The house is dim and smells like a dead person. Dusty, unmopped wooden floors, filthy curtains, overflowing garbage in the kitchen. The patient is down the hall in a bedroom.
Old man living with his two sons, or rather two sons living with their old man because what the old man is doing really isn’t living.
Under a dirty blanket, he is naked with a distended abdomen, and green yellow fungus on his body. He is short of breath with periods of apnea. He moans when you touch him. No distinguishable words. His pressure is 88/48. HR-124. Blood sugar is 500. Sat – 90%.
The son, who says he works in a nursing home has been spoon feeding him for the last week. He called today because he noticed the old man would stop breathing for a period of time and then start again. He repeats again that he works in a nursing home so he notices these things. He says his father hasn’t been to a doctor for forty years.
We carry the old man in a stair chair because we can’t fit the stretcher in the door. In the back of the ambulance I have to open the window on the side door in order to breath. I give him oxygen and a fluid bolus on the way to the hospital. Everytime he goes apneic, I nudge him and he moans.
We tell the story at the hospital and the nurse just says, poor dear, as she looks at the old man.
I wash my hands a couple times, but sitting here now, two hours later, I can still smell him. I feel like I need to take a shower, wash my clothes, shampoo my nose hairs or maybe just rip them all out. The smell won’t go away.
I had a mustache years ago, but I shaved it because I got tired of shampooing it after every smelly call. I know now it isn’t just the mustache that holds the smell, the smell just gets on you and it won’t go away. Your nose, your brain remembers it. It just lingers. It gets in your skin.
And this wasn’t even that bad as smelly calls go. Maybe it’s just that I haven’t had one for awhile or that that smell just recalls all the times I've smelled it in the past.
My partner and I were talking on the way back. What’s up with letting your old man live like that? There wasn’t even a TV in the room. And how could you live with that smell? Did it just creep up on you that you didn’t notice it?
Tonight when I get off work, I’m going to put my running shoes on, and I’m going to run. On this grey day, I’m going to run from that smell, run from inevitable decrepitude, run from dim rooms where fate may put us.
When I get home, I’m going to take a long hot shower and then have a strip steak with a little dab of butter on it. I’m going to have some fresh vegetables, and some long grain rice. And I’m going to have at least one cold 7 ounce beer. Maybe two. And then I’m going to do the dishes and clean the kitchen with bleach. I'm going to do some serious scrubbing. I'm going to scrub until my elbow throbs. The kitchen's going to be sparkling clean and white when I'm done.
I hope to have a restful, dreamless night.
Sunday, April 29, 2007
Thursday, April 26, 2007
Random Comments
Random Comments at the ER this Week
"I'm the only nurse for 30 patients so its going to be awhile."
"No! No! I just got four new patients. I cannot take another. I'm calling her back. She's going to have to put him some place else. We're full here! No! No! No!"
"We don't do appointments at the ER. We only do emergencies. You're going to have to call the doctor's office and take her there, because we don't do that here." (Surprise, you do now.)
"You can put her in the hallway...if you can find a bed."
***
Random Comments from Patients this Week
"I figured I'd get seen quicker this way."
"Its been going on about a month."
"My doctor didn't return my call."
"I hope I won't be down there long. We're going out to dinner tonight."
"The medicine they gave me yesterday didn't work. Take me to another hospital."
***
Random Comments at the Nursing Home This Week
"There's some blood oozing from around her G-tube. She's a full code, we have to send her in."
"This is the fifth time in two weeks we've sent him in, they need to admit him."
"She needs to be suctioned every hour. We can't manage her here."
"I know, but the doctor wants her evaluated anyway."
***
Random Comments from Patient Family Members this Week
"He's drunk and he's crazy and he punched a hole in the wall. Get him out of here man!"
"All she wants to do is sleep."
"She's been throwing up all night. I can't stay with her. I gotta go to work."
***
Random Comments Directed at Radio.
"I'm not answering that."
"No one else is clear? Com'on!"
"But its almost time for our crew change."
"We're f---ed now. We'll never get out."
***
Random Comments from a Pager
CAN ANYONE CLEAR FOR a 911?
"I'm the only nurse for 30 patients so its going to be awhile."
"No! No! I just got four new patients. I cannot take another. I'm calling her back. She's going to have to put him some place else. We're full here! No! No! No!"
"We don't do appointments at the ER. We only do emergencies. You're going to have to call the doctor's office and take her there, because we don't do that here." (Surprise, you do now.)
"You can put her in the hallway...if you can find a bed."
***
Random Comments from Patients this Week
"I figured I'd get seen quicker this way."
"Its been going on about a month."
"My doctor didn't return my call."
"I hope I won't be down there long. We're going out to dinner tonight."
"The medicine they gave me yesterday didn't work. Take me to another hospital."
***
Random Comments at the Nursing Home This Week
"There's some blood oozing from around her G-tube. She's a full code, we have to send her in."
"This is the fifth time in two weeks we've sent him in, they need to admit him."
"She needs to be suctioned every hour. We can't manage her here."
"I know, but the doctor wants her evaluated anyway."
***
Random Comments from Patient Family Members this Week
"He's drunk and he's crazy and he punched a hole in the wall. Get him out of here man!"
"All she wants to do is sleep."
"She's been throwing up all night. I can't stay with her. I gotta go to work."
***
Random Comments Directed at Radio.
"I'm not answering that."
"No one else is clear? Com'on!"
"But its almost time for our crew change."
"We're f---ed now. We'll never get out."
***
Random Comments from a Pager
CAN ANYONE CLEAR FOR a 911?
Saturday, April 21, 2007
Rocky Mountain Medic/Ambulance Driver
If you haven't read:
Rocky Mountain Medic
or
A Day in the Life of an Ambulance Driver,
you are missing two of the best-written EMS blogs out there.
***
A Day in the Life of an Ambulance Driver is written by Steven "Kelly" Grayson, author of Life, Death and Everything in Between: A Paramedic's Memoirs.
He offers an engaging and often humorous view of EMS down Louisiana Way.
***
If Rocky Mountain Medic wrote a book, I'd buy it. His posts, which can include a mixture of fact and fiction, read like excerpts from a novel. Some of the posts are written from the patient's point of view.
Both bloggers are also very prolific with new posts several times a week.
Check them out.
Rocky Mountain Medic
or
A Day in the Life of an Ambulance Driver,
you are missing two of the best-written EMS blogs out there.
***
A Day in the Life of an Ambulance Driver is written by Steven "Kelly" Grayson, author of Life, Death and Everything in Between: A Paramedic's Memoirs.
He offers an engaging and often humorous view of EMS down Louisiana Way.
***
If Rocky Mountain Medic wrote a book, I'd buy it. His posts, which can include a mixture of fact and fiction, read like excerpts from a novel. Some of the posts are written from the patient's point of view.
Both bloggers are also very prolific with new posts several times a week.
Check them out.
Friday, April 20, 2007
Ghost Blood
A medic who used to work for us a decade ago died the other day. He hadn’t yet turned fifty. He worked as a medic for many years, but then got hurt and had to find other work. He’d had some hardships and hadn’t been particularly healthy of late.
We weren’t close, but when I started as a city paramedic twelve years ago, he was my opposite. I had the car during the day, he had it at night. Every morning he’d radio in the list of supplies he needed – large gauge IVs, bags of fluid, maybe an ET tube and suction supplies, trauma dressings. The city was wilder at night, plus he was what we called "a shit magnet."
As a new paramedic I used to wonder about all the people who had died or bled in our ambulance, all the scenes of struggle – the battles of life and death that went on as the ambulance raced lights and sirens through the city’s night streets. I craved experience then, and I wondered about the things I would see if only I just stayed in the ambulance all the time, instead of going home at night. I was in the ambulance 36 hours a week, but the ambulance itself never rested. I’d hear about shootings and horrific car wrecks on the news and find out when I came into work that the patients had been transported in our car. I’d sit alone in the back and try to picture the calls that had played out there. Sometimes I felt the ambulance was full of ghosts.
They had a particularly bad call one night – a traumatic arrest, the type of a call where the wounds were so severe the a body bled out in the ambulance. The medic’s partner apologized that he had done the best he could to clean up the blood. He hoped he hadn’t missed any. We found some spots, which we cleaned up during the day. I wasn’t the neatest person myself, so it wasn’t hard for me to cut them slack.
The next week, the medic pointed out that we had left the ambulance bloody. My partner and I protested we hadn’t had any bloody calls. On another day, we mentioned that they had left blood on the floor, but that made no sense to them. They had a quiet night. Their only bad call -- a cardiac arrest -- had been bloodless. The phantom blood continued for months – not just with us, but with the other crews that used our car on the other end of the week.
We finally figured out that it was old blood that had seeped under the floor boards and fittings. We didn’t know what caused it. Blood had flowed where we couldn’t clean it and now it was just periodically flowing back out. We called it ghost blood.
Quite a number of years ago now, our company was bought out by a large ambulance corporation. All our ambulances were renumbered. For awhile we referred to cars as "the old 451" or "the old 472." Over the years the ambulances would get replaced. I lost track of the old cars.
Soon after they took over, the company also did away with permanent shifts, with everyone working three twelves and with four regular crews sharing the same car. Most full-timers now work two twelves and two eights. Shifts change every six months. So do partners. I got posted in the suburbs so when I work the city now on overtime I am in a different car every shift.
Still though I like to think there is some kind of history that gets passed from crew to crew. Just as their gear and narc keys are passed on, so are tales of the night and day, some tragic, some inspiring, some frustrating, some just funny.
Battlefields and sports arenas have their storied histories, but so do the ambulances in which we work. Ambulances have their ghosts of battles won and lost, of blood spilled, and of men and women who did their best.
Those men and women shouldn't be forgotten.
Godspeed.
We weren’t close, but when I started as a city paramedic twelve years ago, he was my opposite. I had the car during the day, he had it at night. Every morning he’d radio in the list of supplies he needed – large gauge IVs, bags of fluid, maybe an ET tube and suction supplies, trauma dressings. The city was wilder at night, plus he was what we called "a shit magnet."
As a new paramedic I used to wonder about all the people who had died or bled in our ambulance, all the scenes of struggle – the battles of life and death that went on as the ambulance raced lights and sirens through the city’s night streets. I craved experience then, and I wondered about the things I would see if only I just stayed in the ambulance all the time, instead of going home at night. I was in the ambulance 36 hours a week, but the ambulance itself never rested. I’d hear about shootings and horrific car wrecks on the news and find out when I came into work that the patients had been transported in our car. I’d sit alone in the back and try to picture the calls that had played out there. Sometimes I felt the ambulance was full of ghosts.
They had a particularly bad call one night – a traumatic arrest, the type of a call where the wounds were so severe the a body bled out in the ambulance. The medic’s partner apologized that he had done the best he could to clean up the blood. He hoped he hadn’t missed any. We found some spots, which we cleaned up during the day. I wasn’t the neatest person myself, so it wasn’t hard for me to cut them slack.
The next week, the medic pointed out that we had left the ambulance bloody. My partner and I protested we hadn’t had any bloody calls. On another day, we mentioned that they had left blood on the floor, but that made no sense to them. They had a quiet night. Their only bad call -- a cardiac arrest -- had been bloodless. The phantom blood continued for months – not just with us, but with the other crews that used our car on the other end of the week.
We finally figured out that it was old blood that had seeped under the floor boards and fittings. We didn’t know what caused it. Blood had flowed where we couldn’t clean it and now it was just periodically flowing back out. We called it ghost blood.
Quite a number of years ago now, our company was bought out by a large ambulance corporation. All our ambulances were renumbered. For awhile we referred to cars as "the old 451" or "the old 472." Over the years the ambulances would get replaced. I lost track of the old cars.
Soon after they took over, the company also did away with permanent shifts, with everyone working three twelves and with four regular crews sharing the same car. Most full-timers now work two twelves and two eights. Shifts change every six months. So do partners. I got posted in the suburbs so when I work the city now on overtime I am in a different car every shift.
Still though I like to think there is some kind of history that gets passed from crew to crew. Just as their gear and narc keys are passed on, so are tales of the night and day, some tragic, some inspiring, some frustrating, some just funny.
Battlefields and sports arenas have their storied histories, but so do the ambulances in which we work. Ambulances have their ghosts of battles won and lost, of blood spilled, and of men and women who did their best.
Those men and women shouldn't be forgotten.
Godspeed.
Thursday, April 19, 2007
Wine Coolers
The call was for a drunk. We were updated that he was seizing, but he wasn't when we got there. His wife said he'd been drinking vodka for a week and she wanted him to go to detox. I put in an IV lock, checked his ETCO2 which was 35 and his sugar which was 120. His pupils were also equal and only slightly sluggish. He had grabbed my hand when I was putting the IV in, but when we tried to pick him up and put him in the stair chair, he played dead. Carrying him out of the house, I had the foot of the stair chair and backed out of the front door onto the broad top step. Then I stepped down to the second step with my right foot, but there was no second step where I set the foot, which went all the way down four steps to the ground, while my left leg went into a position where my knee was much higher than my thigh. I managed to hold onto to the stair chair without toppling the patient. It was one of those houses where the first three steps are not nearly as wide as the top landing. This is the second time I have done this -- not see the narrower steps and am very lucky both times I have kept my balance and not hurt myself, other than some soreness in my left knee. (I did have a spotter, who must not have seen me stepping off).
In the ambulance, I felt the patient brush against my knee with his hand and then start shaking, doing his best gran mal seizure imitation. I glanced at the capnography.
Breathing just fine, which is impossible when you are having a gran mal seizure.
Knock it off! I said.
He stopped. He tried the same act two more times, each time brushing my knee to catch my attention while I wrote my paperwork. I just shook my head.
"What were you drinking?" I asked. I already knew the answer, but I wanted him to talk to me. He had refused to respond to my question about allergies or what meds he was on.
"I heard you were drinking wine coolers," I said.
He opened his eyes then and looked at me. "No, no, no," he said. "Vodka!" He said it rather proudly.
"Okay," I said. "Are you allergic to any medicine?"
He wouldn't answer. He closed his eyes again, and started his jerking.
I was tempted(my knee throbbing) to put the ECG electrodes on his temples and say listen, "you can't fool this machine, you can't fake brain seizure activity, so you just knock it off or I'm going to electrocute your head."
Instead I ignored him and he stopped. Then he tried holding his breath and he discovered that would make the apnea alarm go off, so he would hold his breath until the alarm went off, then he'd let his breath out a little. I'd hit the alarm button off. We played this little cat and mouse for a while till I finally just shut off the monitor. I saw him glancing at the machine. He couldn't figure out why he couldn't make the alarm go off.
"I turned it off," I said.
He brushed my knee with his hand again and started shaking, but this time he looked at me and said, "Give me medicine."
"No."
At the hospital, he wouldn't talk to the triage nurse, but when we went into the psych ward, he got off the stretcher and asked the nurse if he could have a cigarette. She said no and then gave him a hospital gown to change into. He walked into the bathroom, and came out changed while I sat there finishing my paperwork.
In the ambulance, I felt the patient brush against my knee with his hand and then start shaking, doing his best gran mal seizure imitation. I glanced at the capnography.
Breathing just fine, which is impossible when you are having a gran mal seizure.
Knock it off! I said.
He stopped. He tried the same act two more times, each time brushing my knee to catch my attention while I wrote my paperwork. I just shook my head.
"What were you drinking?" I asked. I already knew the answer, but I wanted him to talk to me. He had refused to respond to my question about allergies or what meds he was on.
"I heard you were drinking wine coolers," I said.
He opened his eyes then and looked at me. "No, no, no," he said. "Vodka!" He said it rather proudly.
"Okay," I said. "Are you allergic to any medicine?"
He wouldn't answer. He closed his eyes again, and started his jerking.
I was tempted(my knee throbbing) to put the ECG electrodes on his temples and say listen, "you can't fool this machine, you can't fake brain seizure activity, so you just knock it off or I'm going to electrocute your head."
Instead I ignored him and he stopped. Then he tried holding his breath and he discovered that would make the apnea alarm go off, so he would hold his breath until the alarm went off, then he'd let his breath out a little. I'd hit the alarm button off. We played this little cat and mouse for a while till I finally just shut off the monitor. I saw him glancing at the machine. He couldn't figure out why he couldn't make the alarm go off.
"I turned it off," I said.
He brushed my knee with his hand again and started shaking, but this time he looked at me and said, "Give me medicine."
"No."
At the hospital, he wouldn't talk to the triage nurse, but when we went into the psych ward, he got off the stretcher and asked the nurse if he could have a cigarette. She said no and then gave him a hospital gown to change into. He walked into the bathroom, and came out changed while I sat there finishing my paperwork.
Monday, April 16, 2007
Obsession?
"Are you going to give me back my husband's medicine list?" the woman asks.
"No," the medic says, deadpan. "I have a collection of them at home. Boxes actually. Overflowing. I particuarly like these -- the little booklets with flowers on the cover. They are the Van Goughs of my collection. I'm seeing a psychiatrist about this obsession. But I haven't been taking my medication."
"All right, all right," the woman says with a small chuckle. She holds out her hand.
"No," the medic says, deadpan. "I have a collection of them at home. Boxes actually. Overflowing. I particuarly like these -- the little booklets with flowers on the cover. They are the Van Goughs of my collection. I'm seeing a psychiatrist about this obsession. But I haven't been taking my medication."
"All right, all right," the woman says with a small chuckle. She holds out her hand.
Sunday, April 15, 2007
Load and Go/Stay and Play/Load and Go Stay and Play
Stay and Play or Load and Go?
I had many interesting comments on this issue following a brief discussion of a call in my post on scene management called An Unappreciated Skill. While my style is always evolving, these are my current thoughts on the continual question.
***
First off, my goal is to arrive at the hospital with an alive patient, a detailed assessment and all treatment done that needs to be done without delaying the patient from receiving life-saving care that I cannot provide.
When I walk into a scene, I am always thinking: How am I going to get the patient to the ambulance? Can we get the stretcher in? Do I need a stair chair? Is the patient ambulatory?
Once I get to a patient, I ask myself: Is this patient about to die? Or is there anything that I need to do for this patient right here that by delaying will harm the patient or make the extrication more difficult and/or harmful to the patient's outcome?
Sometimes the answer is obvious – a first responder is doing CPR; in other cases, I have to talk to the patient, look in their eyes, feel their forehead, feel for a pulse, and if necessary take a blood pressure and or put them on the monitor before I can answer the question.
If the answer to the question is no, which it is 95% of more of all calls, we can then chit chat a little, set the stretcher up, make certain there is someone to feed the dog, water the plants, tell a relative the patient is going to the hospital, make certain they have their keys, and the doors are locked on the way out, etc.
If the answer to the question is yes, I have three choices: Load and Go, Stay and Play or Load and Go to the Ambulance where I can then Stay and Play if necessary (That means if there is just me and my partner, I need his initial help more than I need him to drive).
These patients will get the Load and Go treatment:
Time sensitive trauma or medical call possibly requiring a surgeon to save life or limb or significantly reduce morbidity such as a gunshot to the chest or a AAA.
CVA within the three hour window
ST Elevation MI
And anything the hospital has the ability to fix that I can’t, and any extra time lost on scene or transporting non-emergency may be deleterious to the patient.
If the patient does not meet this criteria, then I have to decide: Do I need to Load and Go to the Ambulance where I can Stay and Play or do I have to Stay and Play on scene(in the 2nd floor apartment, doctor’s office, fastfood restaurnat kitchen, 24th floor office suite, etc)?
Factors I have to consider include: How long will it take to get to the ambulance? How soon does the patient need the treatment? How well can I treat the patient at the scene? (Scene safety, privacy, cleanliness, lighting, access issues). Will moving the patient to the ambulance before treatment harm them? How much help do I have? What are my partner’s capabilities? There is a lot of calculation mental math to do, factoring time, manpower, probablities of success or failure with each approach.
I will pretty much always work a medical cardiac arrest where they fall unless say they have arrested in a car in a parking lot where I can easily pull them out and get them into the back of the ambulance. Anaphylaxis gets an instant shot of epi. An elderly hip fracture I will usually medicate and then wait for the medication to take effect before even putting the patient on a scoop stretcher. An unresponsive hypoglycemic or heroin OD I will usually treat on the spot so they’ll wake up and I won’t have to carry them. An asthmatic I will usually start a treatment on and then carry. A bad CHFer I may or may not treat on the spot depending on many factors. I don’t have CPAP yet. If I think I can slam in a line and start giving him nitro, and then start moving, I’ll do that. If they have poor IV access, I won’t dick around trying to get an IV. I’ll start to the ambulance if it is close, where I have a better chance of quickly and successfully managing the patient. If I think a patient may code, and I don’t think I can stop it with any intervention, I will generally do anything I can to get the patient into the ambulance before they code. Again, I may pop in a quick IV lock for access if I can get it quickly, but I won't sit there looking long for a vein or waiting for a fluid bolus to work.
I much prefer getting the patient into the ambulance. That is my office. The scene is safe. It is clean, well lit and I have all my supplies within arm’s distance and if anything goes wrong, I am or can shortly be on the way to the hospital – not facing a third floor carry down with an intubated patient with multiple lines. And vitally, I believe my ability to successfully manage the patient is often much higher in the ambulance.
Once I am en route to the hospital, I rarely go lights and sirens – only for those patients listed above under Load and Go. The general L&S rule is if the time saved by going lights and sirens will result in the patient receiving treatment in the hospital that will save their lives or prevent further harm in those minutes gained, then it is okay to use L&S. For years I have done most of my treatment (IVs, 12 leads, meds) while en route to the hospital in a non-emergency mode. I have no problem sitting in a hospital parking lot completing my treatment either. Just because you have arrived at a hospital door doesn’t mean you have arrived at treatment. I’ll give my next dose of pain meds in the parking lot. I’ve given nitro in the triage line. Unless the patient is critical, time to the hospital rarely equates to time to treatment.
I have always kept in mind that our job is not just medical care, but also transportation, and that forward moving is what transportation is about. Lately, however (Thanks to the Nadine Levick's lecture on ambulance safety I attended in Baltimore), I have been toying with the idea of doing all of my care in the ambulance on scene, and then securing all the equipment, buckling my seatbelt, putting on a crash helmet and assuming the crash position, before giving the okay to drive to the hospital. But it is hard to change old habits.
Again, these are just my thoughts. I recognize every patient, every scene, every medic, and every system are different, and no variables are ever the same. You do the best you can with your best guess based on everything you know and have learned, and you hope it works out.
***
Here are some of the comments I recieved on the previous post expressing different views:
Anonymous said...
I suppose we medics all practice the way we're most comfortable, but this post brings up a good issue. When I encounter a cardiac patient at a pressure of 70/palp who's trapped "several rooms deep in a crowded apartment," I frequently find myself inclined to stay-and-play. That is, before we begin the extrication, I want to have 1-2 IV lines, fluid running wide, pacer pads in place, Aspirin on board, and maybe dopamine, atropine, or whatever other drugs are indicated. You can attach IV bags to the top rung of a stair chair easily enough. My O2 tank has velcro hooks that affix to the top of the stair chair also. Or, if the house's geometry allows, using a backboard is advantageous if/when the need for CPR arises. With these steps I'm prepared if the patient decides to code on the way outdoors, and I've reduced the odds of that happening in any case.
The rationale for deciding to stay-and-play is twofold: a) "I can't deliver this patient to the inside of my truck any faster than X minutes, no matter how hard I try" and b) "There's a Y% chance this guy will code in the next X minutes." If X=5 minutes and Y=25% (for instance) then I choose to stabilize first and extricate second.
In my younger years I found myself grossly underestimating X -- "but the truck's just outside... I can almost see it..." Now I realize that extrications usually require more time than we'd like them to.
I'm curious what X's and Y's other paramedics use to define their own clinical comfort zones.
EricCSU said...
During paramedic school, I rode with a department that had a similar attitude on call management that you have: get the patient into your environment (the ambulance) so you can work most efficiently. I learned that way and never saw it bite us in the ass. I enjoyed nearly always starting IVs from the bench and being in a comfortable, controlled environment. We never had a patient crash during packaging from scene to ambulance. However, as you mentioned before, it does happen.
I always wondered what we would do if that happened. How would we defend ourselves in court when we saw that we had a critical patient and then delayed treating that patient until we arrived at an environment that we were more comfortable in.
After I graduated from paramedic school, I was hired by a service that has a different attitude on call management. The prevailing attitude at my current employer is: start all interventions on scene and then package and transport. The exceptions to this rule are trauma, STEMI alert, and code stroke. For those calls, the goal is a scene time of 10 minutes or less, and we are scored on those times. A commonly heard phrase is "if the patient needed the blank (IV, drug, etc.), the needed it on scene.
This change in attitude has taken some getting used to for me, but I've accepted it. I feel more comfortable knowing that if my patient does crash, I'm ready. The patient has an IV, is on the monitor and already has interventions started.
We are also lucky in that we have the new stryker stair chairs that make for a quick exit and have an O2 cylinder holder underneath the chair.
In this system, they call it "call management". I am graded on my call management skills on every call as well as other aspects of the call.
shane said...
I tend to work most patient's up in the ambulance unless they need an immediate intervention. My reasoning for this is that if the patient does take a turn for the worse, it's easier to make your way to the hospital if need be since that is one of our ultimate goals. I find that it's much easier to talk to a patient and find out what's really going on in the privacy of the ambulance. The patient seems to be more willing to talk and quite often far less distracted. This allows for a better one-on-one conversation with the patient. This also allows for me to reflect on my initial assessment of the patient, and the scene itself so that when we get to the ambulace, I already have a plan in my head and can begin to execute it. Scene management is a priority for any EMS provider, but especially for ALS providers since most others on scene look to us for guidance. The decision of if immediate intervention is needed or not is based on solid assessment skills. While this is not going to work out perfectly 100% of the time, it should be pretty accurate. I'm not totally positive, but I would think that if you were moving the patient to the ambulance for expeditious transport to the hospital, there wouldn't be much that you'd have to defend in court. You have recognized a need for a higher level of care and you are moving there as quickly as possible.
Anonymous said...
Stay and play works well when we can provide immediate and real relief and intervention. Hypoglycemia, APE, some dysrhythmias, narcotic overdose, asthma/COPD, non-traumatic arrest etc.
We can make a real difference in these patients and our care is comparable to the hospital's initial care. Except we're doing it immediately and the patient doesn't have to wait.
Theres a couple cases where I feel that staying and playing is inappropriate. Stroke. AMI and decreasing E2B/D2B time. Trauma.
Thanks to all who commented.
I had many interesting comments on this issue following a brief discussion of a call in my post on scene management called An Unappreciated Skill. While my style is always evolving, these are my current thoughts on the continual question.
***
First off, my goal is to arrive at the hospital with an alive patient, a detailed assessment and all treatment done that needs to be done without delaying the patient from receiving life-saving care that I cannot provide.
When I walk into a scene, I am always thinking: How am I going to get the patient to the ambulance? Can we get the stretcher in? Do I need a stair chair? Is the patient ambulatory?
Once I get to a patient, I ask myself: Is this patient about to die? Or is there anything that I need to do for this patient right here that by delaying will harm the patient or make the extrication more difficult and/or harmful to the patient's outcome?
Sometimes the answer is obvious – a first responder is doing CPR; in other cases, I have to talk to the patient, look in their eyes, feel their forehead, feel for a pulse, and if necessary take a blood pressure and or put them on the monitor before I can answer the question.
If the answer to the question is no, which it is 95% of more of all calls, we can then chit chat a little, set the stretcher up, make certain there is someone to feed the dog, water the plants, tell a relative the patient is going to the hospital, make certain they have their keys, and the doors are locked on the way out, etc.
If the answer to the question is yes, I have three choices: Load and Go, Stay and Play or Load and Go to the Ambulance where I can then Stay and Play if necessary (That means if there is just me and my partner, I need his initial help more than I need him to drive).
These patients will get the Load and Go treatment:
Time sensitive trauma or medical call possibly requiring a surgeon to save life or limb or significantly reduce morbidity such as a gunshot to the chest or a AAA.
CVA within the three hour window
ST Elevation MI
And anything the hospital has the ability to fix that I can’t, and any extra time lost on scene or transporting non-emergency may be deleterious to the patient.
If the patient does not meet this criteria, then I have to decide: Do I need to Load and Go to the Ambulance where I can Stay and Play or do I have to Stay and Play on scene(in the 2nd floor apartment, doctor’s office, fastfood restaurnat kitchen, 24th floor office suite, etc)?
Factors I have to consider include: How long will it take to get to the ambulance? How soon does the patient need the treatment? How well can I treat the patient at the scene? (Scene safety, privacy, cleanliness, lighting, access issues). Will moving the patient to the ambulance before treatment harm them? How much help do I have? What are my partner’s capabilities? There is a lot of calculation mental math to do, factoring time, manpower, probablities of success or failure with each approach.
I will pretty much always work a medical cardiac arrest where they fall unless say they have arrested in a car in a parking lot where I can easily pull them out and get them into the back of the ambulance. Anaphylaxis gets an instant shot of epi. An elderly hip fracture I will usually medicate and then wait for the medication to take effect before even putting the patient on a scoop stretcher. An unresponsive hypoglycemic or heroin OD I will usually treat on the spot so they’ll wake up and I won’t have to carry them. An asthmatic I will usually start a treatment on and then carry. A bad CHFer I may or may not treat on the spot depending on many factors. I don’t have CPAP yet. If I think I can slam in a line and start giving him nitro, and then start moving, I’ll do that. If they have poor IV access, I won’t dick around trying to get an IV. I’ll start to the ambulance if it is close, where I have a better chance of quickly and successfully managing the patient. If I think a patient may code, and I don’t think I can stop it with any intervention, I will generally do anything I can to get the patient into the ambulance before they code. Again, I may pop in a quick IV lock for access if I can get it quickly, but I won't sit there looking long for a vein or waiting for a fluid bolus to work.
I much prefer getting the patient into the ambulance. That is my office. The scene is safe. It is clean, well lit and I have all my supplies within arm’s distance and if anything goes wrong, I am or can shortly be on the way to the hospital – not facing a third floor carry down with an intubated patient with multiple lines. And vitally, I believe my ability to successfully manage the patient is often much higher in the ambulance.
Once I am en route to the hospital, I rarely go lights and sirens – only for those patients listed above under Load and Go. The general L&S rule is if the time saved by going lights and sirens will result in the patient receiving treatment in the hospital that will save their lives or prevent further harm in those minutes gained, then it is okay to use L&S. For years I have done most of my treatment (IVs, 12 leads, meds) while en route to the hospital in a non-emergency mode. I have no problem sitting in a hospital parking lot completing my treatment either. Just because you have arrived at a hospital door doesn’t mean you have arrived at treatment. I’ll give my next dose of pain meds in the parking lot. I’ve given nitro in the triage line. Unless the patient is critical, time to the hospital rarely equates to time to treatment.
I have always kept in mind that our job is not just medical care, but also transportation, and that forward moving is what transportation is about. Lately, however (Thanks to the Nadine Levick's lecture on ambulance safety I attended in Baltimore), I have been toying with the idea of doing all of my care in the ambulance on scene, and then securing all the equipment, buckling my seatbelt, putting on a crash helmet and assuming the crash position, before giving the okay to drive to the hospital. But it is hard to change old habits.
Again, these are just my thoughts. I recognize every patient, every scene, every medic, and every system are different, and no variables are ever the same. You do the best you can with your best guess based on everything you know and have learned, and you hope it works out.
***
Here are some of the comments I recieved on the previous post expressing different views:
Anonymous said...
I suppose we medics all practice the way we're most comfortable, but this post brings up a good issue. When I encounter a cardiac patient at a pressure of 70/palp who's trapped "several rooms deep in a crowded apartment," I frequently find myself inclined to stay-and-play. That is, before we begin the extrication, I want to have 1-2 IV lines, fluid running wide, pacer pads in place, Aspirin on board, and maybe dopamine, atropine, or whatever other drugs are indicated. You can attach IV bags to the top rung of a stair chair easily enough. My O2 tank has velcro hooks that affix to the top of the stair chair also. Or, if the house's geometry allows, using a backboard is advantageous if/when the need for CPR arises. With these steps I'm prepared if the patient decides to code on the way outdoors, and I've reduced the odds of that happening in any case.
The rationale for deciding to stay-and-play is twofold: a) "I can't deliver this patient to the inside of my truck any faster than X minutes, no matter how hard I try" and b) "There's a Y% chance this guy will code in the next X minutes." If X=5 minutes and Y=25% (for instance) then I choose to stabilize first and extricate second.
In my younger years I found myself grossly underestimating X -- "but the truck's just outside... I can almost see it..." Now I realize that extrications usually require more time than we'd like them to.
I'm curious what X's and Y's other paramedics use to define their own clinical comfort zones.
EricCSU said...
During paramedic school, I rode with a department that had a similar attitude on call management that you have: get the patient into your environment (the ambulance) so you can work most efficiently. I learned that way and never saw it bite us in the ass. I enjoyed nearly always starting IVs from the bench and being in a comfortable, controlled environment. We never had a patient crash during packaging from scene to ambulance. However, as you mentioned before, it does happen.
I always wondered what we would do if that happened. How would we defend ourselves in court when we saw that we had a critical patient and then delayed treating that patient until we arrived at an environment that we were more comfortable in.
After I graduated from paramedic school, I was hired by a service that has a different attitude on call management. The prevailing attitude at my current employer is: start all interventions on scene and then package and transport. The exceptions to this rule are trauma, STEMI alert, and code stroke. For those calls, the goal is a scene time of 10 minutes or less, and we are scored on those times. A commonly heard phrase is "if the patient needed the blank (IV, drug, etc.), the needed it on scene.
This change in attitude has taken some getting used to for me, but I've accepted it. I feel more comfortable knowing that if my patient does crash, I'm ready. The patient has an IV, is on the monitor and already has interventions started.
We are also lucky in that we have the new stryker stair chairs that make for a quick exit and have an O2 cylinder holder underneath the chair.
In this system, they call it "call management". I am graded on my call management skills on every call as well as other aspects of the call.
shane said...
I tend to work most patient's up in the ambulance unless they need an immediate intervention. My reasoning for this is that if the patient does take a turn for the worse, it's easier to make your way to the hospital if need be since that is one of our ultimate goals. I find that it's much easier to talk to a patient and find out what's really going on in the privacy of the ambulance. The patient seems to be more willing to talk and quite often far less distracted. This allows for a better one-on-one conversation with the patient. This also allows for me to reflect on my initial assessment of the patient, and the scene itself so that when we get to the ambulace, I already have a plan in my head and can begin to execute it. Scene management is a priority for any EMS provider, but especially for ALS providers since most others on scene look to us for guidance. The decision of if immediate intervention is needed or not is based on solid assessment skills. While this is not going to work out perfectly 100% of the time, it should be pretty accurate. I'm not totally positive, but I would think that if you were moving the patient to the ambulance for expeditious transport to the hospital, there wouldn't be much that you'd have to defend in court. You have recognized a need for a higher level of care and you are moving there as quickly as possible.
Anonymous said...
Stay and play works well when we can provide immediate and real relief and intervention. Hypoglycemia, APE, some dysrhythmias, narcotic overdose, asthma/COPD, non-traumatic arrest etc.
We can make a real difference in these patients and our care is comparable to the hospital's initial care. Except we're doing it immediately and the patient doesn't have to wait.
Theres a couple cases where I feel that staying and playing is inappropriate. Stroke. AMI and decreasing E2B/D2B time. Trauma.
Thanks to all who commented.
Thursday, April 12, 2007
EMT to Medic School
My post on Tuesday generated quite a number of comments centering around the issue of EMTs going right from EMT class to medic school. Here are my thoughts on it:
When I started you had to have at least a year of field experience before they would even consider you for admission to medic school. I had been an EMT for a number of years when I went to medic school(as a volunteer and in a small commercial emergency, but non-paramedic service), and even at that I had a hard time. Medic school isn't easy. I envied some of the people in my class who were working as EMTs with paramedic partners during class. That gave them a big advantage in understanding what we were learning. I did my 120 hours of field time and then did an extra internship where I rode with a commercial service a couple nights a week for months. When I started at a commercial service, I precepted right away and was cut loose after six weeks. Then I was on my own. I was terrified not of the common call, but of the unknown (some of that terror never goes away, it recedes, but the unknown will always be out there). In my case because my experience while more than some coming out of medic school, still wasn't as much as many, so the unknown was in fact fairly common. I encountered the unknown every day, where now I encounter it infrequently.
One of the differences between a paramedic and a nurse or a doctor in their early days on the job is that the medic is alone with no one to call upon for help, no veteran to say this is not what you think it is -- this person is not really seizing, this person is not really unresponsive, this person is not really having difficulty breathing or to say, while this person might not look it, they really are sick and you better get moving. You will learn the lessons eventually, but without extensive field or hospital experience with emergency patients, as a medic, you have the ability to do a lot of harm. Harm with your drugs and harm with your inability to recognize the severity of a situation or how to deal with the scene.
(One of the commentors made a comparison of a new medic without experience to a new Lieutenant in war without experience -- you are in charge, but if you don't know what is going on, and you don't have a street smart veteran partner, someone may get hurt.)
Now I am used to a one-medic system. And when I started it was a one-medic system with basically no first responders. (As a condition of my medical control, I had to be assigned an experienced EMT as a partner.) If you are working in a two-medic system (one with a junior and senior medic) or in a fire system where there are other medics on the engine with you, then a new medic is going to have it much easier. In this case, I see no problem with a new EMT going right into medic school and then going out on the street -- as long as they are operating under someone else who is in charge of them, and can guide them. No problem here at all.
We all hear the refrain "they don't make medics like they used too." Or "these medics nowadays, don't know..." They were saying that before I started as a medic, when I became a medic and they are still saying it today and they will be saying it in the future. In many ways the medics I see coming out today, at least around here are better trained than I was. At that same time, it seems nowadays anyone who wants to become a medic can become one. Again when I started, 15 of of 85 people who applied to medic school got in. A couple years later they were calling up people who had been rejected previously and asking them to apply. With a proliferation of medic program, they need bodies coming through the door.
Many years ago we had very few medics. I was often one of only two medics on duty covering the whole city, and there were never more than six of us. Today, there are times when every car has a medic in it. Reimbursement practices have made it financially advisable to have a medic in every car to get the paramedic billing when the paramedic does "a paramedic assessment." A problem with so many medics is it becomes harder for new medics to gain the experience they need. Instead of every call being a real emergency or an intercept with a basic car screaming for help, the day can be filled with routine emergencies and transfers. What took a new medic a year to see now may take several.
I was talking with a teacher from a paramedic program recently about the issue of the new EMT going right to medic school and she said that one of the benefits of it is that the educational institution can keep an eye on them all through their training and keep them from developing bad habits, can more completely form them in the model they are aiming for. Maybe. Hopefully they are at least riding with a service after they get their EMT so they have a context in which to place what they are learning in medic school.
I have trained many ER nurses who were going through paramedic school. Instead of doing their ER clinical time in an ER, they get sent to ride with me. They do very well -- in some cases exceptionally well -- on the medical part of the job, but need a lot of guidance when it comes to the scene management. I have also had some very smart students who are going the EMT right to medic school route ride with me, and despite their book smarts, I have seen them struggle mightily with the field.
I am sure that many EMTs going right to paramedic school will eventually become fine paramedics, just as some EMTs with years of street experience will turn out to be poor paramedics. As some commentors have pointed out its what's in the person that counts. Going straight to medic school is just a harder route.
Good luck to all of you who have chosen to become paramedics. It is a difficult job, but if you care about it, no matter the obstacles, you can become good at it. It is a noble thing to do with your life.
You deserve thanks and please, stay safe.
When I started you had to have at least a year of field experience before they would even consider you for admission to medic school. I had been an EMT for a number of years when I went to medic school(as a volunteer and in a small commercial emergency, but non-paramedic service), and even at that I had a hard time. Medic school isn't easy. I envied some of the people in my class who were working as EMTs with paramedic partners during class. That gave them a big advantage in understanding what we were learning. I did my 120 hours of field time and then did an extra internship where I rode with a commercial service a couple nights a week for months. When I started at a commercial service, I precepted right away and was cut loose after six weeks. Then I was on my own. I was terrified not of the common call, but of the unknown (some of that terror never goes away, it recedes, but the unknown will always be out there). In my case because my experience while more than some coming out of medic school, still wasn't as much as many, so the unknown was in fact fairly common. I encountered the unknown every day, where now I encounter it infrequently.
One of the differences between a paramedic and a nurse or a doctor in their early days on the job is that the medic is alone with no one to call upon for help, no veteran to say this is not what you think it is -- this person is not really seizing, this person is not really unresponsive, this person is not really having difficulty breathing or to say, while this person might not look it, they really are sick and you better get moving. You will learn the lessons eventually, but without extensive field or hospital experience with emergency patients, as a medic, you have the ability to do a lot of harm. Harm with your drugs and harm with your inability to recognize the severity of a situation or how to deal with the scene.
(One of the commentors made a comparison of a new medic without experience to a new Lieutenant in war without experience -- you are in charge, but if you don't know what is going on, and you don't have a street smart veteran partner, someone may get hurt.)
Now I am used to a one-medic system. And when I started it was a one-medic system with basically no first responders. (As a condition of my medical control, I had to be assigned an experienced EMT as a partner.) If you are working in a two-medic system (one with a junior and senior medic) or in a fire system where there are other medics on the engine with you, then a new medic is going to have it much easier. In this case, I see no problem with a new EMT going right into medic school and then going out on the street -- as long as they are operating under someone else who is in charge of them, and can guide them. No problem here at all.
We all hear the refrain "they don't make medics like they used too." Or "these medics nowadays, don't know..." They were saying that before I started as a medic, when I became a medic and they are still saying it today and they will be saying it in the future. In many ways the medics I see coming out today, at least around here are better trained than I was. At that same time, it seems nowadays anyone who wants to become a medic can become one. Again when I started, 15 of of 85 people who applied to medic school got in. A couple years later they were calling up people who had been rejected previously and asking them to apply. With a proliferation of medic program, they need bodies coming through the door.
Many years ago we had very few medics. I was often one of only two medics on duty covering the whole city, and there were never more than six of us. Today, there are times when every car has a medic in it. Reimbursement practices have made it financially advisable to have a medic in every car to get the paramedic billing when the paramedic does "a paramedic assessment." A problem with so many medics is it becomes harder for new medics to gain the experience they need. Instead of every call being a real emergency or an intercept with a basic car screaming for help, the day can be filled with routine emergencies and transfers. What took a new medic a year to see now may take several.
I was talking with a teacher from a paramedic program recently about the issue of the new EMT going right to medic school and she said that one of the benefits of it is that the educational institution can keep an eye on them all through their training and keep them from developing bad habits, can more completely form them in the model they are aiming for. Maybe. Hopefully they are at least riding with a service after they get their EMT so they have a context in which to place what they are learning in medic school.
I have trained many ER nurses who were going through paramedic school. Instead of doing their ER clinical time in an ER, they get sent to ride with me. They do very well -- in some cases exceptionally well -- on the medical part of the job, but need a lot of guidance when it comes to the scene management. I have also had some very smart students who are going the EMT right to medic school route ride with me, and despite their book smarts, I have seen them struggle mightily with the field.
I am sure that many EMTs going right to paramedic school will eventually become fine paramedics, just as some EMTs with years of street experience will turn out to be poor paramedics. As some commentors have pointed out its what's in the person that counts. Going straight to medic school is just a harder route.
Good luck to all of you who have chosen to become paramedics. It is a difficult job, but if you care about it, no matter the obstacles, you can become good at it. It is a noble thing to do with your life.
You deserve thanks and please, stay safe.
Tuesday, April 10, 2007
An Underappreciated Skill
What makes a great EMT or a great paramedic? I’ll start of with some common and easy answers –compassion, impressive medical knowledge, outstanding airway and IV skills, cool head under crisis.
I could go on. While this would clearly make a great subject for another post, what I want to talk about today is a skill that is rarely talked about, but nonetheless extremely important. I’ll call it scene management.
Let me set the stage.
2nd floor. Several rooms deep into the cluttered apartment. Man in and out of consciousness at the dinning room table. Cool, clammy, extremely diaphoretic. He says he feels terrible. He can’t even hold his arms up. If his wife were not holding him up, he would keel over. You can’t feel a pulse. The blood pressure is 70/. It’s just you and your partner. You have all your gear with you.
What do you do? And in what order?
You have to treat the patient and you have to get him out of the house, hoping he does not code.
I periodically find myself on calls like this. You can call for help, but help is not always around the corner, and sometimes even if you have say, a first responder with you, it is still a bit of a challenge.
I usually start by telling my partner, “Get the stair chair.” While he does that, I slap the patient on 02, try to get vitals and a quick 12-Lead. Then the fun begins. I usually, if its just two of us, take the patient off everything, tie him into the stair chair and make a dash for it, and then once I get him in the ambulance, I start working him up, while my partner retrieves the equipment, and gets whatever information I didn’t already get or forgot to get on the patient – today it was name, social security and meds.
I always feel awkward going down the stairs with a patient like this, trying to spin the corners, not fall over, constantly making certain the patient hasn’t coded. (I have had several patients code over the years half way down the stairs as we carried them).
Today’s call went okay – the patient didn’t die – but I was thinking during the course of it – even though I have been doing this for years – this type of extrication is really often at the heart of what we do, and it is not well taught or practiced. You need more hands than you have, so you have to make some compromises. The patient comes off the monitor and off the 02. I suppose if you have an oxygen shoulder bag, you could keep them on the 02. If I have a third person I sometimes have them carry the 02 behind the chair as we go down the stairs. That still leaves the monitor detached, and the house bag up in the room. Sometimes I’ve had my partner bring that down when he goes for the stair chair, but never on critical patients like this one.
(I'm from the school of if they code, I work them where they dropped, but if they are a possible pending code, I like to get them in the ambulance if I can before they arrest.)
Even though I think I do it pretty well, I often feel fairly incompetent during this type of extrication. I wonder how it would look on a video camera. This morning we burst out of the apartment building, and then set the man down , both of us had to stretch a little to get the kinks and strains out before we unbuckled the patient, and then lifted him up onto the stretcher, which my partner – the mark of a seasoned EMT -- had put in the down position with a sheet on it and straps undone. So here was our patient (not on any oxygen) bare-chested – I’d removed his shirt to do a twelve lead -- diaphoretic, groggy, too weak to lift his arms up from the sides of the stretcher where they now hung down – out in the morning chill as we quickly pulled his arms up to his side, tossed a blanket over him and then without even strapping him in, raised the stretcher up and high-tailed it over to the ambulance, where I found a new non-rebreather and put it on him, running off the onboard 02 and waited for my partner to come back with the monitor -- and the house bag. In the meantime I took another blood pressure, did a head to toe and started an IV of saline.
My partner came back with all the equipment and then slapped down a piece of paper with name, DOB, SS #, and a second sheet with the med list. Everything I needed. (When I was a brand new EMT, my also brand new EMT partner and I once had a bad CHFer with pink frothy sputum. We did a stair chair and run only to get to the hospital realizing we didn’t even know the guy’s name, much less his DOB and SS or any history. On other scenes, I’ve left my intubation gear). He closed the door, got in front and we were off to the hospital.
So the bottom line of this all, a good medic or an EMT, is isn’t just someone with good skills, medical knowledge, and compassion, it’s someone who knows how to extricate a patient, get moving quickly, efficiently, and without forgetting anything. It is a little appreciated art, but something when we do it well we should be as proud of as hitting the diagnosis on the head, or getting a difficult IV or tube.
***
Just after posting this, another medic handed me a brochure for a Nurse to Paramedic Bridge class that consists of 96 hours of instruction, 72 hours hospital clinical and 96 hours ride time. Many years ago around here, you had to have at least a year of EMT experience in the field before they would even let you apply to medic school. Now many go right from EMT school to medic class. It doesn't matter really what you are -- nurse trying to be a paramedic or new EMT making the jump to medic school, there are certain things with any job that come only from experience. If you don't have it, hope that you have a partner or veteran first responders who can lead you through the "field" part of EMS -- the part that isn't taught in a classroom.
I could go on. While this would clearly make a great subject for another post, what I want to talk about today is a skill that is rarely talked about, but nonetheless extremely important. I’ll call it scene management.
Let me set the stage.
2nd floor. Several rooms deep into the cluttered apartment. Man in and out of consciousness at the dinning room table. Cool, clammy, extremely diaphoretic. He says he feels terrible. He can’t even hold his arms up. If his wife were not holding him up, he would keel over. You can’t feel a pulse. The blood pressure is 70/. It’s just you and your partner. You have all your gear with you.
What do you do? And in what order?
You have to treat the patient and you have to get him out of the house, hoping he does not code.
I periodically find myself on calls like this. You can call for help, but help is not always around the corner, and sometimes even if you have say, a first responder with you, it is still a bit of a challenge.
I usually start by telling my partner, “Get the stair chair.” While he does that, I slap the patient on 02, try to get vitals and a quick 12-Lead. Then the fun begins. I usually, if its just two of us, take the patient off everything, tie him into the stair chair and make a dash for it, and then once I get him in the ambulance, I start working him up, while my partner retrieves the equipment, and gets whatever information I didn’t already get or forgot to get on the patient – today it was name, social security and meds.
I always feel awkward going down the stairs with a patient like this, trying to spin the corners, not fall over, constantly making certain the patient hasn’t coded. (I have had several patients code over the years half way down the stairs as we carried them).
Today’s call went okay – the patient didn’t die – but I was thinking during the course of it – even though I have been doing this for years – this type of extrication is really often at the heart of what we do, and it is not well taught or practiced. You need more hands than you have, so you have to make some compromises. The patient comes off the monitor and off the 02. I suppose if you have an oxygen shoulder bag, you could keep them on the 02. If I have a third person I sometimes have them carry the 02 behind the chair as we go down the stairs. That still leaves the monitor detached, and the house bag up in the room. Sometimes I’ve had my partner bring that down when he goes for the stair chair, but never on critical patients like this one.
(I'm from the school of if they code, I work them where they dropped, but if they are a possible pending code, I like to get them in the ambulance if I can before they arrest.)
Even though I think I do it pretty well, I often feel fairly incompetent during this type of extrication. I wonder how it would look on a video camera. This morning we burst out of the apartment building, and then set the man down , both of us had to stretch a little to get the kinks and strains out before we unbuckled the patient, and then lifted him up onto the stretcher, which my partner – the mark of a seasoned EMT -- had put in the down position with a sheet on it and straps undone. So here was our patient (not on any oxygen) bare-chested – I’d removed his shirt to do a twelve lead -- diaphoretic, groggy, too weak to lift his arms up from the sides of the stretcher where they now hung down – out in the morning chill as we quickly pulled his arms up to his side, tossed a blanket over him and then without even strapping him in, raised the stretcher up and high-tailed it over to the ambulance, where I found a new non-rebreather and put it on him, running off the onboard 02 and waited for my partner to come back with the monitor -- and the house bag. In the meantime I took another blood pressure, did a head to toe and started an IV of saline.
My partner came back with all the equipment and then slapped down a piece of paper with name, DOB, SS #, and a second sheet with the med list. Everything I needed. (When I was a brand new EMT, my also brand new EMT partner and I once had a bad CHFer with pink frothy sputum. We did a stair chair and run only to get to the hospital realizing we didn’t even know the guy’s name, much less his DOB and SS or any history. On other scenes, I’ve left my intubation gear). He closed the door, got in front and we were off to the hospital.
So the bottom line of this all, a good medic or an EMT, is isn’t just someone with good skills, medical knowledge, and compassion, it’s someone who knows how to extricate a patient, get moving quickly, efficiently, and without forgetting anything. It is a little appreciated art, but something when we do it well we should be as proud of as hitting the diagnosis on the head, or getting a difficult IV or tube.
***
Just after posting this, another medic handed me a brochure for a Nurse to Paramedic Bridge class that consists of 96 hours of instruction, 72 hours hospital clinical and 96 hours ride time. Many years ago around here, you had to have at least a year of EMT experience in the field before they would even let you apply to medic school. Now many go right from EMT school to medic class. It doesn't matter really what you are -- nurse trying to be a paramedic or new EMT making the jump to medic school, there are certain things with any job that come only from experience. If you don't have it, hope that you have a partner or veteran first responders who can lead you through the "field" part of EMS -- the part that isn't taught in a classroom.
Friday, April 06, 2007
You Aren't Talking To Me
There is a scene in Apocalypse Nowwhere the Martin Sheen character shows up at an outpost base that is under fire by enemy forces and has been every night for months. He walks through the chaos looking for someone to report to. He asks a soldier who’s in charge and the flustered man says, “I thought you were.” He asks the question again of another man, who just smiles, says nothing and turns away.
I was in an ED the other day and I had flashbacks to this scene. Patients lined the hallways. The trauma rooms were filled, people scurried in and out. A crazy patient shouted to Jesus. It was like bumper cars with stretchers and hospital beds going in and out. Phones ringing unanswered. People being paged on the intercom. A priest giving last rights. The sounds of ventilators. A naked man walking through the middle of it, unnoticed. A janitor moping blood. The smell of feces. Conversations in Spanish. The radio going off – a patch about an elderly man with difficulty breathing. Cops standing next to a shackled tattooed girl. A little boy on the floor playing with a truck. I found a nurse, who was mixing a drip and started giving my report. She looked up at me. “Who are you talking to?" she said. "You aren’t talking to me. Nooo, nooo. You aren’t talking to me.” I pointed to my patient. "80 year old. Rectal bleed. Going on for two days. Stable vitals." I showed her the paperwork and set it on the counter. "I'm leaving it right here for you." She just kept shaking her head. Down the hall came another stretcher, being pulled by a firefighter in turnout gear, a paramedic bagged a nearly blue patient with an ET tube sticking out of his mouth, while an EMT rode the rails doing CPR. My pager went off. “CAN U CLEAR FOR PRI 1?"
***
The next day I worked I did one transport. The hospital was nearly empty.
where the Martin Sheen character shows up at an outpost base that is under fire by enemy forces and has been every night for months. He walks through the chaos looking for someone to report to. He asks a soldier who’s in charge and the flustered man says, “I thought you were.” He asks the question again of another man, who just smiles, says nothing and turns away.I was in an ED the other day and I had flashbacks to this scene. Patients lined the hallways. The trauma rooms were filled, people scurried in and out. A crazy patient shouted to Jesus. It was like bumper cars with stretchers and hospital beds going in and out. Phones ringing unanswered. People being paged on the intercom. A priest giving last rights. The sounds of ventilators. A naked man walking through the middle of it, unnoticed. A janitor moping blood. The smell of feces. Conversations in Spanish. The radio going off – a patch about an elderly man with difficulty breathing. Cops standing next to a shackled tattooed girl. A little boy on the floor playing with a truck. I found a nurse, who was mixing a drip and started giving my report. She looked up at me. “Who are you talking to?" she said. "You aren’t talking to me. Nooo, nooo. You aren’t talking to me.” I pointed to my patient. "80 year old. Rectal bleed. Going on for two days. Stable vitals." I showed her the paperwork and set it on the counter. "I'm leaving it right here for you." She just kept shaking her head. Down the hall came another stretcher, being pulled by a firefighter in turnout gear, a paramedic bagged a nearly blue patient with an ET tube sticking out of his mouth, while an EMT rode the rails doing CPR. My pager went off. “CAN U CLEAR FOR PRI 1?"
***
The next day I worked I did one transport. The hospital was nearly empty.
Tuesday, April 03, 2007
Class in America
We went to a doctor's office for an unknown. The secretary led us to an exam room where a man in his sixties sat in a wheelchair, his chin on his chest,eyes closed, looking very tired. He had a huge distended abdomen and a hint of a yellow tinge to his skin. His wife was with him. She was a few years younger, and very well dressed. It looked like she had used just a touch too much of her tasteful dark red lipstick in the way that once beautiful older women sometimes do.
I asked her what was going on. She seemed taken aback by my question. She looked at me in such a way I almost felt like I was intruding.
"My husband's going to the hospital," she said, and then she gave us the name of the facility as if it were the only facility that one would consider going to.
"Okay, but why were we called?"
"He needs to go to the ER. They're going to admit him."
I've been in this situation before. She wasn't being unkind. She was just looking at us and we were the local people who drive the ambulance, and the doctor had arranged for her husband to go by ambulance down to the hospital where another doctor would see him. She was used to dealing with doctors.
"And what's the medical reason?" I asked.
"Oh, I have all his information. They know about him at the hospital"
I didn't get into it with her. Not that I don't still do it on occasion, but I have found that beating my breast and declaring I am a paramedic fatigues me more than it impresses someone else. While my partner set up the stretcher, I looked around for a doctor or nurse to get a report from. Just then the doctor came out of his office and came over and gave me a detailed and rather excellent report right in front of the wife. The key finding -- the man had cirrhosis and was growing increasingly weak. He had fallen recently and may have broken his hand. The doctor said his wife did a heroic job just getting her husband up to the office but he really needed an ambulance to go to the hospital. I didn't disagree. The husband looked like dead weight. Standing and pivoting him into the wheelchair -- that must have taken determination.
After hearing the doctor give us the report, I noticed the wife was a little friendlier to us. We received a little more recognition. Maybe she saw us now as part of the medical team -- that's good, she must have thought, good to know her husband will be watched over by trained people.
This was just a small moment in the day -- no big deal -- but it made me think about class in America. This man probably at one time was a well-paid executive of a large company. He probably didn't run the company, but he was a boss of a division no doubt with a big office and an attractive competent secretary, a nice salary and expense account, maybe stock options as well.
He was of the cocktail generation. I imagined him everyday having quite a number of cocktails, cocktails at business lunches, cocktails on coming home, cocktails at the country club, cocktails at cocktail parties. Tom Collins, Gin and Tonic, scotch on the rocks, rum and Coke, Whiskey Sours, martinis. Cocktails were a part of the social life of his generation and class, and, for many of those people, social life and business went hand in hand. Over the years he probably had his share and more of cocktails. Not rot gut either. No Mad Dog 20-20 or Yankee Spirit Special, but good grades of bourbon, vodka or gin. Maker's Mark. Grey Goose. Johnny Walker... I don't know, I'm a beer man myself.
It made me think of my parents and of growing up belonging to a country club. My father was the son of a man who worked all his life for the phone company. My mother was the daughter of a mild mannered inventor dreamer mid-level management worker who was always getting scammed out of his money. She lived in a ritzy town where all her friends were wealthy, while she, a scholarship student, had to pretend she came from money. Often there were phone calls from creditors. Both she and my father went to private schools. In my father's case, two childless aunts paid his way, while my mother got scholarships because of her academics and athletics. They went to good colleges. When my father graduated from Harvard, he eloped with my mother, a year younger, who hadn't finished her senior year at Smith. My father joined the Navy, and then, on getting out during the peacetime reductions, worked for Pan Am, as head of a grounds crew, responsible for cleaning the planes between trips, vacuumingthe carpets, cleaning the toilets. We lived in England where I was born, and later in Turkey -- Istanbul. Wanting more for his family, he left to become a trainee for a stock brokerage firm, where he worked for many years. As a boy I remember helping him stuff, lick and stamp envelopes with letters introducing himself to cold clients. He also went door to door seeking business. In time, he rose from managing individual accounts to managing accounts for institutions, and providing his family a good living. His firm paid for our membership at the country club, which the firm's bosses thought would be good for business.
This man and his wife in the doctor's office reminded me of some of my parent's friends. Class-conscious without seeing anything wrong with it, belonging to the country club set, having many doctor friends, always going to the best hospital, and of course, familiar with cocktails. I watched people like them at the country club, some slowly slurring their speech as the night went on, their breath smelling of liquor. Over the years, I saw ballooning bellies in the husbands and increasing makeup on the wives, the world changing around all of us.
My mother loved the country club, loved to tell others I went to a private school. She loved the fancy handcrafted lightship basket my father had made for her one summer by a Nantucket craftsman -- a basket many ladies at the country club had -- a sign of status and that meant much to my mother. I wonder now, many years later, what she might have had to endure as the poor girl pretending to be rich, and how later belonging to a country club and sending her children to private schools without scholarships validated her journey in some way. I never saw her be cruel to a person of a lessor class, although she clearly wanted our family to continue its ascent up the social ladder.
Once she said of my father, what impressed her most about him when they started dating, was that he was always nice to the ladies on the other side of the cafeteria food line. I saw that in him too, every person he dealt with -- company boss or waitress, big client or maintenence man, he looked them in the eye, asked how they were, remembered unique things about them such as their children's names.
Not all parents were that way. Many in the country club were quick to put others down, to order employees around or worse to ignore them. These members weren't necessarily bad people, they were just who they were, who their world and influences had created. I remember how angry one man was that his son was spending the summer crewing a yacht for a rich man -- his son was supposed to have people working for him, not being ordered around. I thought it was pretty cool, being able to sail around the world, but for the father, it was a bitter pill to think of his son cleaning the toilet in another man's boat.
From a young age, I tried to be like my father. He spent his college summers hitchhiking across the country working in pea canneries or driving a truck and other odd jobs. When I was younger I worked in factories, unloaded semi-tricks, drove taxi-cabs, sold Bibles on the telephone, and worked on roofs in the hot sun. I loved seeing the world, meeting people, hearing their stories. Much of my young adulthood was spent going between two worlds, working odd jobs all over the country and wearing a suit and tie and working for a US Senator and then Governor. I'd work a few years in government, and then leave to see the world. A few years later, I'd trade my blue jeans and tee-shirts back for the coat and tie world -- much to the relief of my parents, who encouraged me to think of the future.
But as much as I admired the man I worked for -- I wasn't really cut out for the world of politics, the social climbing involved in it, so I'd go back to the other world, telling my parents I was just taking the jobs I did to support myself while I devoted my time to writing the great American novel. EMS was one of those jobs and it became the one that wouldn't let me go.
In Washington D.C., I used to play tennis with the Senator on this beautiful indoor tennis court in the Dirksen Senate Office Building. It was an amazing court -- hidden from public view. To get there you had to enter a door that said "Warning Hard Hat Area Only" and then walk through a web of heating and air conditioning ducts, and then up some narrow stairs and then there was the court. I played with many Senators -- John Kerry, including George Mitchell, J. Bennett Johnston, Dan Quayle and Ted Kennedy. We played with Quayle, who later became Vice-President, the most because he was the one that was always free. The others were always having to stop in the middle of the match to take important calls or to run off to sudden meetings. One evening, just as I was getting up from my desk to go out for a night of drinking beer with my friends, the senator's secretary called and said Senator Kennedy needed a fourth and had asked if I was available. I was flattered, but I thought about it a moment. I had promised my buddies I was going to go out with them to this new bar where they sold "yards" of beer -- beer in a three foot glass. I was only a kid, but for some reason this decision became one of character. What kind of person was I? Was I going to be faithful to my pals? Or was I going to jump at an opportunity to network, to play tennis with a famous man, who might someday hold the key to a new world for me if I played it right? I saw it as a test of friendship and loyalty and not being a "suck."
Today I am a paramedic, and while I think my decision not to play tennis with the Senator was foolish looking back on it -- experiences should rarely be turned down --my choice not to go was who I was and it was one of a small number of decisions that defined and guided who I became. Maybe I was hearing my mother say of my father, he was always nice to the ladies behind the line, that implicit in that lesson was that no man was more important than another.
Today in many ways when I meet patients like this man and his wife, I am on the other side of the line. I am perhaps, to them, the one washing toilets and not the owner of the yacht. Some of these people see and may respect me, but others do not notice me. Of course, I know enough now to know what my father knew, that there is no real line. People are people, good ones and bad ones, all a product of their lives and worlds, and their parents's lives and worlds. They all have their moments of glory, of being bosses of their worlds and they all have times when they are sick and can't stand on their own, when the world has become something they cannot control, something they could not have imagined.
I've done compressions on the chests of vagrants and millionares. EMS teaches you not to judge too harshly. We're all going to end up in the same place, some sooner than others.
We were gentle with the man. I assured his wife we would take good care of him. And in her eyes, her guard down, I saw how much she appreciated that.
I asked her what was going on. She seemed taken aback by my question. She looked at me in such a way I almost felt like I was intruding.
"My husband's going to the hospital," she said, and then she gave us the name of the facility as if it were the only facility that one would consider going to.
"Okay, but why were we called?"
"He needs to go to the ER. They're going to admit him."
I've been in this situation before. She wasn't being unkind. She was just looking at us and we were the local people who drive the ambulance, and the doctor had arranged for her husband to go by ambulance down to the hospital where another doctor would see him. She was used to dealing with doctors.
"And what's the medical reason?" I asked.
"Oh, I have all his information. They know about him at the hospital"
I didn't get into it with her. Not that I don't still do it on occasion, but I have found that beating my breast and declaring I am a paramedic fatigues me more than it impresses someone else. While my partner set up the stretcher, I looked around for a doctor or nurse to get a report from. Just then the doctor came out of his office and came over and gave me a detailed and rather excellent report right in front of the wife. The key finding -- the man had cirrhosis and was growing increasingly weak. He had fallen recently and may have broken his hand. The doctor said his wife did a heroic job just getting her husband up to the office but he really needed an ambulance to go to the hospital. I didn't disagree. The husband looked like dead weight. Standing and pivoting him into the wheelchair -- that must have taken determination.
After hearing the doctor give us the report, I noticed the wife was a little friendlier to us. We received a little more recognition. Maybe she saw us now as part of the medical team -- that's good, she must have thought, good to know her husband will be watched over by trained people.
This was just a small moment in the day -- no big deal -- but it made me think about class in America. This man probably at one time was a well-paid executive of a large company. He probably didn't run the company, but he was a boss of a division no doubt with a big office and an attractive competent secretary, a nice salary and expense account, maybe stock options as well.
He was of the cocktail generation. I imagined him everyday having quite a number of cocktails, cocktails at business lunches, cocktails on coming home, cocktails at the country club, cocktails at cocktail parties. Tom Collins, Gin and Tonic, scotch on the rocks, rum and Coke, Whiskey Sours, martinis. Cocktails were a part of the social life of his generation and class, and, for many of those people, social life and business went hand in hand. Over the years he probably had his share and more of cocktails. Not rot gut either. No Mad Dog 20-20 or Yankee Spirit Special, but good grades of bourbon, vodka or gin. Maker's Mark. Grey Goose. Johnny Walker... I don't know, I'm a beer man myself.
It made me think of my parents and of growing up belonging to a country club. My father was the son of a man who worked all his life for the phone company. My mother was the daughter of a mild mannered inventor dreamer mid-level management worker who was always getting scammed out of his money. She lived in a ritzy town where all her friends were wealthy, while she, a scholarship student, had to pretend she came from money. Often there were phone calls from creditors. Both she and my father went to private schools. In my father's case, two childless aunts paid his way, while my mother got scholarships because of her academics and athletics. They went to good colleges. When my father graduated from Harvard, he eloped with my mother, a year younger, who hadn't finished her senior year at Smith. My father joined the Navy, and then, on getting out during the peacetime reductions, worked for Pan Am, as head of a grounds crew, responsible for cleaning the planes between trips, vacuumingthe carpets, cleaning the toilets. We lived in England where I was born, and later in Turkey -- Istanbul. Wanting more for his family, he left to become a trainee for a stock brokerage firm, where he worked for many years. As a boy I remember helping him stuff, lick and stamp envelopes with letters introducing himself to cold clients. He also went door to door seeking business. In time, he rose from managing individual accounts to managing accounts for institutions, and providing his family a good living. His firm paid for our membership at the country club, which the firm's bosses thought would be good for business.
This man and his wife in the doctor's office reminded me of some of my parent's friends. Class-conscious without seeing anything wrong with it, belonging to the country club set, having many doctor friends, always going to the best hospital, and of course, familiar with cocktails. I watched people like them at the country club, some slowly slurring their speech as the night went on, their breath smelling of liquor. Over the years, I saw ballooning bellies in the husbands and increasing makeup on the wives, the world changing around all of us.
My mother loved the country club, loved to tell others I went to a private school. She loved the fancy handcrafted lightship basket my father had made for her one summer by a Nantucket craftsman -- a basket many ladies at the country club had -- a sign of status and that meant much to my mother. I wonder now, many years later, what she might have had to endure as the poor girl pretending to be rich, and how later belonging to a country club and sending her children to private schools without scholarships validated her journey in some way. I never saw her be cruel to a person of a lessor class, although she clearly wanted our family to continue its ascent up the social ladder.
Once she said of my father, what impressed her most about him when they started dating, was that he was always nice to the ladies on the other side of the cafeteria food line. I saw that in him too, every person he dealt with -- company boss or waitress, big client or maintenence man, he looked them in the eye, asked how they were, remembered unique things about them such as their children's names.
Not all parents were that way. Many in the country club were quick to put others down, to order employees around or worse to ignore them. These members weren't necessarily bad people, they were just who they were, who their world and influences had created. I remember how angry one man was that his son was spending the summer crewing a yacht for a rich man -- his son was supposed to have people working for him, not being ordered around. I thought it was pretty cool, being able to sail around the world, but for the father, it was a bitter pill to think of his son cleaning the toilet in another man's boat.
From a young age, I tried to be like my father. He spent his college summers hitchhiking across the country working in pea canneries or driving a truck and other odd jobs. When I was younger I worked in factories, unloaded semi-tricks, drove taxi-cabs, sold Bibles on the telephone, and worked on roofs in the hot sun. I loved seeing the world, meeting people, hearing their stories. Much of my young adulthood was spent going between two worlds, working odd jobs all over the country and wearing a suit and tie and working for a US Senator and then Governor. I'd work a few years in government, and then leave to see the world. A few years later, I'd trade my blue jeans and tee-shirts back for the coat and tie world -- much to the relief of my parents, who encouraged me to think of the future.
But as much as I admired the man I worked for -- I wasn't really cut out for the world of politics, the social climbing involved in it, so I'd go back to the other world, telling my parents I was just taking the jobs I did to support myself while I devoted my time to writing the great American novel. EMS was one of those jobs and it became the one that wouldn't let me go.
In Washington D.C., I used to play tennis with the Senator on this beautiful indoor tennis court in the Dirksen Senate Office Building. It was an amazing court -- hidden from public view. To get there you had to enter a door that said "Warning Hard Hat Area Only" and then walk through a web of heating and air conditioning ducts, and then up some narrow stairs and then there was the court. I played with many Senators -- John Kerry, including George Mitchell, J. Bennett Johnston, Dan Quayle and Ted Kennedy. We played with Quayle, who later became Vice-President, the most because he was the one that was always free. The others were always having to stop in the middle of the match to take important calls or to run off to sudden meetings. One evening, just as I was getting up from my desk to go out for a night of drinking beer with my friends, the senator's secretary called and said Senator Kennedy needed a fourth and had asked if I was available. I was flattered, but I thought about it a moment. I had promised my buddies I was going to go out with them to this new bar where they sold "yards" of beer -- beer in a three foot glass. I was only a kid, but for some reason this decision became one of character. What kind of person was I? Was I going to be faithful to my pals? Or was I going to jump at an opportunity to network, to play tennis with a famous man, who might someday hold the key to a new world for me if I played it right? I saw it as a test of friendship and loyalty and not being a "suck."
Today I am a paramedic, and while I think my decision not to play tennis with the Senator was foolish looking back on it -- experiences should rarely be turned down --my choice not to go was who I was and it was one of a small number of decisions that defined and guided who I became. Maybe I was hearing my mother say of my father, he was always nice to the ladies behind the line, that implicit in that lesson was that no man was more important than another.
Today in many ways when I meet patients like this man and his wife, I am on the other side of the line. I am perhaps, to them, the one washing toilets and not the owner of the yacht. Some of these people see and may respect me, but others do not notice me. Of course, I know enough now to know what my father knew, that there is no real line. People are people, good ones and bad ones, all a product of their lives and worlds, and their parents's lives and worlds. They all have their moments of glory, of being bosses of their worlds and they all have times when they are sick and can't stand on their own, when the world has become something they cannot control, something they could not have imagined.
I've done compressions on the chests of vagrants and millionares. EMS teaches you not to judge too harshly. We're all going to end up in the same place, some sooner than others.
We were gentle with the man. I assured his wife we would take good care of him. And in her eyes, her guard down, I saw how much she appreciated that.
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