Postscript

It's funny in EMS how you can get talking about something, and then something similar happens. You talk about a bad motorcycle accident or messy GI bleed code and then that's what you get sent for. Why we were just talking about...

It's really just random chance. How many times do people use the Q-word and then right away you get a call and it gets very busy? But then again how many times do people use the Q-word and you give them a hard time for saying it, but then nothing happens?

Monday night I wrote the post below (Intubation and Capnography) talking about how I had model tested putting the capnography filter on before intubating and trying to use the wave form while the tube was still being placed to aid in the intubation.

The next morning -- the very first call. Not only do I get to try it when orally intubating, I get to try it nasally -- and I haven't done a nasal tube for years.

***

The call was for unresponsive patient with severe dsypnea. We found an 80 year old female with a GSC of 4-5 breathing at a rate of 60 with cool extremities. Unable to hear BP. Heart rate on the monitor 130-140. Blood sugar - 213. I attached the capnography filter to the end of the ET tube. Some of our ET tubes come with stylets already in them. I removed the stylet, but could not put it back in because it was too thick, so I used a thinner stylet we we stock independently. (Inside the capnography filter is a little bar through its diameter.) I went in, and had a hard time getting the woman's jaw open enough to see the chords. We don't have RSI so I was faced with what our intubation survey form calls "inadequate relaxation." I could just barely get an occasional glimpse of the chords under the epiglottis, but couldn't get the tube to pass through. Instead of checking by assessing breath sounds, I just looked at the monitor. The ETCO2 would just go straight and I'd know I had gone below the chords. I tried twice and then gave up. I imagined the woman in her comma dreaming about a demon with horns sticking a piece of cold steel in her mouth, and trying to lift her tongue up.

I ended up nasally intubating her, which I probably should have done first, but I like to get a bigger tube in. The nasal tube went in great. I used some neosynephrine, rolled the tube up in a circle to give it some natural curve, lubed it up with jelly and slid it into her right nostril. I used a 6.0 and watched the wave forms appear as I fed it into the hypopharanx. I kept feeding it slow. Then suddenly the form started getting smaller and then down to nothing. I pulled back and repositioned her head and then advanced the tube again, and felt it go through and had the big wave forms to confirm it.



Her SAT went up to 98% from the 80% and her ETCO2 came up from the mid twenties to low to mid thirties. About ten minutes later she puked, so I was glad I had her airway protected. She opened her eyes by the time we were in the ED.

(The next time I do a nasal tube I am just going to hit print button on the monitor from the start so I have a long strip to cut up and show the wave form changes.)

I'm still waiting to hear what was wrong with her. They were thinking sepsis and cerebral hypoperfusion.

A couple curious things about the call:

1. I was in the back alone when I was intubating her -- we were on the way to the hospital. After I got the tube in, I thought I need some tape to tie this. I had laid out the mouth tube holder, but the tape was out of my reach. I couldn't hold the tube and reach the tape. I could barely reach the ambu bag. I'm kneeling in the back of the bus, I'm calling to my partner to pull over for a minute to give me a quick hand -- he can't hear me -- I'm getting tossed by the bumps in the road. I ended up just letting go of the tube and hoping it stayed in place, I remembered I had the capnography to tell me if I was still in or not. Its part of the reason I dislike the box ambulance. In the vans everything is in my reach.

2. When I brought the patient into the ER and showed the medical staff the wave form on the monitor, the RT took the capnography filter off the tube when she attached the patient to the vent, and then the doctor called for capnography and they handed him a colorimetric device.

***

Anyway, I'll try not to write about hypothetical train wrecks or plane crashes for awhile.

Capnography and Intubation

Note: I am double posting this on this blog and my capnography blog.

When I was at a conference this past year one of the speakers said the data on prehospital intubation is so bad that if EMS had to go before the FDA to get approval to allow medics to intubate, it would be denied. Based on those studies, which include the LA pediatric intubation study, as well as many RSI studies, I can understand why.

However, those studies (to my knowledge) did not incorporporate continuous wave form capnography.

I believe continuous wave form capnography will eliminate all unrecognized misplaced tubes.

Capnography will prevent hyperventilation in head injured patients and critically injured patients(which may be the reason the RSI studies have poor results -- by letting medics intubate patients, RSI puts them at increased risk for hyperventiulation which is much easier to do with an patent airway and an ambu bag just begging to be squeezed.

And capnography can aid in the placement of difficult intubations. It can help prevent multiple attempts and even momentarily delayed recognition of misplaced tubes -- all of which cost the patient critical time without effective oxygenation and ventilation.

I believe continuous wave-form capnography will be the savior of prehospital intubation.

***

When many of us were taught to intubate the golden rule was:

NEVER PASS THE TUBE UNLESS YOU VISUALIZE IT PASSING THROUGH THE CHORDS.

The only ways we had to verify our tubes back then were this mantra, listening to lungs sounds and absence of belly sounds, looking for chest rise and mist in the tube -- all methods that cannot be considered fully reliable. My safety net was a partner who always held crick pressure for me and could tell me if I was in when he felt the tube pass under his fingers. That was my most reliable confirmation, but we didn't work together every shift so it was only part-time reliability. We didn’t have the bulb syringe then or colorimetric capnography much less continuous wave-form capnography.

While we all tried to live the mantra of never passing the tube unless we saw it pass through the chords, not all our tubes were in. Hopefully we recognized them right away – either by not hearing lung sounds or having warm gastric contents come flying up the tube to tell us we weren’t where we were supposed to be. How many times did we legitimately think we had passed the tube through the chords and how many times had we hoped we were through? Does the phrase “I think I’m in” sound familiar? particuarly coming from precepting or student medics?

As was proven in a recent study (see below), capnography has the ability to reduce misplaced ET tubes to zero if used. Instead of answering “You think! Pull it out!" or "You’re better hope you’re in – My license and mortgage and food in my babies mouths are riding on it!" Now capnography will tell you. He thinks right or he thinks wrong.

What I am going to suggest now is controversial. It stems from an interesting discussion I had with an articulate commenter on the November log. I suggest that with capnography’s ability to so quickly confirm or disprove a tube that it might no longer be a sin to pass the tube if you are not sure – particularly in the context of the difficult airway. If it wasn’t difficult we would easily see the chords, right? Now I’ll admit to shoving a tube or two in in my time. When you’re looking down the bloody throat of a gunshot or highway crash victim and you can’t tell what you are looking at or when puke and vomit are rising like a biblical Mississippi flood, sometimes you just put it where you think you see air bubbles or where anatomy wise the chords should be. When your own body is crooked trying to get an airway into the man wedged behind the toilet, sometime the view isn't the best. Ever tried an ice pick style tube?

In people whose chords are hard to see and who are difficult to bag, maybe the best thing to do is just shove the tube in to the best of your ability. And now with capnography, you’ll know you’re in or out almost instantly. Blind tubes are not after all that unusual in EMS. I have done digital intubations, intubations with a bougie and nasal intubations. All blind. I did them that way because that was the only way to get the tube. (Sometimes with IVs on people in extremis, you take a blind shot based on anatomy.) I say if you only have a partial view of the chords or the chords get obscured when you try to pass the tube, go for it if you think you can get it – as long as you have capnography to immediately check the tube.

***

Now here’s a tip. I haven’t done it yet in the field (it only occured to me the other day), but I think I will try it the next time I have to intubate a breathing patient. I have tested the concept and believe it will work.

Before you intubate, attach the capnography filter to the end of the ET tube, insert the stylet – it will fit as long as it is the thin kind, hook up the capnography to the machine, turn it on, and then go in for the tube. If your partner knows how to read wave forms he should be able to tell you if you are in or not when you ask. Either that or listen to the apnea alarm or the lack of an alarm. Make certain you have at least four good wave forms, and then pull the stylet and proceed with your routine checks.



For apneic patients you just have to have your partner ready to attach the ambu bag when you ask. No more looking around for the capnography filter -- it is already in place. Keep in mind as always for pulseless patients you may need a little CPR to get your wave form reading. And of course, you'll need to pull the stylet before you bag the patient.

Make certain you have an extra capnography filter available as backup because if by chance you miss your tube abd gastric contents come up, they will contaminate your filter in addition to your tube.

This method of attaching the capnography filter to the ET tube before intubating also works for nasal tubes. Watch the wave forms as you advance the tube while listening for respirations Once you think you are deep enough and then cough gag and you push through, verify with the wave forms. Just make certain you are not still in the hypopharanx.



Don't misunderstand me. I still believe you should strive for the gold standard of watching the tube pass through the chords. Don’t make capnography your crutch, but in a difficult airway, it may be your new best friend.


***

Misplaced Tubes

The effectiveness of out-of-hospital use of continuous end-tidal carbon dioxide monitoring on the rate of unrecognized misplaced intubation within a regional emergency medical services system.


Silvestri S, Ralls GA, Krauss B, Thundiyil J, Rothrock SG, Senn A, Carter E, Falk J. Annals of Emergency Medicine, May 2005, pgs 497-503l

If there ever was an argument for requiring continuous ETCO2 monitoring on all intubations, this is it. Over a ten month period, in 11 counties in Florida there were 153 intubations. 93 (61%) used continuous ETCO2 Monitoring. 60 (39%) did not. Upon arrival at the Emergency department there were 14 (9%) unrecognized misplaced intubations. There were 0 (0%) misplaced tubes in the group that used continuous ETCO2 monitoring. There were 14 (23%) in unmonitored group.

The authors wrote: “The unobserved unrecognized misplaced intubation risk difference is compelling. This study demonstrates that it is possible to attain a zero unrecognized misplaced intubation rate.”

Four years earlier, another study was done in Florida that showed during an 8 month period out of 108 “intubated” patients brought to a large Florida ED, there were 27 misplaced tubes (27%) on arrival at ED. 18 were in the esophagus, 9 in hypopharanx. 17 of 18 esophageal intubations had an absence of expired CO2, the one with CO2 was nasally intubated and breathing their own. 4 of 9 hyphopharengal intubations had an absence of expired CO2. - Katz SH, Falk JL, Misplaced endotracheal tubes by paramedics in an urban emergency medical services system, Annals of Emergency Medicine, January 2001

The authors wrote: “The incidence of out-of-hospital, unrecognized, misplaced endotracheal tubes in our community is excessively high and may be reflective of the incidence occuring in other communities...Functionally, whether the tubes were misplaced initially or dislodged en route to the hospital makes little difference to the patient....Despite written protocols requiring the out-of-hospital use of ETCO2 devices in our community, we...found their use to be sporadic... We believe that routine use of this technique, both at the time of intubation and as an ongoing monitor during transport, could potentially eliminate the problem of unrecognized misplaced ETT placement....”

Bottom Line: Intubated patients should all have continuous ETCO2 monitoring.

Syncope

Old woman has a syncopal episode at the dinning room table. No prior history. The family says she was out 1-2 minutes. Her eyes rolled back into her head and she vomited. Can't determine whether she vomited and then passed out or passed out and vomited.

She looks terrible, although she is alert. She says she feels weak, but she doesn't want to go to the hospital. Despite her age she had no significant medical history and lives independently. Her pressure is 120/70. Here is her strip:



I tell them in any unexplained syncope, it is important to go to the hospital. I can understand how given the dinner occasion, she might not want to go. I am thinking this is a vasol vagal episode. I want to do orthostatics, just to see what happens, but she says she is too weak to stand. And then she is unresponsive and vomits again. Unfortunately the leads have come off due to her sweaty skin, but I manage to get new leads on all the while supporting her airway, and hoping she doesn't code. Here is what I capture:



She wakes up and her rythm goes back to this:



We still insist she go to the hospital. With the help of her granddaughters, I get her out of her vomit drenched blouse and into a hospital gown, which I carry on the stretcher with the sheets.

We go on a non-priority. I put her on some 02 and put in an IV as we drive. Her color is much better. I get her demographic information, and then go to call the hospital. Right when I get ready to patch, I glance at her and she is vomitting again. I give a quick patch, "Sorry, my patient just started vomiting and is bradying down. Bottom line syncope at the dinner table. Be there in 5 minutes."

I hit print on the monitor while I try to keep the vomit in the small garbadge pail I grabbed and off her face. The episode isn't as long as the others and I can't say she is unresponsive during it. We are already at the hospital now. I have her cleaned off, and we take her in.

I give the report, and then write my run form. When I see the doctor, he shows me her 12 lead. The computer printout says possible posterior MI, although it doesn't jump out at me, and I'm not certain I agree. I show him my strips, and tell him this is what she was doing when vomitting, although she appeared normal at other times.

And then I look closely at the strip I recorded during the last vomiting episode. Here the ST is clearly elevated, but only for a few beats.



Its odd, but maybe what happens to her is similar to what happens when someone gets ST elevation during a stress test. She has a near blockage perhaps, which occludes during the stress of vomiting or is spasming. I'm not really sure.

I was surprised afterward that I didn't do a 12 lead myself and wish I had. I normally always do. I was just sort of busy, and I guess I was just thinking it was all a vagal episode and/or an upset stomach, but maybe it was an MI, and so was lower on my priority list. I think I might have done one in the house if there hadn't been so many firefighters and police offiders standing around the patient. I could have asked them to leave. Not that as health care providers, they shouldn't be involved, just having so many people -- firefighters, cops or medics makes it more awkward for the patient.

I'll post more later on this case when I next see the doctor and I can get more information.

I have also noticed that it is easier to study a strip after a call, than during one. It is hard to pick out subtleties unless you really study the strip. I think I should also have said to myself -- the irregular beats while she was vomiting are not typical of vagal episodes, at least in my experience.

I had another interesting call the same day, which I write about in my November log on my Capnography for Paramedics web site. It is another call where things aren't always what they may appear at first glance.

Hypoventilation not Hyperventilation

Happy Thanksgiving

Happy Thanksgiving everyone. This is the first Thursday since I have been in EMS that I have not had a regular shift scheduled on this day.

When I started in 1989 at a small ambulance company, I worked every Thursday. When I went to work for the state, I rode with a volunteer ambulance every Thursday night. When I became a full-time paramedic in 1995, I worked Tuesdays through Thursdays. When I went to nights, I worked Thursday nights. When my shift changed to being the contract medic in the suburban town, I worked Thursdays through Saturdays. This past year I switched to Sundays through Tuesdays as my regular shift.

So what did I do for my first free Thanksgiving?

I signed up to work 18 hours in the city. 18 hours at double time and a half, and because it is an overtime shift, it really works out to be triple time. For that kind of money, I can roast my turkey on Wednesday.

Earlier this week, one of the ambulance volunteers stopped by and said the Food Share turkey drive was 3,000 turkeys short. He left us $20 to go buy some turkeys, so my partner and I went down to the supermarket and pitched in some money of our own and bought 8 turkeys, which we brought up to the Food Share lot. They were so happy to see us their manager took our picture. Nothing beats giving for putting you in a good spirit.



What am I thankful for on this holiday?

That everyone I have known who has gone to Iraq has come back alive.

That I still have my health and am still working as a paramedic -- that I have a job where I can help people -- help which for the most part, they appreciate. And while it is not everyday I medically save anyone's life, simply by being nice to them, talking to them, making sure they are comfortable, I can make a difference in their day when they are in need of a little compassion.

And I'm thankful for my friends and family, who I should spend more time with than I do, particuarly around Holidays.

Life never takes you where you thought it might, but I still appreciate the chance to walk through the leaves on November days.

***

"walking through the leaves, falling from the trees..."-Bob Dylan
"Mississippi"

Paramedic Obituary

Sirens in the Night

Hit Me With Your Best Shot

My left deltoid is killing me. I can hardly lift my arm up. I got a flu shot last night. Needles don’t bother me. I took the PPD like a pro. The little tuberculin syringe into the right forearm. I hardly felt it. Then the nurse pulled out the flu shot needle. I wasn’t even thinking about it at the time, but I guess it was a 3 cc syringe with maybe a 21 needle(actually it was a smaller 25 needle). I’ve had the shot lots of times and it never bothered me, but this time it was uncomfortable. It didn’t take long for my arm to start aching. Last night I couldn’t sleep on my left side.

Sometimes I think we should have to personally undergo every procedure we do on a patient on ourselves. Some services make their employees ride on the stretcher, looking up at the ceiling to see just how unpleasant the ride can be not to mention how dirty the ceiling might be. But I’m talking about much more than that. Within reason of course.

In our medic class we did IVs on each other. But never gave each other IM or SC injections. We spinally immobilized each other and put on traction splints in EMT school, but we never shoved nasal airways up each other’s nostrils.

I’ve heard of pranksters putting nitro paste on door handles to make their coworkers dizzy, but I’ve never pulled that prank or fallen victim to it. I’ve taken baby aspirin. I’ve had benadryl in pill form, and of course, lots of glucose in a variety of oral forms. I’ve produced natural epinephrine, but never had a shot of it. I had versed IV when I had a cyst removed from my scalp. I had fentanyl for pain then, which we don’t carry, not morphine which we do. I have had an albuterol breathing treatment. But not atrovent. I’ve had phenergan and reglan, but I’ve never popped a nitro, never had cardizem or amiodarone or procainimide. And, no I've never had pitocin, which we no longer carry. I’ll admit I have had curiosity about what it would feel like to hook myself up to a monitor and inject myself with adenosine -- to watch as my heart stops, and then hopefully restarts in not too long a time. But I am not without common sense.

I’ve never had valium or ativan or haldol. No atropine, dopamine, or vasopressin. No solumedrol. No Sodium Bicarb(although I have had a lot of diet soda). Never put tetracaine in my eyes. I have had lidociane as a local anesthetic, but never for V-tack.

I’ve know what it feels like to have electrodes ripped off hairy skin. Painful. But I’ve never been paced, cardioverted or defibrillated. I might have been intubated when I had a bone spur taken off my knee when I was ten, but I’m not certain. Nothing since then. I’ve gotten a few IVs. Once in college I had food poisoning and had been vomiting every hour for six hours. They gave me a bag of IV fluid and it was very cold and unpleasant to feel that slow drip drip of ice cold fluid into my arm. Subsequently I have had IVs of saline when I had the flu and felt much better afterwards. Its a miracle what a 1000 cc bag will do for you. I’ve never had an EJ in my neck or an IO drilled in my bone.

Like everyone I’ve had blood drawn and had to sit there while the tech roots around to hit the vein, even though I have ropes. I’ve wanted to say, give me that needle -- just let me do it.

Tonight when I go to have my PPD read (no swelling yet) by the nurse who stuck the flu shot needle in my shoulder, I probably won’t say anything to her about how much it hurt.

I do think there is some merit in knowing what you will be dishing out feels like on the other end.

To anyone I have hurt with my shots, sorry.

Hole in the Windshield

Past midnight. A giant of a man stands by the open door of his twisted Buick blinded by the lights of the fire truck. He is bare-chested, blood streaming from his severely lacerated head. There is a hole in the windshield the size of a basketball.

“I don’t need a collar,” he says, ripping off the collar I have just put on him after cautioning him to be still. “I’m an EMT. Leave me alone.”

“If you’re an EMT, then you know the game,” I say. “Put the collar on and be still.”

“There’s nothing wrong with me!”

“You’re impaired. You just put your head through the windshield. You’re going to the hospital.”

“I am not! Leave me the F alone.”

“Not going to happen,” the police officer says. “Now shut up and behave. Listen to the paramedic. You should know better.”

He goes with us in the ambulance but he is not happy about it. He lies on the board with his arms crossed, as we head to the hospital, lights and sirens. I notify the hospital. “No loss of consciousness,” I say, “but unbelted, unrestrained, stuck his entire head through the windshield.”

He grudgingly tells me his name and address and medical history. I wonder, if he is an EMT, how many times he has had a similar patient on his stretcher, and what he tells his coworkers later? “Guys says he’s an EMT. What an A-hole, stuck his head right through the windshield, bleeding like a stuck pig, says he’s fine. Can you believe?”

Lying there looking up at the ceiling, he looks angry. I don’t know if he is mad at us, or at himself for totaling his car, or mad at someone else or just life for setting off the events of this night that led to him losing control, bisecting a telephone pole, and ending up head-on into a stone wall, his skull breaking through the glass of the windshield, going through to the other side, and then coming back.

"What an A-hole,” my partner says later. “Can you believe the size of that hole in the windshield? I’m surprised he didn’t cut his head off.”

***

Two days later, we are eating lunch when there is a knock at the station door. There is a giant man with ragged stitches in several places across his forehead and temple standing there taking up the doorway. He smiles and nods his head and offers his hand to shake. “You took care of me,” he says.

“Yeah, how are you?”

“I’m okay. They kept me overnight and stitched me up, prettified my head. I just went to look at the car and…” He vigorously shakes my hand, bowing as he does it. “I just want to thank you; I want to thank you for taking care of me.”

I say no problem, I’m glad he’s okay, good thing he has a hard head. I thank him for coming by.

We go back and sit down to our Mo Shu Pork.

“Nice guy,” my partner says. “Not everyday you get someone saying thank you.”

“Unusual,” I say.

Later I wonder when he stopped to see his car, if he took a picture of the windshield, and if he did, whether he shows it to his EMT buddies at work and laughs about his hard head. Or maybe he’ll just keep the photo under his pillow when he lays his head down, after he has said his night prayers.

Mortal Men (Final Chapters)

I have posted the last chapters of my latest draft at:

Mortal Men

I will keep the book up until Christmas.

Thanks for reading.

Stay Awake

Buy stock in ambulance companies. There is no way around it. There will always be ambulance transports. Talk all you want about treat and release. It’s not going to happen. Here are the problems. Liability. No body wants to take it. Plus people seem to like ambulance rides. There is a certain cachet about them. Nothing but the best for our people. There are a lot of myths out there and one of them is that riding in an ambulance is neccessary more than it really is. Another myth is that patients need to stay awake in the ambulance.

9-year-old midget football player feels dizzy after he tackles another player. No LOC, Pupils equal and reactive. No pain. Good vitals. Maybe he scrimped a little on his pregame meal. Parents insist patient be taken by ambulance to the hospital for evaluation of a possible concussion. I could reassure the mother that I don't think there is anyway he has a concussion seeing as he wasn't knocked out even for a second, but I just say which hospital? She tells me the name and I pass it on to my partner who will drive. Stay awake, the mother tells the boy, as we set him on the stretcher. Goes for you to, I whisper to my partner.

Every fall in every town midget football players get transported for hurt legs and bent fingers and headaches. These are tiny kids wearing more padding than those summa wrestling suits. They can’t generate enough force to do damage to anything. Yet they go to the hospital at epidemic rates. An EMT in one town told me he was called onto the field for a player down. He gets there and the kid’s finger is bent, but everyone is telling him not to move. If you bend your finger at home, you don’t need an ambulance, but I guess ambulances are part of the football experience, along with someone telling you to stay awake.

This weekend a player at a college football game was airlifted from the stadium to the trauma center. The report was he was moving all extremities, but they were telling him to stay awake, stay awake. My guess is that the airlift was more for advertising for the helicopter service than medically necessary. Reports say he was released from the hospital when all tests came back negative.

I saw in the paper the other day an area police officer was in a crash and transported by helicopter for a serious head injury. The officer was released the same day. Maybe it was because they told the officer to stay awake the whole way, shouting it through the noise of the helicopter's whirling blades.

We transport another 9-year-old with a possible leg injury. We find him on the field being told not to move. No deformity. It doesn’t hurt badly, he says. He can move the leg. Family wants him to go to the hospital by ambulance. So do the coaches and the referees and the bystanders. Which hospital? I say. My place is just to transport if they want to go. On the way there, he closes his tired eyes. Stay awake, stay awake, his mother says.

Later in the day, we are sent to a nursing home for unresponsive CPR in progress. We get there and the nurse says, she responded, thank goodness. You didn’t do CPR? I say. No, we didn’t have to. Three sternal rubs finally aroused her.

She is 94-years-old and has Alzheimer’s. It seems she was found unresponsive in her wheelchair. Eyes closed, not responding to the first two sternal rubs. They want her sent to the hospital to be checked. Her vitals are better than mine. I ask if they called her doctor. He ordered it, they say. Don’t want to take chances.

I ask the woman how she feels. She doesn’t respond. I think she is sleeping. I give her a little rub. She opens one eye and looks at me as if to say “Yes?”

“How are you feeling?”

“Tired,” she says.

I am tempted to say “stay awake, stay awake.” Instead, I say, “Well, you nap some and we’ll try to give you a smooth ride. See you at the hospital.”

Before I fill out the billing information on the back of the run form, I finish the front side by writing in the "Clinical Impression" box. I write "Tired."

***

Mythbusting: Concussions and Staying Awake

EMS Stock Quote

RURL Stock Quote

Mortal Men (Chapters Thirty-Six to Forty)

Five more chapters posted at:

Mortal Men

The Edge of the World

It’s a cold rainy evening. We’ve been doing nothing but soaking wet drunks and third floor carry downs of heavy women. Dispatch pages us with a transfer from a local hospital to a town about thirty minutes away. I don’t like transfers except on cold rainy days. They beat doing MVAs in the rain, they beat picking drunks out of lake-size puddles, and they beat third floor carry downs.

I look in the map book to see where we will be going, but the town isn’t in the book. It’s just off the edge of our world. I figure once we get up to the hospital floor, I can call the facility for directions.

Our patient in an old woman in her seventies, who is recovering from a subdural bleed following a fall in which she also sustained a broken arm and several broken ribs. We meet her husband, an old man wearing an overcoat and a bowler hat. Before I introduce myself, I overhear him telling a nurse that he has spent the last two days looking for an acceptable nursing home for his wife. He says he found a lovely one just six minutes from his home, but he found an even better one farther away and it is this home we are taking her too. “The people seemed engaged there,” he says, “They were all out in the halls and in the common rooms. There was a sense of community – a warm place that I believe will help Ethel recover, so that’s why I chose it.”

I ask the man for directions and I scribble furiously as he describes the way. "Get off the exit, go right, and then just keep going, follow the road – it will wind and turn, and then when you come to a light, cross the road – straight across, up the hill, and then take a quick right or you’ll miss it – it’ll be right there.”

The wife is unresponsive. She lies on the bed, all bruised and curled up. We lift her over gently under her husband’s watchful eyes. The nurse hugs the husband and wishes him well. He thanks her for the wonderful care they have given his wife. He then kisses his wife and says he’ll see her shortly.

It is pouring rain and after I’ve gotten off the highway and am on the just keep going – it will wind and turn part of the directions, I hope I am not lost – it seems I am going away from civilization. A foggy mist hangs over the meadows, not beaten in by the rain. And then ahead there is an intersection. I cross, go up the hill, and then there on the right – is the Manor. We made it.

How can I describe the feeling upon entering the facility. I feel like a traveler who has hiked for weeks over mountains and through forests, and who comes upon a warm hunting lodge. There is a fire in the fireplace, the carpet has the grandeur of Persia. People sit lined in wheel chairs, laughing and talking or just sitting serenely. Frank Sinatra plays in the background. A smiling woman greets us, and leads us to the patient’s room. We pass common areas – a room full of books where people sit reading, a pool table, a man sits at a piano and seems to be happily playing soundless air piano.

The patient's room is clean and warm with a colorful flowered beadspread. The smiling woman helps us move the patient into her bed, and talks pleasantly to the woman, who for the first time seems to respond, her face softening. It looks like she is trying to smile.

While my partner remakes the stretcher, I look for a bathroom. It seems I am headed toward the kitchen. The air smells like homemade chicken soup. I see a man with a big mustache in a chef's hat humming as he stirs a large steel pot with a giant wooden spoon. I am tempted to ask for a bowl to go. I see a woman taking loaves of bread out of a big oven.

There on my left is the bathroom. I enter, and it smells like a pine forest. Instead of bare walls, there are photos of old people chopping wood in the snow.

When I go back out to the main lobby, I find myself mesmerized by the scene. The music again is Frank Sinatra or Dean Martin or Tony Bennet -- one of those cool guys from my father’s generation, who wore suits, smoked cigarettes and wooed the prettiest women as they sang of love, broken hearts, tattling towns, and doing it their way. An old man in a robin's egg colored suit sits forward leaning on his cane, his eyes closed, swaying to the music. All around him are old women in wheel chairs, but they all look quite pretty. Some have lively eyes and are smiling. Others, with eyes shut, seem also to be dreaming along with the music. Behind the man is a giant grandfather clock. The biggest one I have ever seen. Its pendulum swings back and forth.

Outside the rain pours down.

Mortal Men (Chapters 31-35)

More chapters posted at:

Mortal Men

14 Chapters to Go. They should all be posted by the end of the month. Once that is done, I will keep the whole book up until Christmas before taking the bulk of it down.

Medical Priority Dispatch

I have written in the recent past about my frustrations with Medical Priority Dispatch (MPD), as well as the recent research that has been published pointing out its failings. The posts include Troublesome, Unformed Idea, Fair Enough and Dispatchers.

Bryan E. Bledsoe, DO, FACEP, who has made a name for himself debunking EMS myths in addition to being the author of the standard EMS text, has now weighed in on Medical Dispatch, commenting on the latest research, which shows that on half the MPD protocols, flipping a coin does a better job of correctly prediciting priority than the protocol.

Anecdote Based EMS

I agree with his conclusion: "Either the system needs to be evidence-based (that is, it works) or it should be abandoned."

"Sixteen of the 32 protocols performed no better than chance alone at identifying high-acuity patients."-Comparison of the medical priority dispatch system to an out-of-hospital patient acuity score.
Acad Emerg Med. 2006 Sep;13(9):954-60.
Feldman MJ, Verbeek PR, Lyons DG, Chad SJ, Craig AM, Schwartz B.

***

In one town where I work, someone calls 911, the town dispatcher answers, takes the information, and then kicks the call to a regional medical dispatch center to "EMD" the call. The town dispather calls us, gives us the address, nature and a priority code. "Code Three" is lights and sirens. "Code One" is no lights and sirens. We then get in the ambulance and contact the regional medical dispatch center, who provides us with "EMD" information after interviewing the caller. We basically get more info and another dispatch code. "Hot" is lights and sirens. "Cold" is no lights and sirens. We then call our town dispatcher in the event we have either been upgraded to lights and sirens or downgraded.

Yesterday one of our calls was for a person with swollen legs who had fallen a few days before, and who's son wanted her to go to the hospital. The town dispatcher send us in nonemergency mode. The medical dispatch center upgraded us to hot because the woman had a heart history. The call was strictly BLS, nonemergency to the hospital.

We do have the ability to overrule the medical dispatch code, which is just "recommended." I have a pretty good feel for what the call will be, particuarly if I have been to the same address before. I often just continue in the nonemergency mode if the time difference between lights and sirens and non lights and sirens will be minimal.

I think it would be interesting to do a small study comparing the accuracy of the town dispatcher, who uses their "common sense" versus the medical dispatcher who follows the algorithm.

Both have their advantages and disadvantages. I have found the medical dispatch center seems to always overtriage us by sending us "hot" if the patient has any kind of cardiac history. The town dispatchers tend to undertriage us when they send us non emergency for any kind of broken bone and overtriage us when they don't understand what the caller is talking about just as when a G-tube comes out. They tell us to go lights and sirens. We say "ah, no."

Changing Season

People were out raking today or in many cases using their high-powered blowers to clear their lawns of the orange and red leaves still falling from the trees. They didn’t have those blowers when I was a kid. I’m lucky though, I have a small yard now and don’t get many leaves. The ones that I do I just ignore. My neighbors who haven’t run me off the street yet, I think have come to accept my yard as it is. It will never make better homes and Gardens, but at least I haven’t put any flamingos up.

It was a beautiful morning, cool and sunny. I went to the gym and rode the stationary bike and then ran on the treadmill. I know on a day like this I should have been running on the slightly sloping streets admiring the November day, but I am just getting into running and didn’t want anyone calling 911 if I have a coughing, phlegm spitting I can’t breathe I can’t breath oh my god my lungs hurt vomiting dizzy fit as I hit the first mile mark. Anyway, it was a good workout. My body is adjusting to my new emphasis on cardio while I maintain my strength-training.

I was going to get my haircut afterwards. I’ve let it get awfully long, which if I was back in the 1970’s or 80’s would be perfectly fine, it is a little bit out of style now. Women my age and slightly older tell me how much they like it. My girlfriend and others younger tell me it is too long and I need to get it cut. I like it long myself. It makes my feel younger and stronger. You know, the Samson sort of thing. I debated the issue, and then in the words of the immortal David Crosby,

Almost cut my hair
But I didn't...

I go into work in the late afternoon. I’m going to be working more overtime shifts between now and the end of the year, and I have decided to work more evening shifts. With all the new hires there aren’t as many openings during the day, and the truth is I am getting a little tired of the city traffic, the constant movement from one post to the next, as well as the heavy load of transfers.

Tonight I am assigned a clean cut young man half my age, who has only been working at the company a couple months. He asks me how long I have been a paramedic.

“I started in EMS in 1989,” I say. “I became a medic in 1993, and started here in the city in 1995.”

“That’s insane!” he says.

(I'm assuming -- hoping -- that expression is similar to the "Crazy! or "Far Out!" sayings of my youth and not a comment on a forty-eight year old sitting behind the wheel of an ambulance.)

Our first call is in the bariatric ambulance for a man who usually requires four people to lift. I’m feeling strong, and my partner is fit so we lift him ourselves and have the patient loaded in the back of the ambulance by the time our lift assist crew arrives.

“We’re all set,” I say.

“Are you sure?”

“No, problem. My partner’s strong,” I say.

It’s good to be working at night again. The years I worked nights in the city remain my favorite on the job. At night – the landmarks are different. What is hidden during the day is visible at night and vice versa. The streets, all lit up, seems like a different city. Aide from downtown the streets are empty, and so it takes little time and much less aggravation to reach the calls. The hospitals are less crowded. Seldom is there a line at triage. Aside from some of the psychs, people are friendlier.

After clearing a call, I get a pulled pork sandwich with onion rings from a place I’d heard was good, and wash it down with a bottle of water. It is good, but a little too pricey to become a regular stop.

We cruise downtown for awhile – many of the bars are new or have at the least changed their names. The women strolling past on their date’s arms, look younger.

We do a staggering drunk outside a liquor store, babbling in an incomprehensible mixture of Spanish and English. He can't tell us his name or date of birth, but we pad him down and find a state card in his back pocket. He is well known at the hospital where we help the nurses restrain him to a recliner.

Later a car goes off the road and down an embankment. The driver, a not quite still pretty woman in her early to mid thirties, says she was just tired. She looks like things haven’t been going her way. She sits in the back of the cruiser and through tears, signs the refusal.

We get off about fifteen minutes late. I zip up my coat as I walk across the darkened parking lot to my car. The temperature has dropped to freezing. Already there is frost on the windows.

Freedom

He is a young barrel-chested man in his thirties with a thick Russian accent. The cops found him asleep in his car outside his apartment building. They have ordered him to the hospital to sober up. “I love you,” he says to the burly officer.

“Okay, fine, buddy,” the officer says. “Just go with them and don’t give them any trouble.”

“Don’t worry,” he says to the officer as the officer steers him towards us. “You are a good man. Will you be my uncle?”

“Not today or tomorrow. You get yourself some treatment. Sober up.”

“I will do whatever you say,” he says. “I give no trouble.”

The man is from Moscow he tells me on our drive to the hospital. He has been in America for seven years. He loves it here. What does he love the most? I ask. “Freedom,” he says.

He has been drinking vodka – “Graaay Gooooose.” He says, “I drink every day for thirty days.”

He says he drinks because he is sad – he has lost his wife and daughter. I ask if they are dead and he says no. “I took my daughter just yesterday to the zoo.” It seems his wife and daughter live in a different town now.

“She also loves freedom,” he says.

“That must be hard being apart. I’m sorry.”

“Thank you. You are a good man,” he says.

“That’s nice of you to say.”

“How did you get in this business?”

“I like helping people,” I say. “It’s a good job.”

He nods. “I wish the world was all good people like you.”

“Thank you, that’s very nice of you.”

“But listen, you want to help me next time.”

“Huh?”

“The ambulance bill is high. Next time have them call a limo for me to the hospital. Cheaper. Save money.”

Later, when I am at home, I picture the hospital parking lot lined with ambulances. And then a long black limo arrives and backs in. A man in a tuxedo with a chauffer cap gets out and goes around and opens up the side door, and our Russian hero, clutching his bottle of Grey Goose, gets out. He hands the chauffer the bottle, and then slowly, sadly walks in through the ER doors, which close behind him.