The Man Who Wouldn't Die (Part 2)

Here's Part 1:

The Man Who Wouldn't Die

Now Part 2:

So I'm just sitting around thinking I've been doing nothing but routine EMS calls -- lots of elderly flu, dehydration, falls, psychiatric, TIA type calls with nothing much to write about despite being so busy when the tones go off and we are sent to respiratory distress -- SEVERE, according to the dispatcher. En route we are updated Respiratory Arrest. I'm sitting in the back so I start setting up. The med radio dispatcher says it is a male patient so I take out a number 8.0 tube, attach the capnography filter, insert a thin stylet, attach a 10 cc syringe, and then set up a saline lock with flush, a Venaguard, a #20 catheter, an alcohol wipe and put them in my pocket.

On entering the house I hear, as many times in the past, "No shock advised, continue CPR." I follow a long 02 cannula into the den where a man lies on his back, his mouth open, attached to a defibrillator, looking quite dead. It has been ten minutes since we were dispatched.

"I felt a pulse when we got here," a first responder says. "But I can't now."

"Start CPR," I say.

Since he is already on a defibrillator, I have my partner attach him to our monitor with just the basic leads. He is in for all intents and purposes asystole with only a rare occasional complex. The tube goes in easy, and the monitor shows the cardiac oscillations of CPR against the lungs causing a small tidal volume without bagging.



(Since I have started attaching the CO2 line to the ET tube before actually intubating I have been fascinated by this initial phenomenon that goes away as soon as I give my first ventilation. To me it is proof that CPR by itself does produce a small amount of ventilation on its own.) My initial ETCO2 is 32, but it quickly declines.

The first responder is doing okay CPR, but I tell him to push faster. We are going to do the new CPR, I say.

While I am going for the IV, the apnea alarm goes off, and the number has dropped to 6 with a very small wave form. The alarm is very annoying. I stopped what I am doing and reconfirm my tube. The lung sounds on both sides are decreased, but there is nothing over the belly. There is good compliance. I undo the ET holder and go back in and visualize. I'm in, the tube is sitting through the chords. The new commercial tube holder we are using snaps when I try to retie it, so I have to get out tape to fasten it. The number stays low. Pound harder on the CPR, I stay. I tell the responder bagging to just squeeze the bag a little. I go back and get the IV, and for the first time remember I carry Vassopressin, and so instead using epi I push in Vassopressin and follow it with an atropine. Still nothing on the monitor. The ETCO2 is only about 5. It seems to me it should be higher. I shut the monitor off and turn it on again to see if it needs a reset. Same reading. I put on a new capnography filter. Same deal.

"Excuse me," a man says coming in from the other room where one of my partners is getting information from the family. "I'm the family pastor, and his wife doesn't want anything done if he can't be helped. He's been very sick."

"Well, I can't stop now. I have protocols to follow, but if we can't get him back soon, I am going to call it."

"She really doesn't want him to be on a machine. It is his wishes as well."

"We're doing the best we can," I say. "We just have to finish out our protocol and if we can't get him back, we won't transport."

He is still, asystole. I push in another round of drugs and then a third.

The responders doing CPR are looking a little tired. I take over, and I really start pounding, and as I pound I am getting for the first time, good complexes on the monitor. "Like this," I say. "You really have to pound it. Fast and deep."

The pastor reappears now with a phone in his hand, saying "It's his doctor, he wishes to speak to you."

I let one of the responders take over CPR and go in the other room to talk to the doctor, who tells me the man has terminal lung cancer and they had spoken about making him a DNR, but thought he had a few more weeks at least before they had to worry about it. I tell him I am sorry for having to work him, but no one said anything to us about his being a possible DNR or having terminal cancer. I explain that I am running through my algorithm and than I don't anticipate transporting. He seems pleased with my explanation.

I go back in the other room and see the first responder is doing CPR to beat the band. I announce that I am going to call the code and I have him stop. I look at the monitor. There is a rhythm.



The ETCO2 is still only about 8. I check for pulses. Nothing. Well, I guess we stick at it a little longer I say.

The cop who is sweating says how about getting a board and getting him on the stretcher. I explain about the terminal cancer and how this is probably just the drugs being circulated by the good CPR, and I am not going to transport unless I get a blood pressure.

He says he understands and goes back to the CPR.

I do another round of drugs. After another five minutes we stop and check the monitor. It looks like he is back to asystole.



Okay, let's stop, I say.

Blip, blip, blip. The rhythm picks up again.

This goes on and on. Every time we stop, the rhythm starts again. His end tidal is up to 10. Nothing to sustain life, but I can't call him with a rhythm, but at the same time I don't want to transport him because after all he has terminal cancer, his pupils are fixed and dilated, and his family doesn't want anything done.

We stop again. I watch the rhythm to see if it will brady down. I am prepared to call him if it does. I am tired and my eyes seem hazy. I think I am seeing things. The man looks a little blurry.

"Is it just me or is he breathing?" the woman at the head doing the ventilations says.

"He's breathing," I say.

His end tidal should be much higher. I can't feel a pulse, but he is moving his chest.

I swear silently. Now what do I tell the family and the doctor. One of my partners has already hinted to them that we are winding down that no survival looks possible.

The man is dead, but he is not dead. We've been working him forty minutes, his pupils are fixed and dilated, he has terminal cancer.

I look at the monitor and he starts to brady down. Start CPR again, I say as it goes flat.

We do two minutes of CPR and I say, if he's flat line, I'm calling it for real.

We stop. He has a rhythm.



I want to just call him, but what if he starts breathing again after we put a sheet over him.

We go back and forth asystole, PEA.

The first responders are drenched and exhausted even with switching CPR every two minutes. They are looking at me for a resolution. Either call him or transport him.

Finally, I do what I probably should have done earlier, I call the hospital and thankfully get a veteran doctor, who I explain the story to. I ask for permission to presume. "Yes, by all means," he says.

When I return, I tell them to stop CPR. I look at the monitor.

At last:



I call the time. Nearly an hour after we started.

***

Some lessons learned and thoughts.

1. I firmly believe a family ought to have the right to say enough is enough. Screw me and my regulations and protocols. A family's wishes ought to count for more than they do.

2. Okay CPR is bad CPR. As a medic, I need to make certain all CPR is pounding hard, fast and deep, exhausting John Henry versus the steam drill CPR.

3. I think what happened was I loaded the guy up with drugs and only when we started really hammering the CPR did they get circulated well, and then he was getting slammed with mega dose vassopressors.

4. Despite the brief period of respirations, I think most of the monitor activity was just electrical.

5. The LP 12 apnea alarm is a pain. It can't be programmed. It goes off when it can't detect a breath, even though the ETCO2 is reading 3-7 and there is a small wave form.

***

All told we worked the man for nearly an hour. While it was physically draining for the first responders. It was emotionally draining for me -- trying to do the right thing, trying to decide what the right thing was, and then just when I would think the issue had been settled, he would come back alive or psuedo alive.

The family and the pastor were very gracious and I guess it worked out in the end. The man passed away at home. No trip to the hospital. No living on a machine.

Pub Med

Back at work after four days off. Not much going on -- a diabetic, and two leg pain calls.

Occassionally when short of material, I have been posting about interesting EMS web sites. Today, I'd like to hightlight Pub Med, which is an online database of medical research.

I use it often to research issues of interest to me. Sometimes, I will just type "prehospital" in the search box. The search will list all the latest research involving prehospital issues. You can then click on an article and read the abstract, which describes the research and details the results and conclusions. Unfortunately, the entire article is usually only available by on-line subscription.

I am lucky that one of the hospitals we transport to is a university medical center with an accessible library that has a subscription to all of the journals. A high speed printer spits the articles out for only 7 cents a page.

Typing "prehospital" into the search box today reveals recent research articles about RSI, pelvic fractures, cuffed ET tubes for pedis, strokes, and the role of ALS in out-of-hospital cardiac arrests.

Miscellaneous

I read today that SAVED, the TNT paramedic drama, will not be renewed.

TNT Dumps SAVED

Yahoo Report

I bet it will come out in DVD and become a cult classic.

***

I have been trying to call for morphine for all my patients with abdominal pain lately unless they are bleeding. So far I have been getting orders. Yesterday I asked for 5 mg for a patient with a history of undifferentiated abdominal pain. The doctor told me since I didn't know what was causing the pain, I could only give 2 mg, which wasn't enough to do much. It was largely my fault. My patch was a bit meandering and most significantly, I forgot to give the patient's weight -- 100 kg, which probably would have clinched the 5 mg. At least they knew she was in pain and had been started on the narcotic route.

***

I've rewritten my 10 Things Every Paramedic Needs to Know about Capnography handout and have done a lot of work to the site:

Capnography for Paramedics

I am also working on a handout for ED staff, called "What We're Talking About," which I will be passing out at a skills session I am teaching at one of the hospitals to educate them about EMS capnography.

***

My paycheck has been screwed up the last couple weeks, partially my fault as sometimes I forget I have punched in, particularly if I come in early, so after checking my gear I repunch in, and end up getting paid for only an hour, instead of twelve. Anyway, I called the timekeeper lady today -- I've dealt with her a few times in the past and each time I am amazed at how calm and friendly she is, and I always hangup feeling like I've just visted another planet where there exists something called customer service.

I wish I could be like that on all my calls, completely unphased by irate and demanding people, leaving them all dazed with pleasantness.

State of the Union

10 calls today starting with two minutes after the moment I laid my head down after checking my gear. I’m on my fourth different crew of the day and I admit I am getting cranky. The goal is to reach a zen-like state where you can do each call 100% with full attention and senses focused on the patient and the evolving scene. I can't always do that.

No spectacular calls, just the drudgery of EMS -- falls, motor vehicles, refusals, anxiety, vomiting, chest pain, COPD, fevers.

There’s nothing like having a great partner, someone who knows your every thought and movement. When you work with so many different people, you have to become your own best partner and that means preparation, knowing your equipment cold, laying out what you need -- making certain the 02 is always full, there is a nebulizer in the house bag, a Johnny on the stretcher, enough electrodes in the monitor to do a 12 lead, a towel on the pillow so you can drape a patient's head before carrying them out into the cold, your IV tray is fully stocked -- all little things that make the call run smoothly in spite of itself.

Preparation. If you want to stand tall, you want to set an example of how a paramedic should be, you have to be prepared. Always.

The great fighter Joe Frazier had a saying:

"You can map out a fight plan or a life plan, but when the action starts, it may not go the way you planned, and you’re down to your reflexes – which means your training. That’s where your roadwork shows. If you’ve cheated on that in the dark of morning – well, you’re getting found out now, under the bright lights."

You need to do the road work. No "opps I forgot to check that" or "I never studied that, I didn't think I'd encounter it." It's hard being prepared. I'm not always, but I want to be. I want to learn from my mistakes. I want to be continually better. When you are and a call goes well, it's a good feeling. You can stand tall.

***

I am still recovering from a case of bronchitis that laid me out for two days last week. I was a pathetic coughing feverish wraith of a man, subsisting on cold meds and ginger ale, and memories of once being able to stand on two feet. Now I am like a man returned to earth for a second chance, trying to make the best of it, a long way off from the days of feeling ten feet tall and bulletproof. I want to humbly go through my day being the best I can, and if I can't be great, at least I will have done my best. I am not close to this, but I want to be.

***

One of our patients today was a powerful captain on industry struck down in recent years by CVAs, broken hips, coronary artery disease, pneumonia, and the onset of dementia. He was surrounded by personal staffers who tried to tell us how to move him and repeatedly told us to be careful. One woman -- the personal secretary -- was very meddlesome and patronizing. In the ambulance on the way to the hospital, the man grabbed my wrist with his still powerful grip and looked me in the eyes and muttered something I couldn’t understand. His breath was foul from his GI vomiting earlier, his tongue black and stained. “Sir?” I said. He muttered again and nodded. I still don’t know what he was trying to tell me, but it felt like he was trying to share some important lesson he had only recently learned, maybe to give me a warning.

Another call was for a man who slipped out of bed and needed help getting back in. He had COPD and skin fungus, and was short of breath from the exertion of us picking him back up. He didn’t want to go to the hospital. His companion, who was also his power of attorney, signed the refusal. My partner and I remarked afterwards how many male couples there were in town, older men, who had spend most of their lives together and were helping each other even though they probably never imagined themselves or their lovers in such poor health, just like everyone else. The family in whatever form is what it is about – people standing by each other.

Overtime shifts are still hard to come by. I’m looking at four days off ahead. Instead of lying in bed, I hope to be productive. Cleaning the house, working out, writing, spending some time with my girlfriend, playing with her kids, and maybe later even seeing a movie. The Oscar nominations just came out and every year I try to watch the best picture nominees. The one I most want to see is Clint Eastwood’s Japanese Letters from Iwo Jima. He made Flags of our Fathers in English about the men who raised the flag above the sandy rocky island, and then made another movie from the Japanese point of view, about the men left on the island to fight the Americans, men who knew they would die – that there was no escape.

I think I am also going to go and buy a CD. I’m thinking about Neil Young’s new album, including the angry anthem “Looking for a Leader.” At the end of the night I will have a beer and crank the stereo, and let loose some air guitar.

"Looking for a leader to bring our country home..."

I admire people who try to do the best they can, who are not buffons at their jobs, who don't coast through life, people who are out doing their roadwork.

"Walking among our people, there's someone who's straight and strong...to lead us from desolation and a broken world gone wrong..."

Neil Young. Still Rocking.

"Looking for a leader with the great spirit on his side..."

A Tale of Two Codes

The Chain of Survival

After finishing my paperwork I come out of the ER and sit in the front seat of the ambulance. My partner, who is in the back putting linen away, says, “About five minutes ago they sent an ambulance up to Pilson Way for a call where they are doing CPR.”

“We should probably clear,” I say. “No telling where they are coming from, plus at any rate they’ll need backup.”

We clear with our dispatch and they put us on the call. Pilson Way is a hike. The Med radio updates us that it is a sixty year old woman who is not breathing. She was breathing when her husband called in, but has stopped and they gave the husband CPR instructions. The police are on scene now.

It takes us about eight minutes to get there. Ahead we see two police cruisers and a commercial ambulance. I ask an officer standing in the driveway what is going on, and he says they shocked her once and she started breathing. I start in through the open garage door, but he says no, they are already in the back of the ambulance.

I open the side door and ask what I can do to help. The medic is one of our town medics who works the night shift at the end of the week. Like me, he works a lot of city overtime for the commercial service. “I’m just putting on the capnography,” he says. “Wilson here shocked her and got her back.”

I look at the cop. Bob Wilson sits there squeezing the ambu-bag. “Wilson, I say, you are amazing. “ I can’t count the number of saves I have had where Officer Wilson was there first to either shock or do CPR. “Than man with the magic hands.”

“Just doing my job,” he says.

I take over the airway and ride in with the medic. I get the story along the way. The woman just came home with her husband. He went in the house and noticed she didn’t follow. He found her beside the car. She was breathing funny and not responding, he called 911. Officer Wilson got there and shocked her once, and then immediately started CPR. The medic got there moments later. The woman appeared to be in PEA, but then she started breathing as he intubated her. Her pressure now is 74/40Her ETCO2 is 51, but with measured assisted breathing we get it down to 35. 300 cc of saline and her pressure is much better. Her color is good. Pupils sluggish but reacting. She’s in an a-fib in the 120-130 range. Her sugar is fine. We even do a 12-lead. Pressure on arrival at the hospital is 140/80. SAT is 100%. The doctor says, “Fine job.”

Wilson calls me later to find out how she did.

“Great,” I say, and tell him what I know. “You are the man!” I say.

“Just doing my job,” he says.

***

Futility

That afternoon we get called for unconscious, not breathing at the nursing home. 94-year-old terminal cancer patient with a lengthy list of other medical problems. I walk in the room and see the officers doing CPR. His body is misshapen. He has a huge distended abdomen, which the nurse says has been normal for him of late. He has kifosis of the neck, so his head is about nine inches off the bed. The defibrillator was no shock advised. He is asystole. The nursing home confirms he is a full code. I get the tube easy enough. His initial ETCO2 is 14, but within a few ventilations it is down in the 5-8 range. I have a hell of a time getting an IV. I finally get it in of all places the AC. I dump in epi and atropine, but he is still asystole. I call it after a half an hour. We pick up all our medical trash – IV wrappers, stylet, defib pads, empty epi vials, syringes, two by twos. Two nurses’ aides put him in a fresh gown, and then pull the sheet up over him. We push our stretcher back down the hall, carrying all our equipment and the long board. On the way, we pass a nurse leading a stunned woman, who says to the nurse, “What do you mean, My Daddy’s dead?”

Why Can't They Fix It?

The suburban town where I work three days a week abuts the northern border of the city. It begins with a lower middle class black neighborhood, small one story homes tightly packed together. As you head north the houses get gradually bigger. On the mountain that lines the north and west of the town are the million dollar houses. In between are five nursing homes and many elderly housing projects. The average age of my patients is 69. Last year it was 68, the year before 67. I've learned a lot about aging, about decline. It isn't limited to any one part of town.

***

Today we are up on the mountain.

A woman in her early fifties, a trim attractive brunette wearing a grey turtleneck and a gold necklace meets us at the door. My husband was just released from the hospital today, she explains as we follow her through the expansive house. I note the wood floors and modern art. He had a kidney transplant a year ago, she says, now today he doesn’t even know what medicine he is supposed to take.

The overweight man is slumped at the kitchen table. His body is bloated. His skin is cool, and clammy. I'd say he is at least fifteen years older than his wife. On the table in front of him are his prescriptions, some bottles standing, others knocked over. There are discharge papers from the hospital. I see glyburide written on one of the bottles.

His wife is beside herself. I wonder how long they have been married. Is she the first wife or the trophy second wife taken when he was a leader of industry?

“It’s probably his sugar,” I say as I prick his finger. “Yeah, sure enough. 23.”

“His sugar! They said they fixed that at the hospital.”

I tell her how being sick can really mess with your sugar, it can wear your body down.

"Why can't they fix it?" she says. "Why can't they just fix it? He just got out of the hospital today. He was there for seven days. Shouldn't they have fixed it?"

"It doesn't work like that," I say.

“I can’t believe this,” she says. “He was there for seven days.”

She looks at him and shakes her head. She tries to explain. "This was once a vibrant man," she says.

I push the D50 and gradually he opens his eyes, but his body is still bloated, the skin on his balding head is discolored. "Where am I?" he asks.

She stands back, her arms crossed, shaking her head. She looks very unhappy.

Teaching

I have been in EMS since 1989 when I became an EMT (a paramedic in 1993). While I have been a preceptor for almost ten years, I have rarely done any traditional teaching such as CPR or EMT classes of ACLS. I love one on one teaching, but I don’t like standing in front of a group of uninterested students, and also at least early on in my career, I felt, for right or wrong reasons, I needed more time in the street to build up a certain street credibility before I could confidently teach.

In the last couple years I have taught a couple special classes of the new American Heart updates and on capnography. In both classes I made my own Power Points and did quite a bit of research. The classes went over well I believe because I had a certain passion for the material, and I think there was new information for the students so they would leave feeling like they had learned something.

I love the street, and I hope that I will be able to be a fulltime field medic until my middle sixties – another twenty years. But recently I have felt some of the effects of age – increased stiffness at times, I’m not as spry jumping in and out of the back of the ambulance, and when I get sick as I am now with a bad chest cold, I just feel old and weary and like I might be coming to the end of the line. In the last couple years I have worked about sixty hours a week, sometimes up to eighty. I know I won’t be able to continue that pace for another twenty years.

That was one of the reasons I signed up to take the ACLS Instructors class. Maybe now instead of doing a shift hauling people up and down stairs, I can get paid for teaching in a classroom where the most I have to lift is pen to sign the student’s check off sheets. But I do want more than just a break from the street, and I would like to do more than just lift a pen to sign a check off sheet. I would like to be a good teacher, one who can convey my own love for the work to others.

The Instructors class is a two day class, but if you take the new AHA Instructor’s Core Class on-line or on CD-ROM(I did this on Monday in between calls), you only have to take a one day class going over the 10 ACLS Core Cases. This is the class I took yesterday. It wasn’t too different from the regular ACLS class. We covered the same material, but our sessions were sprinkled with information about how to teach the sessions.

I’ve been taking PALS and ACLS every other year for over ten years now, and I often find that many classes have the “you know the material, but we just have to do this, because its required” attitude. But sometimes, I get an instructor who challenges you and teaches you something new. I had this yesterday in one of the instructors, who is also a longtime medic, but one who many years ago moved into more or less full-time teaching/supervising education, relegating his field time to one shift a week.

When we left his class, one of the students said to another “I learned something there.” The other said, “He’s very much knowledgeable.”

That’s the kind of teacher I want to be.

Update

I should have some new posts along with responses to comments in a day or two. I'm been getting killed at work, while trying to prepare for an ACLS instructor's class tomorrow. I took a CD-ROM course called the AHA Core Instructor Course that means I only have to go to the first day of the class. It took me two days to get it done in between calls.

Thanks for your patience.

Change

This week we had a training session to introduce us to the new CPAP machines we are getting, as well as to review intubation and surgical crichs.

It all set me thinking about the changes I have seen since I became an EMT in 1989 and a paramedic in 1993. (I'm sure people who have been in EMS longer than me have an even longer list.)

Here’s what we had:

Wide open fluid for trauma
EOAs as backup airway
Old CPR
On-line Medical Control required for any controlled substance, including valium for status epilepticus
Isoproterenol and bretylium
MAST pants (We actually still have them but they are buried so deep we rarely bother to look for them much less ever use them)
LifePack 5s (10's were on some trucks)
hands on paddles with gel
paramedic certification
separate pacing pads
syrup of ipecac
demand valves
Stokes baskets for large people
dopamine and lidocaine we had to mix ourselves
two straps on the stretcher
wood long boards
ammonia inhalants for drunks
chemstrips to check sugar
lots and lots of patients with CHF
towel rolls
tape or oxygen tubing to tie ET tubes
We did CPR on and transported everyone except complete stiffs
we c-spined everybody in an MVA and everyone who fell
two man stretchers

What we have now:

CPAP
New CPR
Continuous Wave Form Capnography
LP 12s with 12 Lead ECGs
paramedic licensure
standing orders for controlled substances
bougies
glucometers
combitubes and LMAs
bulb syringes to check tubes
commercial tube holders
100% hands off defibrillation (we have no paddles anymore)
Combi-pads
HIPPA
restricted fluid for trauma
commercial surgical crich kits
Cardizem
Ativan and Haldol for violent psychs
amiodarone
selective spinal immobilization protocol
permissive hypotension
field termination of resuscitation
atrovent
phenergan and raglan for nausea
stair chairs with tracks
one man stretchers
solumedrol
Morgan Lenses
mandatory seat belts
black box technology
safety nets
bariatric ambulances
three straps and shoulder straps on the stretcher
needles syringes
protective catheters
Easy IO (coming soon)

I may be missing more -- I'm sure I am. Here's my votes for the three best changes over that time span.

#3 Field Termination of Resuscitation

There is so much more dignity in dying at home, even if it means an ACLS workup.

#2 Selective Spinal Immobilization

Again, anytime we can stop doing anything pointless like immobilizing everyone regardless of whether or not they have neck or back pain is a good thing.

#1 One-Man stretchers.

I can't help but think that at some point I would have injured my back doing the old two man dead lifts where we had to lift the patient and stretcher up and then toss it in the back of the ambulance. Now we just load the head end, squeeze the handle while our partner manually lifts the wheels while most of the weight is supported at the head. Easy as can be.

(And the thing of it is, many of us resisted the one-man stretchers when we started to get them. I'm strong enough to do my own lifting!)

I wonder what we'll have new another ten years down the road?

Regional Meetings

On the second Tuesday of every month, I spend four hours at our regional educational standards and medical advisory meetings. I am not a meeting guy, but we have a good group of people and we get things accomplished, although as with any group sometimes it seems we are always rearguing the same issues.

In the educational standards meeting the discussion has been about our yearly skill sessions which each medic is required to take. We have sessions scattered throughout the year -- usually one in April, one in June, one in September and one in December -- but inevitably people wait until the last one in December. This year we had to add a third session to the two we already had scheduled to accommodate the stragglers. Each session is limited to 40 people.

Each year we try to figure out how to avoid the December rush and how to hold people accountable for getting the sessions taken. My position has always been whatever we do, we have to let the paramedics know what is expected of them. Too often we make decisions, but neglect to tell anyone. We had a big arguement about paramedic accountability. I argued that instead of trying to create hoops for paramedics, we should try to make it easier for them. What is wrong with just having an extra session in December? Other people wanted to assign people to specific sessions based on their birthdays. I made the motion we keep the setup the same. I lost. While we didn't vote on what the new system would be, the new system proponents will have to come up with a plan for a new system. We'll see if anything happens. We have the same vote every year.

We also have the same periodic discussion as to the purpose of the skill sessions -- are they to be used to teach people or to drill people. We usually have six or seven stations -- a megacode, an airway station that includes use of the bougie, combitube, LMA, an IV station that includes an IVs and the IO, a crich station, a BLS station that has spinal immobilization and KED, and then specialty sessions such as child birth, and the one I taught this year, which was the AHA update. Most people feel the skill sessions are pointless -- why do I need to stick a needle in an IV arm when I do it everyday on real people? One arguement has been this is neccessary so the MDs can sign off on people's National Registry forms. Some say we need to prove people can do the skills, yet I believe the way we do them anyone who sleeps at a Holiday Inn Express can walz through. No one has ever failed a skills session. I prefer to think of the skill sessions as a chance to learn new information or to practice skills we don't do much such as the needle crich.

We argue back and forth each year. Sometimes some of us switch sides of the arguement, and we always end up doing it the same way.

Still, we do get work accomplished. The education group is made up of the clinical coordinators from each hospital in the region, and a couple educators and myself.

The Medical Advisory or MAC also includes the medical directors from each hospital. For the last three meetings we have been redoing our protocols, which is a very tedious process. We go page by page, arguing over every little wrinkle and wording. Each year the pressure that we can give Nitro at changes or at least is discussed. Its 100 now. It has been as high as 120 and as low as 90. This year we moved the blood glucose number for "low blood sugar" from 80 down to 70, although since these are guidelines, you can still give D50 to someone with an altered Mental status and a Blood glucose of 73.

I don't mean to be critical because all of the discussion is neccessary and I think we have decent protocols, but like I said, the discussion can get tiresome. Whenever the debate gets too heated, we just table the topic to the next meeting when either side of the arguement will have either cooled down or not been able to attend due to other committments. Sometimes we pass a measure easily one meeting, and then it gets brought up and vigorously redebated the next. This has happened repeatedly with morphine for abdominal pain this year. We couldn't give it, then it was on standing orders, and now it is requires online control. In the end it is all about consensus. We never meet our rollout deadline on January 1, but we get it done.

Here are some of the changes we have agreed on at least for now:

Incorporating the new AHA Cardiac guidelines.
Increasing dose for morphine we can give on standing orders from 0.1 mg/kg to 0.15mg/kg.
Permitting MS on standing orders for certain back pain.
Adding undifferentiated abdominal pain as an indication for medical control orders for MS.
Adding torodol as a medical control option.
Putting Solumedrol on standing orders for asthma and allergic reactions.
IV Magnesium for severe asthma.
Putting epi on standing orders for asthma if the patient is under 50 and has no cardiac history.
Putting up to 2 mg of Ativan on standing order for nonviolent anxiety.
Putting Dopamine and fluid boluses on standing order for cardiogenic shock (None of us had realized medics required online medical control to do either in this scenario.)
Clarifying the indications for narcan to a person with altered mental status with RR less than 10, who is hypoventilating.
Adult IO.
Increased use of capnography.
Changing eye irrigation from NS to Lactated Ringers
We are able to now mix Haldolol and Ativan in the same syringe for violent psychs.
Standing orders for nitro paste for pulmonary edema.

We have also done a lot of language change in the guidelines, and reordering steps.

Some things still being debated, include:

Adding zofran for nausea.
A Taser policy
Relooking at indications for spinal immobilization
Adding some new procedure sheets.
Changing fluid thresholds for Trauma patients.

I think we have a few more months of meetings until we are done.

What I like about the committee and the process is that in the end our work hits the street and makes a difference to the patients.

Musings

It's been very busy lately(five days in a row) -- nothing exceptional, just the meat and potatoes of EMS -- vomiting, hip fractures, asthma, hypoglycemics, lift assists, seizures, TIAs, MVAs.

***

Some of our syringes have retracting needles. After you use them, you hit a button and the needle zips back into the syringe. I noticed that if there is any fluid left in the syringe, it zips out the front when you hit the button. Now whenever I draw up saline to flush a lock, I draw up 5 cc, but only use three ccs to flush the lock. Then I point the syringe toward my partner driving and hit the button. Just like a squirt gun. Some of my partners have figured it out, some don't notice the fluid landing on their right arm, others are puzzled where the water is coming from.

***

The public probably doesn't think this happens -- ambulances getting lost on the way to the hospital -- but we have all been there. I can't count how many times I have been in the back treating a patient and then looked out the window and wondered where the hell we were, or why we were heading in the direction we were. "Where are you going?" I shout or "We're going to X hospital not Y!"

Not every person driving has been on the road twenty years. With the turn over at commercial services and the sheer number of people at volunteer services who don't work that much, it happens a lot. I've looked out and been crossing the river going East when the hospital is on the West side.

To be fair, even when I drive, sometimes I tune out and make a wrong turn or forget where I am going.

One thing I do hate, even when I know where I am going, is when the family member who is following in their car, sees you at the hospital later and tells you "You went the long way." Its like we should know the way everyone who has lived at one address for twenty years uses to go to their hopsital of choice at each particular time of day. One day when I was in an irritable mood, I said, "Sorry, I don't know your little 'secret' route." Point taken. Once when I did make a wrong turn, and the patient's family member said, "You sure went the long way." I said, "The normal route was shut down due to an accident." Yeah.

As long as we get there and the patient doesn't die because of the extra time, everything is all right.

I did do a shooting once in the city, went right by the hospital. "Where the...!!!"

New EMT just bombing down the road, lights and sirens wailing, no idea where they are going, no idea they are lost.

It can be a little stressful, telling them how to go when you have a critical patient.

I wish I had a 100 cc syringe with a retracting needle just for those occasions.

Hey!

***

There is a new oriental restaurant in town -- a sort of fushion between Japanesse, Thai and Chinnese. We got the lunch box special. $8 bucks for teriyaki shrimp, a California roll, beef gyzo, miso soup, rice, and salad. Not bad. The Shrimp was outstanding.

The day before I went to a place where I hadn't been for four years -- a Southern food cafeteria. I used to go there all the time, and then one day I had the serious runs after eating there -- running to the bathroom on the hour, and then praying I didn't get a call. So I went back -- it was good, barbecue -- pulled pork, black-eyed peas and collard greens with a slice of cornbread. Plus when I walk in the door, the proprietor goes, "Why Looky here -- there's a tall fine-looking white man standing in the door. Isn't that something? My, my. I've seen you before, haven't I? You've been in here before." "Yes, I have," I said. I didn't tell her why I had been away. "Well, good to see you again. Now what can Mae, dish up for you?"

Someday I am going to write a Paramedic's Guide to Eating Out. One of the best parts of this job is the array of food choices. Puerto Rican, Domminican, Jamaician, Southern, Oriental, Italian, Brazilian. Not to mention all the different hospital cafeterias -- each with their own specials -- one has great pasta specials, another a super cheap salad, another a great sandwich bar, another with great lunch deals.

***

In the last couple days I have done a couple IVs where I had to use 24 gauge needles to get into real tiny veins. While I got both, I noticed I had to really, really squint to see the needle and the vein together. I have never needed reading glasses, but maybe I should get my eyes checked. At least my hands aren't shaking yet.

***

I didn't get to bed until late last night. I was tired this morning with a possible cold coming on. I checked out my gear, and then got in bed. Three hours later, the buzzer goes off. I'm only allowed to sleep until eight, but it was nine. No one said anything. Let the man sleep. I snagged a coke on the way out the door. Off to a hip fracture.

***

It's pouring rain today. I am sure glad it isn't snow. It's January 8 and still no snow. Fine by me.

The polar ice caps may be melting, global warming destroying the planet, but the good news is I don't have to shovel snow.

***

I'm off tomorrow for my monthly regional EMS meetings, which means I can stay up late and watch the NCAA football championship game, have a beer or two, and then sleep late and still get to the gymn.

***

A Paramedic's life is okay.

Helpless

A week ago I responded to a fall, a little eighty-year-old lady with failing balance, tripped and fell on the bedroom carpet. She was laying on her right side and couldn’t get up, she said. Her right arm was at an odd angle, but when I repositioned her arm, she had full range of motion. When I pressed against her hips, I thought I saw a slight grimace. She had some screws in her right hip from an old hip fracture, she said, but denied any pain. She was able to move the leg. There was no shortening or rotation. One of my partners, an eighty-year-old woman herself, said our ambulance had transported the woman's husband to the hospital a few days before. The woman said her husband wasn’t doing well. She didn’t really want to go to the hospital, she said, could we put her back in to bed?

My partner convinced her to let us take her to the hospital and get checked out. With her husband sick, it was best to make certain she was okay, instead of leaving her alone.

In the ambulance, I asked her again about the pain and she said, matter-of-factly -- zero on the one to ten scale. While I wrote up my paperwork, she and my partner chatted about old days in the town where they both lived most of their lives, and knew all of the same people.

Today I saw my partner and she said she had followed up on the woman who was now in a local nursing home. She had gone and visited her and found out she had broken her leg in three places, but since her bones were so frail they would be unable to operate. They hadn’t even let her go to her husband’s funeral. She told my partner she had been in a great deal of pain and had known that she had broken her leg, but hadn’t told us. She told my partner she didn’t want me to see she was helpless.


There is a town in north Ontario,
With dream comfort memory to spare,
And in my mind
I still need a place to go,
All my changes were there.

Blue, blue windows behind the stars,
Yellow moon on the rise,
Big birds flying across the sky,
Throwing shadows on our eyes.
Leave us

Helpless, helpless, helpless
Baby can you hear me now?
The chains are locked
and tied across the door,
Baby, sing with me somehow.

Blue, blue windows behind the stars,
Yellow moon on the rise,
Big birds flying across the sky,
Throwing shadows on our eyes.
Leave us

Helpless, helpless, helpless.
- Helpless
Neil Young

Baby Medic - EMS Blog

I ran into a medic yesterday who tipped me off to a new EMS blog being written by an EMT/medic student who works for us. I have just read all the entries -- it is excellent. So far it is about his ride time as a medic student, but I am hoping he continues it throughout his promising medic career.

Check it out at:

Baby Medic

Here are three of the best posts:

Shooting

Footprints

Morgue

Bare Wrist

90-year-old man, unresponsive. The medical dispatch updates us, unresponsive, aides not certain if he is breathing.

As I walk across the dark lawn in the rain I see in the picture window two large police officers lifting an old man out of a wheelchair and starting to lower him toward the floor.

"The aide says he's a DNR, but they can't find the bracelet -- they took it off a couple days ago," one officer tells me. The other officer has put a pillow under the old man's head because of the kifosis in his spine. There is no question he is dead, but he is warm and his jaw is limber.

"Do they have paperwork?" I ask.

"No paperwork," he says.

"All right, we have to work him then. Start CPR."

***

Now until recently I would have handled this differently. I would have said, he's 90, they say he's a DNR. Asystole. I'll just walk out to the ambulance, call medical control and get permission not to resuscitate. I do that, and then walk back in, and tell everyone, and record the time and that's that. Put a sheet on him, console the family, make a comment about dying at home with dignity, surrounded by loved ones.

I may have mentioned recently a newer medic who tried to do just that. Walked out to the ambulance, called the hospital, said the patient was old, terminal cancer, just returned from hospice with DNR papers signed by the patient, but not the doctor. A slipup. The medical control doctor then told him to immediately commence CPR with full ALS resuscitation, and transport. So he had to walk back into the house and explain this to the horrified family who then had to witness a resuscitation, and transport of their family member, who had wanted to die at home.

The state regs (I have discovered) are clear. Unless a person has a valid DNR or are beheaded, transected, burnt beyond recognition or have dependent lividity with rigor mortis, you must at least begin CPR before calling to get permission to cease resuscitation. But why have to call? What can a doctor miles away bring to the situation that a medic on scene can't acertain for himself? This person shouldn't be worked. Some medics say they just do pseudo CPR -- pretend CPR -- while the call is made. That rubs me wrong too, although I have done it and understand it.

Here's what I do this time:

***

I drop a 7.0 tube, put in an IV and hit him with 3 epis and 2 atropines. If I am going to be told I have to work the code, then I am going to work it from the start. The ETCO2 is low and I notice the officer is doing delicate CPR. Like this I say. I do a couple compressions, but then instead of my hand rebounding, the chest gives way and my hand sinks as I feel ribs break off. I wince. "Well, do the best you can," I say.

An aide hands me the phone. It is the patient's daughter, who wants to know what is going on. I apologize that we are trying to resuscitate her mother, but the DNR bracelet wasn't on and there was no paperwork. She tells me they keep the bracelet by the bed in the other room. She is understanding as I explain the law. She wants to know how her father is doing and I say he is not responding and I will soon be presuming him dead, so he won't be transported to the hospital. She says she will be there in about thirty minutes. I tell her to drive safely.

After our 20 minutes of ACLS is up, the patient is still asystole, I call the time. I extubate him, take out the IV, and pick up all the wrappers and put them in the big plastic bag the ambu-bag came in.

An aide comes into the room now and shows me the DNR bracelet. They had cut it off because his wrists had been swelling in recent days.

We lay a sheet over him.

I wait around with the police officers for the daughter to arrive so I can apologize and explain again why we did what we did.

I keep looking at the sheet. He's not in his bed or his wheelchair, but it doesn't look too terrible -- him on the floor of his living room beside his wheelchair. I mean at least, he's still in his house, and aside from his ribs, isn't too much the worse for the wear and tear of the code. I think well he was after all dead anyway.

The daughter still hasn't arrived, but it is past crew change and my partner needs to get home, so after ten minutes, we express our condolences to the aides again, shake hands with the cops and wish them Happy New Year, and then carry our stuff back out into the night, across the yard and through the rain to where our truck, its red lights still flashing, waits for us.

***

I liked the way I used to do it better.