File under: Something New Every Day
The group home patient with a history of mental retardation was found unresponsive in his wheel chair. The small frail man has significant kifofis. His body is flaccid and he cannot even hold his head up. The quick story is he was found that way this morning. Normally he is alert. He seems to be having periods of apnea, but his color is good and he has a decent radial pulse. I'm guessing CVA. "He's a no compression," the aide says.
"A DNR?"
"No, he's no compressions only. He doesn't have a bracelet."
"But he's a DNR?"
"You can breathe for him."
"But I can't do compressions?"
"Right."
"So he's a DNR?"
"No, he's a full code, just no compressions. He has osteoporosis and compressions won't work. They'll break his ribs. We have a doctor's order."
"I'll need to see that."
They produce it:
"Notice of "No Chest Compressions" for "Patient name"
In the event "Name" goes into cardiac arrest, immediately call 911 and start rescue breathing. When emergency personal arrive, inform them of no chest compressions and give them a copy of the Dr's order for no chest compressions along with this notice.
This has been agreed upon by "state agency responsible for patient" and ordered by his PCP.
I shake my head. I don't argue with the aide, but I am thinking to myself -- this isn't going to fly. Our state is pretty rigid on its DNR/resusitation order forms and this one -- while being agreed upon by a doctor and a state agency -- is most certainly not valid. Additionally it is over two years old. Our DNR orders must be updated every six months.
I think it is a way around what I am told is a rule that no patient in the care of the state can have a DNR order, so this is not a DNR order, per se, but a half-assed resucitation order. I suppose it would be okay if I took a scapel out and sliced the patient open and reached in an did open cardiac massage just so long as I wasn't doing compressions.
Fortunately, the patient doesn't code on me or get much worse than an occasional apniec pause that responds to stimulation. At the ED, I relay the info to the hospital staff who all admit they have never seen such an order. I later talk to a hospital staffer who tells me of a lengthy conversation he has with the case worker. The case worker tells him he can defibrillate the patient repeatedly, but can't do compressions because they will break the patient's ribs. He doesn't seem to understand that you need to do something to circulate the blood. You can intubate and defibrillate, the case worker says again.
***
My preceptee, who wasn't with me that day, asked what I would have done had the patient coded. I would have called medical control, I said. I would have said, "Doc, this what I got, Whaddya think?"
That's why they get the big money.
Thursday, May 31, 2007
Tuesday, May 29, 2007
Slither
We are called to a nursing home for a lift assist. I have never done a straight lift assist in a nursing home before, so I am a little puzzled. Isn't this something that nursing homes are supposed to do themselves?
The short, squat nurse demands to know why we have brought in our stretcher, monitor, house bag, oxygen and long board. "We don't need the stuff. We just need you to help pick him up. You don't need all that."
"We always bring it," I say.
"Suit yourself. Follow me."
On the way, we walk by a hoyer lift, which I take as a bad sign. It doesn't appear broken.
"He slipped and can't get up," the nurse says pointing in the room. "The guys here don't know how to lift."
My preceptee enters the room first and I hear a voice say, "A girl, they send a little girl?"
I enter the room next. There on the floor is a human blob. Jabba the Hut. I have a hard time making out the flat flabby legs from the flab that emanates from al sides of the patient. He sits upright, his head like the cooked yellow yolk of an egg, with his fat all the white surrounding it.
"Two of you," he says, "Just two of you?"
My other two partners come in the room, nearly running into each other as they stop suddenly at the sight of the patient.
"You guys don't look very big," he says. "You're going to need an army to lift me -- me -- the fat guy -- the humiliated fat guy."
"We should be able to do it," I say.
I have picked up big patients before, patients even heavier than this one, who I am guessing is 500 pounds tops. I have a great method. I slide a board under them, lay them down, and strap them to the board. I have two people -- preferably strong firefighters or cops on each side of the board near the head, facing each other, holding the board under the patient's arms. I have my partner stand in front. I take the end of the board, squat down and lift up, as the two responders pull up on their sides of the board. My partner in the front is there just to help balance the patient as we use the leverage of the board to get the patient to a standing position, from which the patient can either walk or we can slide a giant wheelchair underneath them.
The problem here is the patient's mishapen legs make it impossible for him to stand, so that method is out. Adding to the problem, the patient has numerous open wounds on his legs.
I announce my plan -- get the patient on the board, and then try to lift the board up enough to get the head of the board on the bed, and then we can lift the other end of the board from the feet and swing the patient around onto the bed.
But then the nurse starts telling me how she would do it.
I just look at her until she quiets. "You called us?" I said.
"Yes," she says.
"That's right," I say, "And we have it under control, thank you."
I think I imperceptibly nod toward the door for her to leave.
In the meantime, my partner has radioed dispatch for some first responders to come help, and before I know it the radio is full of units coming out to help. "We need more strength here," my partner said. I don't know if it is the desire to help or curiosity that is bringing them, but it seems everyone wants to come help.
"We'll at least get her on the board and then wait for them to help lift," I say.
It takes awhile, but we get the board under the patient, with much moaning and groaning from the patient, who seems to protest at any touch of his skin. The constant "owws" bring the nurse back into the room. "Why don't you wait for the others to come?" she says. "You've got to be careful with his legs."
This time I definately nod toward the door. "We're just putting him on the board. We've got it."
While the board is too wide to disappear in the patient's bottom crack, the thought does come to my mind. There is more of the patient on either side of the board than there is on the board. We need to link two nine foot straps together to properly secure a strap around the patient's middle.
Our support arrives -- more it seems than can fit into the room. I pick three to help. I have two on each side, one at the feet and I have the head. The patient sits upright on the board. "Don't drop me. I don't want to be dropped."
"We never drop anyone on days that end in 'Y'," one of my partners says.
"That's reassuring," the patient says.
"It'll be okay, trust me," my preceptee says. She had been doing a fine job easing the patient's mind. I think my annoyance with the nurse has scared the patient.
I stay away from my normal routine of 'We won't drop you, not after what happened to the last guy. The last guy? Oh, that's right, we're not supposed to talk about that -- the lawyers, you know.'
"Just don't reach out," I say.
I bend down in the squat position, and start to lift, driving my legs up. Something is wrong. The patient wavers and reaches out frantically. I can feel the board starting to split. "Abort!" I say quickly, and we set the patient down before the board can disintegrate.
"Do you want me to call the fire department?" the nurse says from the door. "That's who we asked for."
I ignore her. She leaves again.
"You're going to have to lay down," I tell the patient. "I know it might be hard for you to breathe, but we need to distribute the weight across the board, and not have it all in the center. And you can't reach out."
"You're going to drop me. I know you're going to drop me. You've never had anyone as fat as me."
I keep my mouth shut.
I reposition everyone. I share the end with another strong EMT. We lift on my count. Up we go and over onto the bed. The force takes me off my feet and onto the bed. I feel the patient slither over me. I at least have some of the board between us and I can pivot it enough to keep from being crushed.
"I squished him," the man says. "Oh, god, this is embarrassing. Is he all right? I squished him."
"I'm fine," I say, my eyes saying to my partners, "Help me out here."
I make it back to my feet. People look at me with astonishment as if I have come out of a collapsed coal mine after they thought there could be no survivors.
"I'm okay, I'm okay," I say.
On the way out, the seated nurse says, "thanks for coming."
I give a little wave and keep on going, headed for the merciful exit.
The short, squat nurse demands to know why we have brought in our stretcher, monitor, house bag, oxygen and long board. "We don't need the stuff. We just need you to help pick him up. You don't need all that."
"We always bring it," I say.
"Suit yourself. Follow me."
On the way, we walk by a hoyer lift, which I take as a bad sign. It doesn't appear broken.
"He slipped and can't get up," the nurse says pointing in the room. "The guys here don't know how to lift."
My preceptee enters the room first and I hear a voice say, "A girl, they send a little girl?"
I enter the room next. There on the floor is a human blob. Jabba the Hut. I have a hard time making out the flat flabby legs from the flab that emanates from al sides of the patient. He sits upright, his head like the cooked yellow yolk of an egg, with his fat all the white surrounding it.
"Two of you," he says, "Just two of you?"
My other two partners come in the room, nearly running into each other as they stop suddenly at the sight of the patient.
"You guys don't look very big," he says. "You're going to need an army to lift me -- me -- the fat guy -- the humiliated fat guy."
"We should be able to do it," I say.
I have picked up big patients before, patients even heavier than this one, who I am guessing is 500 pounds tops. I have a great method. I slide a board under them, lay them down, and strap them to the board. I have two people -- preferably strong firefighters or cops on each side of the board near the head, facing each other, holding the board under the patient's arms. I have my partner stand in front. I take the end of the board, squat down and lift up, as the two responders pull up on their sides of the board. My partner in the front is there just to help balance the patient as we use the leverage of the board to get the patient to a standing position, from which the patient can either walk or we can slide a giant wheelchair underneath them.
The problem here is the patient's mishapen legs make it impossible for him to stand, so that method is out. Adding to the problem, the patient has numerous open wounds on his legs.
I announce my plan -- get the patient on the board, and then try to lift the board up enough to get the head of the board on the bed, and then we can lift the other end of the board from the feet and swing the patient around onto the bed.
But then the nurse starts telling me how she would do it.
I just look at her until she quiets. "You called us?" I said.
"Yes," she says.
"That's right," I say, "And we have it under control, thank you."
I think I imperceptibly nod toward the door for her to leave.
In the meantime, my partner has radioed dispatch for some first responders to come help, and before I know it the radio is full of units coming out to help. "We need more strength here," my partner said. I don't know if it is the desire to help or curiosity that is bringing them, but it seems everyone wants to come help.
"We'll at least get her on the board and then wait for them to help lift," I say.
It takes awhile, but we get the board under the patient, with much moaning and groaning from the patient, who seems to protest at any touch of his skin. The constant "owws" bring the nurse back into the room. "Why don't you wait for the others to come?" she says. "You've got to be careful with his legs."
This time I definately nod toward the door. "We're just putting him on the board. We've got it."
While the board is too wide to disappear in the patient's bottom crack, the thought does come to my mind. There is more of the patient on either side of the board than there is on the board. We need to link two nine foot straps together to properly secure a strap around the patient's middle.
Our support arrives -- more it seems than can fit into the room. I pick three to help. I have two on each side, one at the feet and I have the head. The patient sits upright on the board. "Don't drop me. I don't want to be dropped."
"We never drop anyone on days that end in 'Y'," one of my partners says.
"That's reassuring," the patient says.
"It'll be okay, trust me," my preceptee says. She had been doing a fine job easing the patient's mind. I think my annoyance with the nurse has scared the patient.
I stay away from my normal routine of 'We won't drop you, not after what happened to the last guy. The last guy? Oh, that's right, we're not supposed to talk about that -- the lawyers, you know.'
"Just don't reach out," I say.
I bend down in the squat position, and start to lift, driving my legs up. Something is wrong. The patient wavers and reaches out frantically. I can feel the board starting to split. "Abort!" I say quickly, and we set the patient down before the board can disintegrate.
"Do you want me to call the fire department?" the nurse says from the door. "That's who we asked for."
I ignore her. She leaves again.
"You're going to have to lay down," I tell the patient. "I know it might be hard for you to breathe, but we need to distribute the weight across the board, and not have it all in the center. And you can't reach out."
"You're going to drop me. I know you're going to drop me. You've never had anyone as fat as me."
I keep my mouth shut.
I reposition everyone. I share the end with another strong EMT. We lift on my count. Up we go and over onto the bed. The force takes me off my feet and onto the bed. I feel the patient slither over me. I at least have some of the board between us and I can pivot it enough to keep from being crushed.
"I squished him," the man says. "Oh, god, this is embarrassing. Is he all right? I squished him."
"I'm fine," I say, my eyes saying to my partners, "Help me out here."
I make it back to my feet. People look at me with astonishment as if I have come out of a collapsed coal mine after they thought there could be no survivors.
"I'm okay, I'm okay," I say.
On the way out, the seated nurse says, "thanks for coming."
I give a little wave and keep on going, headed for the merciful exit.
Thursday, May 24, 2007
Oxygen
You arrive on scene for a patient with a painful broken hand. The first responder, as he is trained, has a nonrebreather on the patient. You thank him for the report, and then take the nonrebreather off and say to the patient, we're going to see how you do without this for a minute.
Sometimes I see in the first responder's eyes the hint of a reprimand. Am I quietly putting them down for putting on the 02 or am I a bad medic for taking it off? The scene plays out over and over every day. Sometimes I have to tell them later that I know they are just following their protocols, but I need to assess the patient off the 02, and I don't mean against them when I take it off the patient.
But who ever came up with this idea of putting a nonrebreather on everybody, respiratory distress or not?
I got into a discussion once with one of my preceptees about their putting a nonrebreather on a patient who wasn't in respiratory distress. Why? I asked. because it will make them better, he answered. Because that's what we're taught. And besides oxygen can't hurt.
Yes, I've heard that before, but I've been hearing and reading other things as well. Here's the latest:
UCLA imaging study reveals how pure oxygen harms the brain
Now this is just one study (one of a growing number) and I'm certainly in no position to advocate not giving someone in respiratory distress or arrest high-flow oxygen, but can't someone authorize the first responders to ease up on it instead of telling them to continue putting high-flow oxygen on everyone.
Someone is making a lot of money selling oxygen and oxygen masks.
***
Here are some of the (conflicting?) things the American Heart Assosiation has to say about oxygen.
Oxygen by first responders:
There is insufficient evidence to recommend for or against the use of oxygen by a first aid provider (Class Indeterminate), and concern exists that oxygen administration may delay other interventions.
Oxygen by basic life support and advanced life support:
To improve oxygenation, health care providers should give 100% inspired oxygen (FiO2 + 1.0) during basic life support and advanced cardiovascular life support as soon as it becomes available
Oxygen for Asthma:
Provide oxygen to all patients with severe asthma, even those with normal oxygenation. Titrate to maintain SaO2 >92%.
Oxygen for stroke patients:
Both out-of-hospital and in-hospital medical personnel should administer supplementary oxygen to hypoxemic (ie, oxygen saturation <92%) stroke patients (Class I) or those with unknown oxygen saturation. Clinicians may consider giving oxygen to patients who are not hypoxemic (Class IIb).
Oxygen for people having chest pain:
EMS providers may administer oxygen to all patients. If the patient is hypoxemic, providers should titrate therapy based on monitoring of oxyhemoglobin saturation (Class I).
And more:
Administer oxygen to all patients with overt pulmonary congestion or arterial oxygen saturation <90% (Class I). It is also reasonable to administer supplementary oxygen to all patients with ACS for the first 6 hours of therapy (Class IIa). Supplementary oxygen limited ischemic myocardial injury in animals, and oxygen therapy in patients with STEMI reduced the amount of ST-segment elevation. Although a human trial of supplementary oxygen versus room air failed to show a long-term benefit of supplementary oxygen therapy for patients with MI, short-term oxygen administration is beneficial for the patient with unrecognized hypoxemia or unstable pulmonary function. In patients with severe chronic obstructive pulmonary disease, as with any other patient, monitor for hypoventilation.
Oxygen for Pediatric Basic Life Support:
Despite animal and theoretic data suggesting possible adverse effects of 100% oxygen,82–85 there are no studies comparing various concentrations of oxygen during resuscitation beyond the newborn period. Until additional information becomes available, healthcare providers should use 100% oxygen during resuscitation (Class Indeterminate). Once the patient is stable, wean supplementary oxygen but ensure adequate oxygen delivery by appropriate monitoring.
***
I was teaching a protocol rollout class the other day talking about how we are now doing things we thought were bad (morphine for abdominal pain) and no longer doing some things we thought were good (Hi-flow fluid recusitation in trauma). Who would have thought oxygen might be harming people?
Sometimes I see in the first responder's eyes the hint of a reprimand. Am I quietly putting them down for putting on the 02 or am I a bad medic for taking it off? The scene plays out over and over every day. Sometimes I have to tell them later that I know they are just following their protocols, but I need to assess the patient off the 02, and I don't mean against them when I take it off the patient.
But who ever came up with this idea of putting a nonrebreather on everybody, respiratory distress or not?
I got into a discussion once with one of my preceptees about their putting a nonrebreather on a patient who wasn't in respiratory distress. Why? I asked. because it will make them better, he answered. Because that's what we're taught. And besides oxygen can't hurt.
Yes, I've heard that before, but I've been hearing and reading other things as well. Here's the latest:
UCLA imaging study reveals how pure oxygen harms the brain
Now this is just one study (one of a growing number) and I'm certainly in no position to advocate not giving someone in respiratory distress or arrest high-flow oxygen, but can't someone authorize the first responders to ease up on it instead of telling them to continue putting high-flow oxygen on everyone.
Someone is making a lot of money selling oxygen and oxygen masks.
***
Here are some of the (conflicting?) things the American Heart Assosiation has to say about oxygen.
Oxygen by first responders:
There is insufficient evidence to recommend for or against the use of oxygen by a first aid provider (Class Indeterminate), and concern exists that oxygen administration may delay other interventions.
Oxygen by basic life support and advanced life support:
To improve oxygenation, health care providers should give 100% inspired oxygen (FiO2 + 1.0) during basic life support and advanced cardiovascular life support as soon as it becomes available
Oxygen for Asthma:
Provide oxygen to all patients with severe asthma, even those with normal oxygenation. Titrate to maintain SaO2 >92%.
Oxygen for stroke patients:
Both out-of-hospital and in-hospital medical personnel should administer supplementary oxygen to hypoxemic (ie, oxygen saturation <92%) stroke patients (Class I) or those with unknown oxygen saturation. Clinicians may consider giving oxygen to patients who are not hypoxemic (Class IIb).
Oxygen for people having chest pain:
EMS providers may administer oxygen to all patients. If the patient is hypoxemic, providers should titrate therapy based on monitoring of oxyhemoglobin saturation (Class I).
And more:
Administer oxygen to all patients with overt pulmonary congestion or arterial oxygen saturation <90% (Class I). It is also reasonable to administer supplementary oxygen to all patients with ACS for the first 6 hours of therapy (Class IIa). Supplementary oxygen limited ischemic myocardial injury in animals, and oxygen therapy in patients with STEMI reduced the amount of ST-segment elevation. Although a human trial of supplementary oxygen versus room air failed to show a long-term benefit of supplementary oxygen therapy for patients with MI, short-term oxygen administration is beneficial for the patient with unrecognized hypoxemia or unstable pulmonary function. In patients with severe chronic obstructive pulmonary disease, as with any other patient, monitor for hypoventilation.
Oxygen for Pediatric Basic Life Support:
Despite animal and theoretic data suggesting possible adverse effects of 100% oxygen,82–85 there are no studies comparing various concentrations of oxygen during resuscitation beyond the newborn period. Until additional information becomes available, healthcare providers should use 100% oxygen during resuscitation (Class Indeterminate). Once the patient is stable, wean supplementary oxygen but ensure adequate oxygen delivery by appropriate monitoring.
***
I was teaching a protocol rollout class the other day talking about how we are now doing things we thought were bad (morphine for abdominal pain) and no longer doing some things we thought were good (Hi-flow fluid recusitation in trauma). Who would have thought oxygen might be harming people?
Sunday, May 20, 2007
Good Folk
One of my EMS heroes is Thom Dick, the author of People Care, and a regular contributor to both JEMS and Emergency Medical Services. He has an interesting column in the April Jems called “Spring-Man: What are your jittery patients going to do next?” The gist of the article is to be quiet, to listen, and be nonadversarial. Don’t try to win an argument. He mentions a paramedic from Iowa who “believes that if you find yourself in a situation…and whatever you say feels good (or you wouldn’t say it in front of your mom), you’re probably out of line.”
Dick concludes, “When it’s your job to help people in crisis, the smartest mouth in the room is not necessarily an asset. What is useful is the knack of getting everybody home safe – time after time, and year after year. If that sounds like plain old work, it often is.”
I thought of his article yesterday – not in the context of dealing with psychs, but in dealing with people who seem to always push our buttons on calls. You work in the same town, you respond to many of the same places and run into many of the same people over and over. Most are nice, friendly, courteous and helpful. Then there are some who just always seem to get on your nerves. The senior coordinator who repeatedly tries to talk the person who tripped and scrapped their knee into going to the hospital even when it is clear they not only don’t want to go, they don’t need to go -- they just have a scrape and they don't hurt. The nurse who insists on taking phone calls while she writes up the W10 and won't give you a report until she is done chatting, the cop who won’t let you question the obviously injured patient until he is done getting his answers. Most of the time we suffer them in silence or quietly say what we need to do without hostility. Every once in awhile we say what we want to, and stir up a confrontation. We tell the bystander that the decision is the patient’s and that it won't be the bystander sitting in the ED waiting room for ten hours only to be told to go home because all they have is a scratch. We tell the nurse to quit the chit-chat, hang up the phone and tell us why we came lights and sirens. We tell the cop he can hobknob with the patient at the hospital, and then step in front of him.
One of our biggest nemeses is the chaplain at a local nursing home. He is a large round man who is sometimes the only person with the patient, and who seems to always be between us and the patient, gives inaccurate medical reports instead of getting the nurse for us, and tries to control the way we move the patient. Often it even seems he is forcing himself on the patients, many of whom seem to have little clue who the chaplain is. We’ve been on calls together for years and usually manage to get along after an early rough go. I don’t let him get in the way, but I always will allow him his chance to pray with the patient on the way out, even stopping the stretcher briefly if necessary.
Yesterday we arrived at the main building to which we were dispatched, only to find no security guard waiting for us. Instead, here came the chaplain waving his radio at us and castigating us for going to the wrong building. I told him this was the address we were sent to, and then I asked my partner to call our dispatcher back to verify the building, instead of, as I might have, allowing the chaplain his moment of helping to investigate where we were going. As my partner spoke on the radio, the radio squawk made it hard for the chaplain to speak and hear on his. The chaplain told us to hush, insisting “Quiet!” while he tried to raise security on his walkie-talkie. He even jabbed his finger at us. "One moment!”
The problem as often is the case at certain larger retirement communities is the 911 call comes in on the enhanced 911 with the address of the main office, and not the address of the actual apartment or room's location in the complex. Our dispatcher rectified it- providing a more accurate address, and we were on our way back out, past the chaplain who was still trying to raise security on his walkie-talkie, and out to our ambulance and then a short drive to the proper building. There security met us with a smile and asked about our encounter with the chaplain. The security guard shook his head and said the chaplain had complained about our attitudes. He said the chaplain was always getting in people’s ways, always stepping on others toes. We traded stories about him on the way down to the room.
Later that day we were called back to the facility for another respiratory distress. The security guard smiled at us and mentioned he had told the chaplain to stay out of our way. He joked he’d restrain the man for us if we requested it. While I watched as my preceptee assessed the patient and prepared with the rest of our crew to move her onto the stretcher, the guard stuck his head in the room and said the chaplain was coming down the hall. I found myself standing with my back to the door blocking it, thereby creating a situation where the chaplain would have to to ask me to move if he wished to enter the room. And briefly, it felt good. I imagined the chaplain standing in the hall being forced to think, well, I’ll have to say excuse me to that paramedic, and I don’t want to have to lower myself to do that. But standing there blocking the doorway, I felt not tall and broad, but fairly petty and foolish and I was relieved when the crew had a little difficulty lifting the woman out of her arm chair and I had to step forward to ease her over, leaving the doorway free for the chaplain to enter should he choose.
The chaplain was waiting in the hall when we came out. He didn’t smile or say hello nor did we. He just went right to the patient and put his hand on her forehead and blessed her and told her not to worry. I stopped the stretcher briefly so he could complete his prayer. He told the patient not to worry, and said that we were “good folk.” And then he stepped back and we continued on our way out to our ambulance.
Everyone has a job to do, and some of us at times need to prop our chests out to insist we are recognized. Both the chaplain and I like to be in charge. I think we are both well meaning people, although sometimes our egos may get in our way. I think the chaplain probably felt bad that the guard had told him to stay out of our way. The chaplain needed to come down to assert his authority, to do his job, and yet at the same time, he needed to apologize to us, to recognize us, as he did by calling us “good folk.” And we needed to do the same, by letting the chaplain in to do his job, by stopping our stretcher and letting him reassure the patient with his prayer.
We all have our flaws and one of the best ways to deal with our own is to allow other people theirs. There isn’t always a need to put someone else in their place, although it might feel good to do so. In the end it’s about getting the patient to the hospital, and doing what needs to be done without making anyone feel bad about it.
Dick concludes, “When it’s your job to help people in crisis, the smartest mouth in the room is not necessarily an asset. What is useful is the knack of getting everybody home safe – time after time, and year after year. If that sounds like plain old work, it often is.”
I thought of his article yesterday – not in the context of dealing with psychs, but in dealing with people who seem to always push our buttons on calls. You work in the same town, you respond to many of the same places and run into many of the same people over and over. Most are nice, friendly, courteous and helpful. Then there are some who just always seem to get on your nerves. The senior coordinator who repeatedly tries to talk the person who tripped and scrapped their knee into going to the hospital even when it is clear they not only don’t want to go, they don’t need to go -- they just have a scrape and they don't hurt. The nurse who insists on taking phone calls while she writes up the W10 and won't give you a report until she is done chatting, the cop who won’t let you question the obviously injured patient until he is done getting his answers. Most of the time we suffer them in silence or quietly say what we need to do without hostility. Every once in awhile we say what we want to, and stir up a confrontation. We tell the bystander that the decision is the patient’s and that it won't be the bystander sitting in the ED waiting room for ten hours only to be told to go home because all they have is a scratch. We tell the nurse to quit the chit-chat, hang up the phone and tell us why we came lights and sirens. We tell the cop he can hobknob with the patient at the hospital, and then step in front of him.
One of our biggest nemeses is the chaplain at a local nursing home. He is a large round man who is sometimes the only person with the patient, and who seems to always be between us and the patient, gives inaccurate medical reports instead of getting the nurse for us, and tries to control the way we move the patient. Often it even seems he is forcing himself on the patients, many of whom seem to have little clue who the chaplain is. We’ve been on calls together for years and usually manage to get along after an early rough go. I don’t let him get in the way, but I always will allow him his chance to pray with the patient on the way out, even stopping the stretcher briefly if necessary.
Yesterday we arrived at the main building to which we were dispatched, only to find no security guard waiting for us. Instead, here came the chaplain waving his radio at us and castigating us for going to the wrong building. I told him this was the address we were sent to, and then I asked my partner to call our dispatcher back to verify the building, instead of, as I might have, allowing the chaplain his moment of helping to investigate where we were going. As my partner spoke on the radio, the radio squawk made it hard for the chaplain to speak and hear on his. The chaplain told us to hush, insisting “Quiet!” while he tried to raise security on his walkie-talkie. He even jabbed his finger at us. "One moment!”
The problem as often is the case at certain larger retirement communities is the 911 call comes in on the enhanced 911 with the address of the main office, and not the address of the actual apartment or room's location in the complex. Our dispatcher rectified it- providing a more accurate address, and we were on our way back out, past the chaplain who was still trying to raise security on his walkie-talkie, and out to our ambulance and then a short drive to the proper building. There security met us with a smile and asked about our encounter with the chaplain. The security guard shook his head and said the chaplain had complained about our attitudes. He said the chaplain was always getting in people’s ways, always stepping on others toes. We traded stories about him on the way down to the room.
Later that day we were called back to the facility for another respiratory distress. The security guard smiled at us and mentioned he had told the chaplain to stay out of our way. He joked he’d restrain the man for us if we requested it. While I watched as my preceptee assessed the patient and prepared with the rest of our crew to move her onto the stretcher, the guard stuck his head in the room and said the chaplain was coming down the hall. I found myself standing with my back to the door blocking it, thereby creating a situation where the chaplain would have to to ask me to move if he wished to enter the room. And briefly, it felt good. I imagined the chaplain standing in the hall being forced to think, well, I’ll have to say excuse me to that paramedic, and I don’t want to have to lower myself to do that. But standing there blocking the doorway, I felt not tall and broad, but fairly petty and foolish and I was relieved when the crew had a little difficulty lifting the woman out of her arm chair and I had to step forward to ease her over, leaving the doorway free for the chaplain to enter should he choose.
The chaplain was waiting in the hall when we came out. He didn’t smile or say hello nor did we. He just went right to the patient and put his hand on her forehead and blessed her and told her not to worry. I stopped the stretcher briefly so he could complete his prayer. He told the patient not to worry, and said that we were “good folk.” And then he stepped back and we continued on our way out to our ambulance.
Everyone has a job to do, and some of us at times need to prop our chests out to insist we are recognized. Both the chaplain and I like to be in charge. I think we are both well meaning people, although sometimes our egos may get in our way. I think the chaplain probably felt bad that the guard had told him to stay out of our way. The chaplain needed to come down to assert his authority, to do his job, and yet at the same time, he needed to apologize to us, to recognize us, as he did by calling us “good folk.” And we needed to do the same, by letting the chaplain in to do his job, by stopping our stretcher and letting him reassure the patient with his prayer.
We all have our flaws and one of the best ways to deal with our own is to allow other people theirs. There isn’t always a need to put someone else in their place, although it might feel good to do so. In the end it’s about getting the patient to the hospital, and doing what needs to be done without making anyone feel bad about it.
Thursday, May 17, 2007
Richter Scale
Precepting has been going well. My preceptee has a knack for us getting calls – no cardiac arrests yet, but a steady diet of low grade ALS calls – chest pains, COPD, hypoglycemia, broken hips, pneumonias, syncopes. For the most part, I just sit back and watch her. I might draw up a saline lock or put the electrodes on the monitor leads, or take a blood pressure for her, but it’s her show. She’ll lay out her course of treatment and I’ll nod. Sounds good.
Earlier this week we had one of our better calls. It came in as a nursing home pass from the commercial service for a man who had a high blood sugar. The nurse met us at the door and said the man had a sugar of 500, was agitated and just needed some insulin. And why wasn’t he getting it? He wasn’t on insulin, but the nurse thought the doctor should just order some units for them to give the patient so they wouldn’t need to bother us. The other nurse, she said, wanted to send him out.
The patient, normally verbal, was very restless in bed, moving from side to side of the bed, unable to focus or answer questions. We got him moved over onto the stretcher and then out to our ambulance. I stayed and waited for the nursing supervisor to finish the paperwork. I asked for the med sheet, but the nurse said the man, who had a history of HTN and NIDDM, oddly wasn’t on anything. I asked how long the patient had been restless and she said it started an hour earlier when the patient was found on the floor incontinent of stool and urine. That didn’t sound like hyperglycemia, it sounded more like a seizure. I noticed on the paperwork the patient was a DNR, so I asked for a copy of that official paperwork as well, which the nurse reluctantly dug out for me.
Out in the ambulance, as my preceptee sunk an IV in the patient’s forearm, I relayed the new information, which was different from what my preceptee had gotten from the other nurse. We put an ETCO2 cannula on the patient, but he kept grabbing at it with his left hand and yanking it off. We held his arm down long enough to get a reading – 35 – normal. There was no Kussmal breathing, no fruity acetone smell to his breath. Our blood sugar came up HI, which means greater than 500. We switched the ETCO2 cannula to a regular nasal cannula thinking the mouth piece was what was bothering him. He reached again and yanked it out of his nose. I was sitting in the right hand seat, and noticed that the patient kept looking at my preceptee on the left bench, but I couldn’t get him to turn and look at me. It was apparent there was something neurological going on. When my preceptee held down his left hand, the patient reached with the right hand to try to yank the cannula out, but he kept hitting his nose and eyes. By now we were going lights and sirens to the hospital, and calling in a possible stroke alert.
To stop him from hitting himself, I held his right arm down. If I was alone in the back I would have been busy doing the 12 lead or making the radio patch, but I was able to just sit there and watch the patient. I felt a little tremor in the patient’s arm. “Get the Ativan,” I said. I felt like a technician watching a Richter Scale needle start to go crazy as the tremor gained in intensity. Run for the hills! The big ones coming! The seizure now apparent to the eye progressed in intensity until it was rocking the stretcher full blown. We were in the parking lot of the ED now. We managed to get the ETCO2 back on the patient and while it showed he continued to breath during the early part of his seizure, his ETCO2 was rising steadily all the way up to 69, by which time we had the ambu bag out and were trying to ventilate him in between suctioning him as secretions frothed from his mouth. The Ativan took effect and the seizure broke finally. He began to breathe effectively on his own again and his ETCO2 came back to normal.
I’ll be curious to get the full follow up on the patient. It was a great precepting call, and I was glad to see my preceptee managed to keep her calm through the surprises the call offered.
Earlier this week we had one of our better calls. It came in as a nursing home pass from the commercial service for a man who had a high blood sugar. The nurse met us at the door and said the man had a sugar of 500, was agitated and just needed some insulin. And why wasn’t he getting it? He wasn’t on insulin, but the nurse thought the doctor should just order some units for them to give the patient so they wouldn’t need to bother us. The other nurse, she said, wanted to send him out.
The patient, normally verbal, was very restless in bed, moving from side to side of the bed, unable to focus or answer questions. We got him moved over onto the stretcher and then out to our ambulance. I stayed and waited for the nursing supervisor to finish the paperwork. I asked for the med sheet, but the nurse said the man, who had a history of HTN and NIDDM, oddly wasn’t on anything. I asked how long the patient had been restless and she said it started an hour earlier when the patient was found on the floor incontinent of stool and urine. That didn’t sound like hyperglycemia, it sounded more like a seizure. I noticed on the paperwork the patient was a DNR, so I asked for a copy of that official paperwork as well, which the nurse reluctantly dug out for me.
Out in the ambulance, as my preceptee sunk an IV in the patient’s forearm, I relayed the new information, which was different from what my preceptee had gotten from the other nurse. We put an ETCO2 cannula on the patient, but he kept grabbing at it with his left hand and yanking it off. We held his arm down long enough to get a reading – 35 – normal. There was no Kussmal breathing, no fruity acetone smell to his breath. Our blood sugar came up HI, which means greater than 500. We switched the ETCO2 cannula to a regular nasal cannula thinking the mouth piece was what was bothering him. He reached again and yanked it out of his nose. I was sitting in the right hand seat, and noticed that the patient kept looking at my preceptee on the left bench, but I couldn’t get him to turn and look at me. It was apparent there was something neurological going on. When my preceptee held down his left hand, the patient reached with the right hand to try to yank the cannula out, but he kept hitting his nose and eyes. By now we were going lights and sirens to the hospital, and calling in a possible stroke alert.
To stop him from hitting himself, I held his right arm down. If I was alone in the back I would have been busy doing the 12 lead or making the radio patch, but I was able to just sit there and watch the patient. I felt a little tremor in the patient’s arm. “Get the Ativan,” I said. I felt like a technician watching a Richter Scale needle start to go crazy as the tremor gained in intensity. Run for the hills! The big ones coming! The seizure now apparent to the eye progressed in intensity until it was rocking the stretcher full blown. We were in the parking lot of the ED now. We managed to get the ETCO2 back on the patient and while it showed he continued to breath during the early part of his seizure, his ETCO2 was rising steadily all the way up to 69, by which time we had the ambu bag out and were trying to ventilate him in between suctioning him as secretions frothed from his mouth. The Ativan took effect and the seizure broke finally. He began to breathe effectively on his own again and his ETCO2 came back to normal.
I’ll be curious to get the full follow up on the patient. It was a great precepting call, and I was glad to see my preceptee managed to keep her calm through the surprises the call offered.
Monday, May 14, 2007
CPAP
This morning we had a call for a 70 year old man with dsypnea and found him guppy-breathing with a BP of 210/100, HR - 144, skin ice cool and clammy, unable to get a SAT, ETCO2 of 50, RR of 32. Wheezes and crackles in lungs. Upright CO2 wave form.
He was sitting on his front steps, probably hoping the fresh air would help, but it wasn't. We threw him on the stretcher and got him in the back of the ambulance quick.
We put him on CPAP -- first time for me (we've only had it a couple weeks) -- and started pounding in the nitros and in no time he was warm and dry. RR down to 24, ETCO2 down to 34. HR down to 132. He was still full of fluid, but at least we weren't having to intubate him. Niether did the hospital. They put him on bi-pap and a nitro drip. His PH was 7.25 on arrival. The doctor said he probably would have coded if we hadn't gotten there and started treating him as soon as we did.
I was trying to imagine how the call would have gone if we didn't have CPAP. The nonrebreather wouldn't have helped much. We had it on for about a minute before we got the CPAP out and he was tearing it off gasping that he couldn't breathe. We would have had to start bagging him and maybe dropped a tube. Much more invasive than putting the CPAP on.
I saw him later in the hospital and they had him down to a Venturi mask and he was sleeping comfortably.
I made sure to thank our medical control doctor and clinical coordinator for helping us get CPAP. It certainly made a big difference -- just as advertised.
Here's an article from JEMS about the type of CPAP (Boussignac) we have.
Hands On: 10 cm of CPAP In a 10-oz. Package
He was sitting on his front steps, probably hoping the fresh air would help, but it wasn't. We threw him on the stretcher and got him in the back of the ambulance quick.
We put him on CPAP -- first time for me (we've only had it a couple weeks) -- and started pounding in the nitros and in no time he was warm and dry. RR down to 24, ETCO2 down to 34. HR down to 132. He was still full of fluid, but at least we weren't having to intubate him. Niether did the hospital. They put him on bi-pap and a nitro drip. His PH was 7.25 on arrival. The doctor said he probably would have coded if we hadn't gotten there and started treating him as soon as we did.
I was trying to imagine how the call would have gone if we didn't have CPAP. The nonrebreather wouldn't have helped much. We had it on for about a minute before we got the CPAP out and he was tearing it off gasping that he couldn't breathe. We would have had to start bagging him and maybe dropped a tube. Much more invasive than putting the CPAP on.
I saw him later in the hospital and they had him down to a Venturi mask and he was sleeping comfortably.
I made sure to thank our medical control doctor and clinical coordinator for helping us get CPAP. It certainly made a big difference -- just as advertised.
Here's an article from JEMS about the type of CPAP (Boussignac) we have.
Hands On: 10 cm of CPAP In a 10-oz. Package
Sunday, May 13, 2007
A Tip
Instead of writing about one of my calls - I haven't had much to write about lately -- I'm going to write about a call a medic I know did a few weeks ago. In addition to being a good story, it is instructive.
The call comes in as a syncope. A basic crew responds along with the first responders. They find a fifty-year old woman who passed out while running on the treadmill. She has no medical history. She insists she is in good shape and refuses transport. Her vitals are BP 118/70, P-64, RR-18. A medic has been drifiting toward the location in case the basic crew needs ALS. The dispatcher checks with the basic crew, who relays what the first responders told them -- that the patient is refusing so they won't need the medic.
The medic, even though she has been told she is not needed, goes anyway (keeping herself available) -- call it a sixth sense or whatever. She finds a woman who is pale and clammy, whose skin the medic says feels like a cold fish. The woman repeats she has no medical problems. No history, no meds, not even an allergy. But the medic will not take no for an answer. The patient finally agrees to let the medic do a 12-Lead ECG.
Even with the poor quality of the copy, you can see the tombstone ST segments in the inferior leads -- the hallmark of an acute life-threatening heart attack.
Can we say on our way to the hospital? The medic gives the patient some aspirin and due to the possible right-sided MI, withholds nitro.
The hospital, notified over the radio by the medic, is getting the cath lab ready.
The medic drops the patient off, and then goes to write her paperwork. A few minutes later, her partner comes into the EMS room and tells her the woman just coded. The medic goes back down to check and sees the MD shocking the patient. The patient's eyes open suddenly, she sits up, sees the medic and says "You again? What you've come back for a tip?"
Even the medic is speechless.
The patient then apologizes for going to sleep. The doctor has to explain that they were actually doing CPR on her, and they need to get her up to the cath lab right now.
***
You can talk all you want about medics with great intubation or IV skills, medics who get blood pressures back from dead people in arrest, but this medic saved this woman's life simply by deciding to go on in and check her out. She knew that syncope is not something to trifle with and then seeing the woman, and knowing that a workout isn't going to leave a healthy person that cold and clammy, refused to settle for a refusal.
The woman is lucky to be alive and people of her fair city are lucky to have a great paramedic riding their streets.
Well done.
The call comes in as a syncope. A basic crew responds along with the first responders. They find a fifty-year old woman who passed out while running on the treadmill. She has no medical history. She insists she is in good shape and refuses transport. Her vitals are BP 118/70, P-64, RR-18. A medic has been drifiting toward the location in case the basic crew needs ALS. The dispatcher checks with the basic crew, who relays what the first responders told them -- that the patient is refusing so they won't need the medic.
The medic, even though she has been told she is not needed, goes anyway (keeping herself available) -- call it a sixth sense or whatever. She finds a woman who is pale and clammy, whose skin the medic says feels like a cold fish. The woman repeats she has no medical problems. No history, no meds, not even an allergy. But the medic will not take no for an answer. The patient finally agrees to let the medic do a 12-Lead ECG.
Even with the poor quality of the copy, you can see the tombstone ST segments in the inferior leads -- the hallmark of an acute life-threatening heart attack.
Can we say on our way to the hospital? The medic gives the patient some aspirin and due to the possible right-sided MI, withholds nitro.
The hospital, notified over the radio by the medic, is getting the cath lab ready.
The medic drops the patient off, and then goes to write her paperwork. A few minutes later, her partner comes into the EMS room and tells her the woman just coded. The medic goes back down to check and sees the MD shocking the patient. The patient's eyes open suddenly, she sits up, sees the medic and says "You again? What you've come back for a tip?"
Even the medic is speechless.
The patient then apologizes for going to sleep. The doctor has to explain that they were actually doing CPR on her, and they need to get her up to the cath lab right now.
***
You can talk all you want about medics with great intubation or IV skills, medics who get blood pressures back from dead people in arrest, but this medic saved this woman's life simply by deciding to go on in and check her out. She knew that syncope is not something to trifle with and then seeing the woman, and knowing that a workout isn't going to leave a healthy person that cold and clammy, refused to settle for a refusal.
The woman is lucky to be alive and people of her fair city are lucky to have a great paramedic riding their streets.
Well done.
Miscellaneous
I like it when my preceptee beats me to work. It shows good work ethic. And I'm almost always 15 minutes early.
***
There is a pro and con article in one of this month's emergency medical services magazines about cell phone use on the job. I hate it when my partner's phone goes off while we are assessing a patient and he answers it and says, "I'll have to call you back." I had a preceptee once who carried his cell phone on his belt and he had these ring tones that helped him identify who was calling. Right in the middle of a call, he gets a call, and he answers it and I'm thinking I am going to chew him a giant hole when we are done with this. Well, it turns out it was a family emergency and he had to go and I could hardly say anything considering the news.
I also hate it when a partner is driving lights and sirens and talking on his cell phone. Not cool.
I have a cell phone now -- I'm probably the last person to get one in EMS. I admit it is very handy. I don't have to beg anyone to borrow their phone. If a shift is paged out, I don't have to wait until I get to the hospital to try to call in to get it. I admit I have answered it on calls -- when I am transporting a transfer and my patient care is done. I usually just say I'm on a call, I'll call you back. It raises the question if the non-emergency patient has dementia is it okay to yap on your cell phone during the transport. Probably not from an ethical standpoint.
I have lent my cellphone to accident victims on several occasions so they could call family members to let them know they had been in an accident. Hell, its only 10 cents a minute and they are thankful.
***
Our new regional protocols are finally approved. We are set to start using them now at the one service I work for because we have all been trained in them. In the city, we will have to wait until July 1. I can't wait to use them. Because I worked on them I feel a special pride every time I get to do something new. Wow, I raised this one up to the group and everyone went for it, and now it is making a difference. Or, hey I used to have to call the doc and now I can just go ahead and do it.
We also have CPAP and LMAs now, but I haven't gotten a chance to use either.
***
A number of weeks ago I wrote about missing a step when I was carrying a guy backwards out of a house. I have been having periodic knee pain when I go down stairs. I can run five miles pain free, or charge up the stairs of a third floor walk up no problem, but when I walk down from the third floor too quickly, I really feel it. I think I may have stretched a ligament or something. I found myself thinking what if I can't climb stairs, then I'm done for. I told my partner this will be a good day if I don't have to walk down any stairs. Last call of the day was to a motel for an overdose. Two sets of stairs. It turned out to be a refusal. I walked down the stairs with baby steps. No pain.
***
A couple weeks ago I gave morphine to a large young woman who turned her ankle. The triage nurse mentioned she had a history of drug seeking. Well, she's a drug seeker with a busted ankle, I said. I mentioned the case to a nurse at the other hospital in town and she knew the patient's name and knew her as a drug seeker. She said she was always falling and complaining of ankle pain. Either that or having a really bad toothache. The nurse called me up yesterday and said, guess who's here with ankle pain, claiming she fell and turned it?
I wonder if her ankle always look deformed.
I'm looking forward to responding to "the fall with ankle pain" and finding our friend sitting on the ground holding her ankle.
***
I read an article the other day about an economist who claimed that plumbers were better paid than physicians. He came up with that by comparing all the years a doctor had to go to school and the cost of education and low pay as a resident and then all the costs of malpractice and setting up a practice. I told the wife of a resident how much money I made a couple years ago and she couldn't believe it. They had so much debt and her husband's salary was still minimal. He should have been a medic she said. (So what if when he finally has his loans paid off and has the dough to drive a Lexus, I'll be eating cat food.)
I'm not saying medics are overpaid, but I don't have a lot of costs. I don't have to buy business suits or dine at fancy restaurants or go to charity balls. I wear my uniform at work and blue jeans off work. Some people work all day and hope to get a half hour of reading before bed. I read books on the job all the time. Sometimes I bring my bike to work and ride around the industrial complex where our base is located, doing .7 mile loops. If we get a call, by the time my partner has pulled the ambulance out, I am zipping into the garage. Other days I work out with dumbbells. There are some advantages to this job. Not that I would ever oppose a hefty raise.
***
I'm glad its Spring.
***
There is a pro and con article in one of this month's emergency medical services magazines about cell phone use on the job. I hate it when my partner's phone goes off while we are assessing a patient and he answers it and says, "I'll have to call you back." I had a preceptee once who carried his cell phone on his belt and he had these ring tones that helped him identify who was calling. Right in the middle of a call, he gets a call, and he answers it and I'm thinking I am going to chew him a giant hole when we are done with this. Well, it turns out it was a family emergency and he had to go and I could hardly say anything considering the news.
I also hate it when a partner is driving lights and sirens and talking on his cell phone. Not cool.
I have a cell phone now -- I'm probably the last person to get one in EMS. I admit it is very handy. I don't have to beg anyone to borrow their phone. If a shift is paged out, I don't have to wait until I get to the hospital to try to call in to get it. I admit I have answered it on calls -- when I am transporting a transfer and my patient care is done. I usually just say I'm on a call, I'll call you back. It raises the question if the non-emergency patient has dementia is it okay to yap on your cell phone during the transport. Probably not from an ethical standpoint.
I have lent my cellphone to accident victims on several occasions so they could call family members to let them know they had been in an accident. Hell, its only 10 cents a minute and they are thankful.
***
Our new regional protocols are finally approved. We are set to start using them now at the one service I work for because we have all been trained in them. In the city, we will have to wait until July 1. I can't wait to use them. Because I worked on them I feel a special pride every time I get to do something new. Wow, I raised this one up to the group and everyone went for it, and now it is making a difference. Or, hey I used to have to call the doc and now I can just go ahead and do it.
We also have CPAP and LMAs now, but I haven't gotten a chance to use either.
***
A number of weeks ago I wrote about missing a step when I was carrying a guy backwards out of a house. I have been having periodic knee pain when I go down stairs. I can run five miles pain free, or charge up the stairs of a third floor walk up no problem, but when I walk down from the third floor too quickly, I really feel it. I think I may have stretched a ligament or something. I found myself thinking what if I can't climb stairs, then I'm done for. I told my partner this will be a good day if I don't have to walk down any stairs. Last call of the day was to a motel for an overdose. Two sets of stairs. It turned out to be a refusal. I walked down the stairs with baby steps. No pain.
***
A couple weeks ago I gave morphine to a large young woman who turned her ankle. The triage nurse mentioned she had a history of drug seeking. Well, she's a drug seeker with a busted ankle, I said. I mentioned the case to a nurse at the other hospital in town and she knew the patient's name and knew her as a drug seeker. She said she was always falling and complaining of ankle pain. Either that or having a really bad toothache. The nurse called me up yesterday and said, guess who's here with ankle pain, claiming she fell and turned it?
I wonder if her ankle always look deformed.
I'm looking forward to responding to "the fall with ankle pain" and finding our friend sitting on the ground holding her ankle.
***
I read an article the other day about an economist who claimed that plumbers were better paid than physicians. He came up with that by comparing all the years a doctor had to go to school and the cost of education and low pay as a resident and then all the costs of malpractice and setting up a practice. I told the wife of a resident how much money I made a couple years ago and she couldn't believe it. They had so much debt and her husband's salary was still minimal. He should have been a medic she said. (So what if when he finally has his loans paid off and has the dough to drive a Lexus, I'll be eating cat food.)
I'm not saying medics are overpaid, but I don't have a lot of costs. I don't have to buy business suits or dine at fancy restaurants or go to charity balls. I wear my uniform at work and blue jeans off work. Some people work all day and hope to get a half hour of reading before bed. I read books on the job all the time. Sometimes I bring my bike to work and ride around the industrial complex where our base is located, doing .7 mile loops. If we get a call, by the time my partner has pulled the ambulance out, I am zipping into the garage. Other days I work out with dumbbells. There are some advantages to this job. Not that I would ever oppose a hefty raise.
***
I'm glad its Spring.
Monday, May 07, 2007
Conversations
One of the best parts of this job is the conversations you can have with your patients, but not yesterday. Every patient I had yesterday had dementia or was incapable of coherent verbal speech.
An old lady from a nursing home trips on a curb at the supermarket. Her friend says she is more disoriented than normal. “Who are you?” the patient says to me. “What happened? My head hurts. Where am I?”
I explain. “I’m Peter. I’m a paramedic. It looks like you tripped and hit your head. You’re at the supermarket.”
“How did I get here?” she says. She looks at me like she has never seen me before this instant. “Who are you?”
I explain again, and again. We go through the same conversation about ten times en route to the hospital.
“I’m Peter. I’m a paramedic. You tripped and fell. I’m taking you to the hospital.”
“What happened?”
At the hospital, they CAT scan her and it is negative. She waits in the hallway for an ambulance to come take her home. I say hello when I come in with another patient. “Do I know you?” she asks.
The patient I am bringing is has Alzheimer's’s dementia. The nursing home staff thinks she is having slight mental status changes. She babbles incoherently, her sounds more like those of an infant than formed words.
We do a 12 year old with MR and cerebral palsy who had a seizure and is only capable of grunting.
We finish the day with another Alzheimer’s patient who fell and screams her hip hurts. “Who are you?” she keeps demanding of me. She won’t let me touch her without screaming. “My hip hurts. My right hip. Don’t touch me. Who are you?”
“I’m Peter. I’m a paramedic here to help you?”
“Don’t touch me, my hip hurts? How did I get here? Who are you? Why won’t this man introduce himself?"
“I’m Peter,” I say. “I’m the paramedic who comes to help people who have fallen and have pain in their right hip.”
“Oh, really,” she says. “Who is he?” She points to my partner.
“He’s the left hip guy.”
“Well, neither of you touch me. My hip hurts.”
Her diagnosis reads “labile, psychotic, aggressive, hypermanic dementia.” She is on a Lorazepam/Diphenhydramine/Haloperidol topical gel every 6 hours.
I ask her to tell me how much pain she is in on a 1-10 scale.
“Pain, I’ll tell you about pain,” she says. “But why should I talk to you. I don’t even know who you are.”
A relative shows up and this gets her going all over again. “My hip hurts. I don’t know who these people are. Why don’t they just let me get up.”
I give her some morphine, but she still makes quite a commotion when we finally move her.
In the ambulance, the words continue, “Who are you? This isn’t good. I don’t feel well. Let me out of here. I don’t know you. Let me out of here right now.”
I give her some phenergan in case the “I don’t feel well” is her code for she’s feeling nauseous from the morphine.
“Labile, psychotic, aggressive, hypermanic dementia,” the triage nurse reads from the W10 I show her. She looks over at the patient, who is dead asleep on our stretcher, with her mouth wide open.
"A real chatterbox," she says.
An old lady from a nursing home trips on a curb at the supermarket. Her friend says she is more disoriented than normal. “Who are you?” the patient says to me. “What happened? My head hurts. Where am I?”
I explain. “I’m Peter. I’m a paramedic. It looks like you tripped and hit your head. You’re at the supermarket.”
“How did I get here?” she says. She looks at me like she has never seen me before this instant. “Who are you?”
I explain again, and again. We go through the same conversation about ten times en route to the hospital.
“I’m Peter. I’m a paramedic. You tripped and fell. I’m taking you to the hospital.”
“What happened?”
At the hospital, they CAT scan her and it is negative. She waits in the hallway for an ambulance to come take her home. I say hello when I come in with another patient. “Do I know you?” she asks.
The patient I am bringing is has Alzheimer's’s dementia. The nursing home staff thinks she is having slight mental status changes. She babbles incoherently, her sounds more like those of an infant than formed words.
We do a 12 year old with MR and cerebral palsy who had a seizure and is only capable of grunting.
We finish the day with another Alzheimer’s patient who fell and screams her hip hurts. “Who are you?” she keeps demanding of me. She won’t let me touch her without screaming. “My hip hurts. My right hip. Don’t touch me. Who are you?”
“I’m Peter. I’m a paramedic here to help you?”
“Don’t touch me, my hip hurts? How did I get here? Who are you? Why won’t this man introduce himself?"
“I’m Peter,” I say. “I’m the paramedic who comes to help people who have fallen and have pain in their right hip.”
“Oh, really,” she says. “Who is he?” She points to my partner.
“He’s the left hip guy.”
“Well, neither of you touch me. My hip hurts.”
Her diagnosis reads “labile, psychotic, aggressive, hypermanic dementia.” She is on a Lorazepam/Diphenhydramine/Haloperidol topical gel every 6 hours.
I ask her to tell me how much pain she is in on a 1-10 scale.
“Pain, I’ll tell you about pain,” she says. “But why should I talk to you. I don’t even know who you are.”
A relative shows up and this gets her going all over again. “My hip hurts. I don’t know who these people are. Why don’t they just let me get up.”
I give her some morphine, but she still makes quite a commotion when we finally move her.
In the ambulance, the words continue, “Who are you? This isn’t good. I don’t feel well. Let me out of here. I don’t know you. Let me out of here right now.”
I give her some phenergan in case the “I don’t feel well” is her code for she’s feeling nauseous from the morphine.
“Labile, psychotic, aggressive, hypermanic dementia,” the triage nurse reads from the W10 I show her. She looks over at the patient, who is dead asleep on our stretcher, with her mouth wide open.
"A real chatterbox," she says.
Tuesday, May 01, 2007
Pain Control
My new preceptee is doing great. On most calls I am a complete invisible man, just sitting back and watching her work. If I offer anything, it is usually just a small trick of the trade. Since she is only part-time, we only work together a couple times a week so I am still doing plenty of calls myself on her off days.
We gave morphine the other day to a lady with back pain, which until the new protocols come out in another month, still requires medical control. I told her how to ask for it(ask for an initial amount and then further doses based on response), and she gave such a good radio patch, the med control doctor said, "yeah, go ahead, give her whatever you said and how you said it." It was an amazingly precise patch that went something like this "I'd like to give her 0.05 mg/kg, which for her is 5 milligrams slow iv push to start over 4-5 minutes, followed in ten minutes, by an additional 2 mg q 5 minutes titrated to pain, provided her pressure, respirations and ventilations remain within normal limits to a total dose max of 0.15 mg/kg if necessary."
I was as impressed as the doctor was.
Today working by myself I called in for permission to give morphine to a 40 kg 102 year old woman who was fully alert and functional but had back pain that she rated as an 8-10. I asked for 2 mg to start followed by an additional 2 mg if her pain persisted and her vitals remained normal. I only got orders for the initial 2 mg and was told to call back if I still wanted more. I was a little annoyed with this doctor, who usually always approves my requests. The 2 mg hardly touched her, but when I tried to call back (after ten minutes -- her pain was 7-8), I couldn't get through because the radio operators were tied up on 911 calls. She was still in pain when we got to the hospital and when I got the signature from the doctor on my narc sheet, I mentioned the 2 mg hadn't helped much, and that I had tried to call for the other 2 mg but couldn't get through. He grunted as he signed. I thanked him without judgement. I hope I didn't come off as disrespectful. I know he was thinking -- 102 years old, 40 kg, I don't want her to go into respiratory arrest, but I was thinking -- she's 102 years old and she shouldn't be in pain and I ought to have some judgement allowed here. I'm not going to give her the second dose if she is getting obtunded. Later I talked with another doctor -- the one who took care of her and he said she had a compression fracture, but the 2 mg of morphine I had given her chilled her out nicely so he didn't give her any more.
There is a certain dilemma here with prehospital morphine. You want to give them enough to take away their pain, but not so much that you completely zone them out at the ED. The problem is the transport can be rough on the patient as compared to the stillness of the more comfortable ED beds. The 102 year old was in pain during the transport and only after laying in a quiet comfortable ED bed for awhile did she start to chill out.
Later in the day, we got a call for an 80 year old lady who had dislocated her hip. When I came in the door, the family recognized me and I could see some relief in their eyes that I was there. "Oh, I'm glad it's you," the daughter said. That's about as nice a compliment as you can get. Sometimes I get tired of doing so many old people calls in my town, but one of the benefits is I really get to know the patients and their families because so many of them are repeat customers. This is the fourth time (over a period of years) I have been to this lady's house because her hip keeps popping out. I have the routine down. After getting her vitals and doing a full survey, I give her 5 mg of MS SQ, which I have found is a much gentler way to start getting the drug. I then get an IV (I usually end up with a 24 in a tiny arm vein because that's all I can find on her) and after ten minutes or so, I give her another 3 mg SIVP. We then wait another five minutes or so until she is good and relaxed, and then we gently get her on a scoop stretcher and pad her up before we carry her out to the ambulance. My partner drives nice and slow. By the time we get to the ED, her eyes are closed and her pain is down from the initial 10 to maybe a 1 or 2. What's nice about our protocols for extremity injury (including hip) is for the most part we are given the leeway to give the amount necessary to take care of a patient's pain. Soon our protocols will be expanded to include back and spine pain, as well as sickle cell crisis on standing order. In addition we will be able to give up to 0.15 mg/kg up to a 15mg max, where now we can only give a max of 10 before calling.
If my preceptee learns one thing from me, I want it to be to treat a patient's pain. Not just with morphine, but with lots of pillows and allowing time for the drug to work before moving the patient. And to not be afraid to call medical control back and ask for more if the patient needs it. Sometimes they will turn you down (you can't take it personally), and at least you advocated for your patient.
We gave morphine the other day to a lady with back pain, which until the new protocols come out in another month, still requires medical control. I told her how to ask for it(ask for an initial amount and then further doses based on response), and she gave such a good radio patch, the med control doctor said, "yeah, go ahead, give her whatever you said and how you said it." It was an amazingly precise patch that went something like this "I'd like to give her 0.05 mg/kg, which for her is 5 milligrams slow iv push to start over 4-5 minutes, followed in ten minutes, by an additional 2 mg q 5 minutes titrated to pain, provided her pressure, respirations and ventilations remain within normal limits to a total dose max of 0.15 mg/kg if necessary."
I was as impressed as the doctor was.
Today working by myself I called in for permission to give morphine to a 40 kg 102 year old woman who was fully alert and functional but had back pain that she rated as an 8-10. I asked for 2 mg to start followed by an additional 2 mg if her pain persisted and her vitals remained normal. I only got orders for the initial 2 mg and was told to call back if I still wanted more. I was a little annoyed with this doctor, who usually always approves my requests. The 2 mg hardly touched her, but when I tried to call back (after ten minutes -- her pain was 7-8), I couldn't get through because the radio operators were tied up on 911 calls. She was still in pain when we got to the hospital and when I got the signature from the doctor on my narc sheet, I mentioned the 2 mg hadn't helped much, and that I had tried to call for the other 2 mg but couldn't get through. He grunted as he signed. I thanked him without judgement. I hope I didn't come off as disrespectful. I know he was thinking -- 102 years old, 40 kg, I don't want her to go into respiratory arrest, but I was thinking -- she's 102 years old and she shouldn't be in pain and I ought to have some judgement allowed here. I'm not going to give her the second dose if she is getting obtunded. Later I talked with another doctor -- the one who took care of her and he said she had a compression fracture, but the 2 mg of morphine I had given her chilled her out nicely so he didn't give her any more.
There is a certain dilemma here with prehospital morphine. You want to give them enough to take away their pain, but not so much that you completely zone them out at the ED. The problem is the transport can be rough on the patient as compared to the stillness of the more comfortable ED beds. The 102 year old was in pain during the transport and only after laying in a quiet comfortable ED bed for awhile did she start to chill out.
Later in the day, we got a call for an 80 year old lady who had dislocated her hip. When I came in the door, the family recognized me and I could see some relief in their eyes that I was there. "Oh, I'm glad it's you," the daughter said. That's about as nice a compliment as you can get. Sometimes I get tired of doing so many old people calls in my town, but one of the benefits is I really get to know the patients and their families because so many of them are repeat customers. This is the fourth time (over a period of years) I have been to this lady's house because her hip keeps popping out. I have the routine down. After getting her vitals and doing a full survey, I give her 5 mg of MS SQ, which I have found is a much gentler way to start getting the drug. I then get an IV (I usually end up with a 24 in a tiny arm vein because that's all I can find on her) and after ten minutes or so, I give her another 3 mg SIVP. We then wait another five minutes or so until she is good and relaxed, and then we gently get her on a scoop stretcher and pad her up before we carry her out to the ambulance. My partner drives nice and slow. By the time we get to the ED, her eyes are closed and her pain is down from the initial 10 to maybe a 1 or 2. What's nice about our protocols for extremity injury (including hip) is for the most part we are given the leeway to give the amount necessary to take care of a patient's pain. Soon our protocols will be expanded to include back and spine pain, as well as sickle cell crisis on standing order. In addition we will be able to give up to 0.15 mg/kg up to a 15mg max, where now we can only give a max of 10 before calling.
If my preceptee learns one thing from me, I want it to be to treat a patient's pain. Not just with morphine, but with lots of pillows and allowing time for the drug to work before moving the patient. And to not be afraid to call medical control back and ask for more if the patient needs it. Sometimes they will turn you down (you can't take it personally), and at least you advocated for your patient.
Subscribe to:
Posts (Atom)