example of the need to focus on the person.
2. Capnography Classes with Baruch Krauss and Bob Page. This was why I went out to Vegas. Baruch Krauss, a physician from Harvard, is the leading proponent of capnography in EMS. He has conducted research, written articles and given lectures on the subject. His class was packed to capacity, and was very informative.
Bob Page is a paramedic from Missouri, and one of the best lecturers I’ve seen. Many years ago I took a great 12 lead class from him. I wasn’t expecting to hear him, but one afternoon while wandering through the convention hall, I went by the Zoll booth and saw him as he was getting ready to give a 30 minute mini-class on capnography. I was one of five people who sat in on the class.
Both lecturers were excellent. I spoke to each of them very briefly after their talks and discovered they are both writing textbooks on capnography. Finally! I will be posting my notes on the lectures on my blog, Capnography for Paramedics. If you ever get a chance to hear either of these fine teachers, don’t miss the opportunity.
3. Drinking beers by the pool on the last day and then going to the Jeff Beck concert at the House of Blues. I stayed with an old friend of mine, who has worked in EMS at all levels from paramedic to clinical coordinator to state administrator. It was good hanging out with him – he introduced me to Thom Dick and some other interesting EMS people who I had read about but never met, and he got the best seats for the show. Jeff Beck is an enigmatic guitarist, who instead of pursuing fame, although he has plenty, has always chosen to play just what he wants regardless of commercial success. A peer of Clapton and Hendrix, a former member of the Yardbirds and The Jeff Beck group featuring Rod Stewart, he barely said a word to the crowd, just played his blazing guitar. He did an amazing version of the Beatles “A Day in the Life.” I always admire people, who do what they love, who pursue their own excellence regardless of what others think they should do.
Other notes:
I took a class called "What’s New in EMS," which was a review of the latest research: According to the lecturer, capnography, pain relief, particularly fentanyl, CPAP and nitro for pulmonary edema, permissive hypotension for trauma, 12 lead ECGs, are all proving their worth. On the downside, lasix and Morphine for pulmonary edema, intubation for head injured patients, and amiodarone are not faring well in research.
As I mentioned the EXPO floor was akin to a Tijuana market with so many vendors competing for your attention.
There were a multitude of ambulances and rescue vehicles, hundreds of different mannequins, including a dog mannequin for animal CPR, training and data software vendors, all kinds of monitors and other gizmos. Here were my non-commercial favorites:
1. Safety Ambulance – a prototype with ideas from EMTs and medics on how to make the ambulance safer.
2. The National Association of Emergency Medical Technicians (NAEMT) booth. – I’ve been in EMS for 18 years now and have never joined a national association. They signed me up and I am now a member.
3. The National EMS Museum – I gave them the requested $5 donation. The museum is just an idea now, but a needed one. I’m posting their web site, although it is still under construction. They plan to start with a virtual museum, and maybe one day get to the brick and mortal.
The next EMS EXPO is scheduled for Orlando in 2007. The next JEMS EMS Todayconference will be in Baltimore on March 6-10, 2007.
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