The old man with Alzheimer’s who used to stand out by the road and watch the traffic go by isn’t there this morning as we pass. He hasn’t been out there for awhile. Ahead there’s a For Sale sign in the yard of the now vacant split-level ranch where for a time we used to get called at least once a week to pick up the woman with multiple sclerosis who often fell in the bedroom or sometimes the kitchen and needed our help getting up.
I’m thinking about these people this rainy morning – thinking about how life ends and life goes on -- as we respond for a presumption – a report of a patient who passed away during the night.
We enter the hundred-year-old house through the kitchen. On the wooden table there is a small bunch of yellow bananas in a white porcelain bowl. The kitchen is spare and clean.
We go down the hall to the bedroom where the woman lies in bed. She is cold, stiff and peaceful. I run a six second strip of asystole and call the time.
I learn from the officers on scene that the woman was eighty-seven, lived alone and had been in slowly failing health. Her daughter, who lives in Georgia, had been concerned that her mother hadn’t answered the phone last night or again this morning when she called to check on her. The police were sent on a welfare check. They entered the house by using the key that was kept in the watering can in the unlocked garage.
I write my name, date of birth and license number along with the presumption time and hand it to the officer, and then pick my monitor up and swing it over my shoulder. I walk back out through the kitchen, and then out to the ambulance.
The rain has stopped and as we drive back to our base I see a hint of sun breaking through the clouds.
All day long now I find myself thinking about those bananas. What’s going to happen to them? Are they going to sit in that bowl until they turn black and rot? Who’s going to throw them out? Or will someone take them home and eat them while they are still ripe?
Tuesday, April 29, 2008
Sunday, April 27, 2008
24s and Snipers
The President was in town the other day. The first I found out about it was seeing a string of police cars and sawhorses by the side of the road. My partner mentioned she'd heard he was coming to speak at one of the local schools. As soon as we passed (headed South into the city), they closed the road.
Dispatch posted us in the north end. We got sent on a call to the northern suburb, but were cancelled before we got out of the parking lot where we'd been idling.
Twenty minutes later, we were sent north again this time for an intercept with the volunteer ambulance. I told my partner to head up a side street as the main road was probably closed.
We ran smack into a roadblock. I guess I should have known they wouldn't let us through, but I still rolled down the window and told the local cop that we had an emergency up ahead. Sometimes they let you pass, but not I guess when it comes to the President. The cop had his orders. No one passes. I asked for advice on getting there. He said we basically had to go through another town. He at least let us pull past the saw horse so we could do a U-Turn. I wondered later if we had kept on, at what point we would have attracted sniper fire.
We notified dispatch that we were being rerouted and it would be awhile. I thought they might have someone closer, but I guess they didn't, so we drove a couple miles south back into the city, then drove west and then north again, finally entering the town from a different border.
It worked out all right. We still beat the volunteer crew to the intercept point. It turns out the call was the original one we had been sent and canceled on. A woman with a low blood sugar. A couple IV attempts later (Yes, I am still missing with a disturbing frequency) and we had the woman alert and chatting with us.
Later I saw the woman being discharged from the ED. She was on Baby Medic's stretcher. "Oh, you brought her in," he said. "We were making fun of the the 24 in her arm."
"She was a tough stick," I said. "It got the job done."
Baby Medic said he was at the school doing the Presidential standby. He mentioned all the snipers he saw on nearby rooftops.
I neglected to tell him he might have had us a patients had we decided to push our luck at the road block. I would have needed more than a 24. At least I'm an easy stick.
***
Many years ago, I did a presidential standby and was basically told, if the President needs medical attention for any reason, his detail was going to throw him in his limo and race him to he ED. We would not be touching or treating him. I guess maybe the standby ambulances are for the snipers' victims.
Dispatch posted us in the north end. We got sent on a call to the northern suburb, but were cancelled before we got out of the parking lot where we'd been idling.
Twenty minutes later, we were sent north again this time for an intercept with the volunteer ambulance. I told my partner to head up a side street as the main road was probably closed.
We ran smack into a roadblock. I guess I should have known they wouldn't let us through, but I still rolled down the window and told the local cop that we had an emergency up ahead. Sometimes they let you pass, but not I guess when it comes to the President. The cop had his orders. No one passes. I asked for advice on getting there. He said we basically had to go through another town. He at least let us pull past the saw horse so we could do a U-Turn. I wondered later if we had kept on, at what point we would have attracted sniper fire.
We notified dispatch that we were being rerouted and it would be awhile. I thought they might have someone closer, but I guess they didn't, so we drove a couple miles south back into the city, then drove west and then north again, finally entering the town from a different border.
It worked out all right. We still beat the volunteer crew to the intercept point. It turns out the call was the original one we had been sent and canceled on. A woman with a low blood sugar. A couple IV attempts later (Yes, I am still missing with a disturbing frequency) and we had the woman alert and chatting with us.
Later I saw the woman being discharged from the ED. She was on Baby Medic's stretcher. "Oh, you brought her in," he said. "We were making fun of the the 24 in her arm."
"She was a tough stick," I said. "It got the job done."
Baby Medic said he was at the school doing the Presidential standby. He mentioned all the snipers he saw on nearby rooftops.
I neglected to tell him he might have had us a patients had we decided to push our luck at the road block. I would have needed more than a 24. At least I'm an easy stick.
***
Many years ago, I did a presidential standby and was basically told, if the President needs medical attention for any reason, his detail was going to throw him in his limo and race him to he ED. We would not be touching or treating him. I guess maybe the standby ambulances are for the snipers' victims.
Tuesday, April 22, 2008
Cutting Clothes
We all carry trauma shears. Of all the tools, a medic has to carry, I would say there are only three -- a pen, a stethoscope and trauma shears that are essentials. I wear my stethoscope around my neck, my pen or pens in various shirt and or pants pockets, and I carry my trauma shears in a side pants pockets in the little holder space with a piece of cloth strung through one of the scissor handle loops and then snapped to keep them from falling out.*
I really can't work without any of these three tools. I have to be able to take down information with a pen, I really need to listen to lung sounds and auscultate the BP with my stethoscope.** And I need the scissors to cut off the patient's clothes to expose the skin and check for injury.
When I started in EMS back in 1989, the trauma chief at the local hospital insisted that any trauma brought into his trauma room be completely stripped of clothes prehospitally, and covered only with a sheet. He was of course talking about moderate to major traumas and not little fall and go booms.
I did a call once back then for an old woman who had fallen and hurt her shoulder on the church steps in winter. I was pretty certain her arm was broken, but I got my trauma scissors out to cut the coat so I could see better, but my partner Kevin stopped me. "This is probably her only coat," he said. "Let's see if we can't slip it off her." He was right. We were able to hold c-spine and still get the coat off. She had a broken arm, but she didn't have to go buy a new coat.
In the years since, I have tried to find the proper balance between exposing what needs to be exposed, protecting the patient from potentially harmful movement and destroying someone's wardrobe unnecessarily.
I will also say I have never used my trauma shears to cut a down coat and turn the ambulance into a tempest of feathers.
At our local hospitals, we have the right to ask for the trauma room if we think the patient merits it. Some calls (gunshot to the chest) the merit is so obvious, we don't even have to ask for the trauma room. Others (certain MVAs) we need to request it. Sometimes, the hospital (depending on the triage nurse and doctor covering the trauma room) will give us the trauma room even when we do not ask for it.
Unless it is a major multisystem trauma, I try to cut only what needs to be exposed if I think there is an injury there. If a young woman has a broken shoulder, I will rarely cut jeans, unless my survey has elicited evidence of a pelvic or lower extremity injury as well. When I do cut the jeans, I leave the undergarments uncut unless there is an obvious injury there.
The trauma team cuts everything (in addition to poking their fingers and tubes into every possible orifice as well as creating several new ones). I feel sorry for many of my patients, particularly the ones who are alert and whose injuries might be more limited than others.
I am not in any way criticising the trauma team for doing what they do. Their mandate is to be thorough, and they are. They do not like clothes. They like naked.
It doesn't matter to them. Clothes have no economic or sentimental value -- a poor woman's coat, a young girl's designer jeans, an army veteran's old unit jacket. I've seen veterans rip themselves out of being c-spined and take swings at the person trying to cut their army jacket. Don't tread on me!
The trauma team doesn't care. It's a clothes destroying machine. An insatiable beast.
I had a call the other day. Man at work is talking to a coworker. He turns to leave, falls face forward and hits his head. Presto! He's having a gran mal seizure. No apparent seizure history. The guy he was talking to at the time -- the witness -- can't say what came first -- the fall or the seizure causing the fall. He can't say if turning caused the man to trip, if the man started to syncopize, or if he started to seize and then fell. Big Unknown. We have the chicken and egg situation.
The patient is a bloody mess. Big puddle of blood on the floor, hair is caked with blood, but the only wound I can find is a jagged laceration above his eyebrow. The man is no longer unconscious, but he is still out of it. We manage to c-spine him, and get a pressure dressing on the head lac, which is still bleeding.
In the ambulance, he is alert enough to answer questions. He knows who he is, what his birth date is, but he is unaware anything has happened to him, and he categorically rejects that he has any medical history. Never had a seizure. No history of seizures, on no meds.
I need to get a blood pressure and pop in an IV line, but the man is wearing a long-sleeved Yankees tee-shirt that I can't roll up. If this was a straight forward seizure, I might take the BP over the shirt and try to stick an IV in the hand, but I really don't know what this is, but I do know I need a good pressure and decent IV access because I suspect that this patient is going to wind up in the trauma room.
Sorry, I say, but I am going to have to cut your shirt. Aw, com'on, he says. It's my Yankee shirt. Sorry, man. And I cut quickly from the wrist right up to the shoulder. I take the pressure 140/100 and pounding, and pop in an 18 in his forearm. I ask him again about medical history and if he has ever had seizures and he again tells me no. He gets more and more coherent as we approach the hospital, but continues to deny the seizure history.
When I call the hospital, they ask me if I want the trauma room. I tell them well, since I don't know if it is a medical causing a trauma or a trauma causing a medical that means it could be a trauma, in which case I probably should be seeing them in the trauma room. Very good, see you there, they say.
I tell the man since I already cut the arm of his shirt, I might as well cut the rest of the shirt off. (Since we are going to the trauma room, I have to show I at least exposed his upper torso.) He tries to protest, but my scissors are too quick. I cut the shirt off and cover him with a sheet. I leave his new jeans on. I tell him when we get to the hospital, I am going to take him into a room where there will be a lot of doctors and nurses and other staff and they will asking him a lot of questions.
About what? he says.
About what just happened to you.
Nothing happened to me. I'm fine.
You had a seizure.
No I didn't. Why do you have to cut my Yankees shirt?
You ever had seizures before? I ask.
No, he says, I told you that before.
They strip him in no time in the trauma room. Their shears are like a school of piranhas. (I am always careful to fully disconnect the patient from my monitor before moving him over to the trauma bed because we have lost many leads to the frenzied team. Snip. Snip. Snip. The patient is naked and where we once had four long wires, we now have three long wires and one short one.)
I give my report and then stay for a little while to repeat my story a few times because whenever a member of the team relays their version of what they heard to a newly arriving member the story morphs. I try to keep it straight. No history of seizures. Patient, who had complained of nothing during the day, talking to a coworker, ends conversation, turns, falls hits head, and then is observed having a gran mal seizure for 2-3 minutes. Posticital. Now more alert. Denies any seizure past. Chicken or egg. Your guess is as good as mine.
After writing my run report in the EMS room, I am walking back down the hall when I see the patient being wheeled to CAT Scan. "Hey," one of the trauma team says, "He wants the guy who cut his Yankee shirt off to buy him a new one."
"Sorry," I say, and keep going.
What's a Yankees shirt cost? About $15? Hey, I'm not a millionaire.
I wonder if the trauma team is ever asked for financial compensation? How many designer jeans, Armani suits, sweaters patient's grandmothers made for them, and favorite old t-shirts have fallen victim to the trauma teams scissors? Have they ever thought to replace them out of their wages? I'm just a poor paramedic.
And besides, while I might be sympathetic about an old woman's coat, when it comes to a Yankees shirt -- Not!
***
Later after bringining in another patient to the same hospital, I stop by and see the man. It turns out I had picked up his glasses at the scene and put them in my pocket, and then forgot about them, only to discover them later. His eye is swollen shut with a huge hematoma. He says he needed twenty stitches to close the gash. They are going to keep him over night for observation. I ask him if he remembers what happened, and he says he has no recollection. And he never had seizures before, he says.
He is happy I found his glasses. I apologize about cutting his shirt. He says its okay, he was just upset because it was his Yankees shirt.
I tell him I did enjoy cutting it.
He looks at me. "You're a Red Sox fan?"
"That's right, partner," I say as I quickly unholster my trusty trauma shears. "I made quick work of that shirt too." I twirl the shears like a six-gun, catch the grip and then make lightning fast snips in the air. "A-Rod, Jeter, Posada. 26 snips for 26 championships." I bring the scissors to my lips and blow out the smoke. "Another Yankee shirt bites the dust."
"Ha, ha," he says.
Good thing he has a sense of humor.
***
A story of another encounter with a Yankee Fan.
***
* Some EMTs have what we used to call "whoop" belts -- holsters that attach to your belt to carry an array of tools such as trauma shears, various size scissors, a penlight or flashlight, window-punch, multipurpose tool, tape, whatever. When I started I had a small one(penlight, bandage scissors, trauma shears and window punch), but stopped wearing it after a month or so as I saw it wasn't in fashion, and besides the penlight and trauma shears, I never needed the other stuff. I did one day at a medical conference obtain a free salesman sample of one of those reflex hammers that they use to tap against your knee. I wore that one day in the side holster as a gag.
** Once I did leave my stethoscope in the ambulance, there was none in the bag, and neither my partner nor any of the first responders had one. After I intubated the patient, I had to check for positive lung sounds by pressing my ear under the dead guy's arm pits on each side so I could hear if my tube was good. This was pre-capnography, of course.
I really can't work without any of these three tools. I have to be able to take down information with a pen, I really need to listen to lung sounds and auscultate the BP with my stethoscope.** And I need the scissors to cut off the patient's clothes to expose the skin and check for injury.
When I started in EMS back in 1989, the trauma chief at the local hospital insisted that any trauma brought into his trauma room be completely stripped of clothes prehospitally, and covered only with a sheet. He was of course talking about moderate to major traumas and not little fall and go booms.
I did a call once back then for an old woman who had fallen and hurt her shoulder on the church steps in winter. I was pretty certain her arm was broken, but I got my trauma scissors out to cut the coat so I could see better, but my partner Kevin stopped me. "This is probably her only coat," he said. "Let's see if we can't slip it off her." He was right. We were able to hold c-spine and still get the coat off. She had a broken arm, but she didn't have to go buy a new coat.
In the years since, I have tried to find the proper balance between exposing what needs to be exposed, protecting the patient from potentially harmful movement and destroying someone's wardrobe unnecessarily.
I will also say I have never used my trauma shears to cut a down coat and turn the ambulance into a tempest of feathers.
At our local hospitals, we have the right to ask for the trauma room if we think the patient merits it. Some calls (gunshot to the chest) the merit is so obvious, we don't even have to ask for the trauma room. Others (certain MVAs) we need to request it. Sometimes, the hospital (depending on the triage nurse and doctor covering the trauma room) will give us the trauma room even when we do not ask for it.
Unless it is a major multisystem trauma, I try to cut only what needs to be exposed if I think there is an injury there. If a young woman has a broken shoulder, I will rarely cut jeans, unless my survey has elicited evidence of a pelvic or lower extremity injury as well. When I do cut the jeans, I leave the undergarments uncut unless there is an obvious injury there.
The trauma team cuts everything (in addition to poking their fingers and tubes into every possible orifice as well as creating several new ones). I feel sorry for many of my patients, particularly the ones who are alert and whose injuries might be more limited than others.
I am not in any way criticising the trauma team for doing what they do. Their mandate is to be thorough, and they are. They do not like clothes. They like naked.
It doesn't matter to them. Clothes have no economic or sentimental value -- a poor woman's coat, a young girl's designer jeans, an army veteran's old unit jacket. I've seen veterans rip themselves out of being c-spined and take swings at the person trying to cut their army jacket. Don't tread on me!
The trauma team doesn't care. It's a clothes destroying machine. An insatiable beast.
I had a call the other day. Man at work is talking to a coworker. He turns to leave, falls face forward and hits his head. Presto! He's having a gran mal seizure. No apparent seizure history. The guy he was talking to at the time -- the witness -- can't say what came first -- the fall or the seizure causing the fall. He can't say if turning caused the man to trip, if the man started to syncopize, or if he started to seize and then fell. Big Unknown. We have the chicken and egg situation.
The patient is a bloody mess. Big puddle of blood on the floor, hair is caked with blood, but the only wound I can find is a jagged laceration above his eyebrow. The man is no longer unconscious, but he is still out of it. We manage to c-spine him, and get a pressure dressing on the head lac, which is still bleeding.
In the ambulance, he is alert enough to answer questions. He knows who he is, what his birth date is, but he is unaware anything has happened to him, and he categorically rejects that he has any medical history. Never had a seizure. No history of seizures, on no meds.
I need to get a blood pressure and pop in an IV line, but the man is wearing a long-sleeved Yankees tee-shirt that I can't roll up. If this was a straight forward seizure, I might take the BP over the shirt and try to stick an IV in the hand, but I really don't know what this is, but I do know I need a good pressure and decent IV access because I suspect that this patient is going to wind up in the trauma room.
Sorry, I say, but I am going to have to cut your shirt. Aw, com'on, he says. It's my Yankee shirt. Sorry, man. And I cut quickly from the wrist right up to the shoulder. I take the pressure 140/100 and pounding, and pop in an 18 in his forearm. I ask him again about medical history and if he has ever had seizures and he again tells me no. He gets more and more coherent as we approach the hospital, but continues to deny the seizure history.
When I call the hospital, they ask me if I want the trauma room. I tell them well, since I don't know if it is a medical causing a trauma or a trauma causing a medical that means it could be a trauma, in which case I probably should be seeing them in the trauma room. Very good, see you there, they say.
I tell the man since I already cut the arm of his shirt, I might as well cut the rest of the shirt off. (Since we are going to the trauma room, I have to show I at least exposed his upper torso.) He tries to protest, but my scissors are too quick. I cut the shirt off and cover him with a sheet. I leave his new jeans on. I tell him when we get to the hospital, I am going to take him into a room where there will be a lot of doctors and nurses and other staff and they will asking him a lot of questions.
About what? he says.
About what just happened to you.
Nothing happened to me. I'm fine.
You had a seizure.
No I didn't. Why do you have to cut my Yankees shirt?
You ever had seizures before? I ask.
No, he says, I told you that before.
They strip him in no time in the trauma room. Their shears are like a school of piranhas. (I am always careful to fully disconnect the patient from my monitor before moving him over to the trauma bed because we have lost many leads to the frenzied team. Snip. Snip. Snip. The patient is naked and where we once had four long wires, we now have three long wires and one short one.)
I give my report and then stay for a little while to repeat my story a few times because whenever a member of the team relays their version of what they heard to a newly arriving member the story morphs. I try to keep it straight. No history of seizures. Patient, who had complained of nothing during the day, talking to a coworker, ends conversation, turns, falls hits head, and then is observed having a gran mal seizure for 2-3 minutes. Posticital. Now more alert. Denies any seizure past. Chicken or egg. Your guess is as good as mine.
After writing my run report in the EMS room, I am walking back down the hall when I see the patient being wheeled to CAT Scan. "Hey," one of the trauma team says, "He wants the guy who cut his Yankee shirt off to buy him a new one."
"Sorry," I say, and keep going.
What's a Yankees shirt cost? About $15? Hey, I'm not a millionaire.
I wonder if the trauma team is ever asked for financial compensation? How many designer jeans, Armani suits, sweaters patient's grandmothers made for them, and favorite old t-shirts have fallen victim to the trauma teams scissors? Have they ever thought to replace them out of their wages? I'm just a poor paramedic.
And besides, while I might be sympathetic about an old woman's coat, when it comes to a Yankees shirt -- Not!
***
Later after bringining in another patient to the same hospital, I stop by and see the man. It turns out I had picked up his glasses at the scene and put them in my pocket, and then forgot about them, only to discover them later. His eye is swollen shut with a huge hematoma. He says he needed twenty stitches to close the gash. They are going to keep him over night for observation. I ask him if he remembers what happened, and he says he has no recollection. And he never had seizures before, he says.
He is happy I found his glasses. I apologize about cutting his shirt. He says its okay, he was just upset because it was his Yankees shirt.
I tell him I did enjoy cutting it.
He looks at me. "You're a Red Sox fan?"
"That's right, partner," I say as I quickly unholster my trusty trauma shears. "I made quick work of that shirt too." I twirl the shears like a six-gun, catch the grip and then make lightning fast snips in the air. "A-Rod, Jeter, Posada. 26 snips for 26 championships." I bring the scissors to my lips and blow out the smoke. "Another Yankee shirt bites the dust."
"Ha, ha," he says.
Good thing he has a sense of humor.
***
A story of another encounter with a Yankee Fan.
***
* Some EMTs have what we used to call "whoop" belts -- holsters that attach to your belt to carry an array of tools such as trauma shears, various size scissors, a penlight or flashlight, window-punch, multipurpose tool, tape, whatever. When I started I had a small one(penlight, bandage scissors, trauma shears and window punch), but stopped wearing it after a month or so as I saw it wasn't in fashion, and besides the penlight and trauma shears, I never needed the other stuff. I did one day at a medical conference obtain a free salesman sample of one of those reflex hammers that they use to tap against your knee. I wore that one day in the side holster as a gag.
** Once I did leave my stethoscope in the ambulance, there was none in the bag, and neither my partner nor any of the first responders had one. After I intubated the patient, I had to check for positive lung sounds by pressing my ear under the dead guy's arm pits on each side so I could hear if my tube was good. This was pre-capnography, of course.
Monday, April 21, 2008
Fund for Injured EMTs
I receieved an update on the condition of the EMT who lost her arm in a recent crash, as well as her partner, who also suffered serious injuries.
JKosprey writes: "I am a regular partner of both EMTs involved in that horrible accident. Seems to me there wasn't much that could have been done to stop it unfortunately, but both are progressing slowly but surely into recovery."
A fund has been set up for their benefit:
RPS/Regional EMS Benevolent Fund
***
Article About Crash
Article about Injured EMTs
JKosprey writes: "I am a regular partner of both EMTs involved in that horrible accident. Seems to me there wasn't much that could have been done to stop it unfortunately, but both are progressing slowly but surely into recovery."
A fund has been set up for their benefit:
RPS/Regional EMS Benevolent Fund
***
Article About Crash
Article about Injured EMTs
Black Flies (Author Comment)
I received the following very enlightening comment from "pozzo" - Shannon Burke, the author of Black Flies
.
I’ve seen the comments about the novel Black Flies and was holding my tongue, but…I wanted to say that the book was not meant to demean paramedics or the job they do. Just the opposite. I meant to aggrandize paramedics, but not with some cornball catch the baby from the burning building sort of thing, but by dramatizing the real struggles of a first year medic in a hostile environment. After Safelight, which was a sort of love story, I wanted to write a real paramedic novel, a novel where every scene took place on the ambulance, and specifically, a novel that a medic just starting out could read and say, ‘Wow, this is what I can expect in the next year. These are the pressures I’ll be put under. These are the choices that will present themselves. And these are the risks.’
So, I dramatized what I’d seen personally and I tried to mark the psychological stages in that critical first year—what the pitfalls are, and how the job really does spiral down to choices of good versus evil, but those choices come in such banal and offhand settings that unless you’re reminded of those moments you can almost miss them. That was the thing that haunted me as a medic. How small decisions had huge implications for the patient, and if you didn’t pay attention, didn’t follow up to see what impact your treatment had, you could go on blithely mistreating and even hurting patients without even knowing it. And, yeah, there’s boredom, and laziness, and burnout, and I wanted to show how these manifest themselves in the EMS world and how a lapse has real consequences. We all know this. We’ve all seen it. It’s part of the job.
Anyway, I wanted to write about the hurdles for a rookie medic, and to have him make some mistakes and start going down the wrong path, but in the end, good does conquer evil, the main character does the right thing and comes out on the other side of his struggles, and will go on trying to do the right thing longer because of his past crises. The endpoint, I hope, is a hard won battle for the rookie medic, and a new respect for medics in general and the struggles they go through to do their job. If this isn’t the impression the book gives, then…I failed in my goal. But that was my intent.
And, just as an aside, I know the NYC system has a reputation of being a hostile environment, and it’s hard for me to say if it’s worse than other places because I have nothing to compare it to, but I can say with all certainty that the burnt out medics I wrote about in the book are less burnt out and do less bad things than what the real bad guys I knew did in my first six months on the job. It’s possible I just stumbled into a dysfunctional situation, but I swear to you that what I wrote is an understatement rather than an exaggeration, and anyone who was working out of the old Station 18 back in the nineties can back me up on this. There was some wild shit going on and everybody knew it.
Thanks for the insight into your writing.
I would like to add, as someone who has written fiction, both EMS and non EMS (without the success of Burke), that Black Flies is a tremendous achievement. It is a "good" book -- a page-turner with an ultimate moral message that brings light to a dark place.
I encourage you to buy it and if you do, after you have read it (it won't bore you), please send your comments in. I would be interested to know what you all think about it.
***
Black Flies (4-13-08)
Comments and Followups 4-20-08)
.I’ve seen the comments about the novel Black Flies and was holding my tongue, but…I wanted to say that the book was not meant to demean paramedics or the job they do. Just the opposite. I meant to aggrandize paramedics, but not with some cornball catch the baby from the burning building sort of thing, but by dramatizing the real struggles of a first year medic in a hostile environment. After Safelight, which was a sort of love story, I wanted to write a real paramedic novel, a novel where every scene took place on the ambulance, and specifically, a novel that a medic just starting out could read and say, ‘Wow, this is what I can expect in the next year. These are the pressures I’ll be put under. These are the choices that will present themselves. And these are the risks.’
So, I dramatized what I’d seen personally and I tried to mark the psychological stages in that critical first year—what the pitfalls are, and how the job really does spiral down to choices of good versus evil, but those choices come in such banal and offhand settings that unless you’re reminded of those moments you can almost miss them. That was the thing that haunted me as a medic. How small decisions had huge implications for the patient, and if you didn’t pay attention, didn’t follow up to see what impact your treatment had, you could go on blithely mistreating and even hurting patients without even knowing it. And, yeah, there’s boredom, and laziness, and burnout, and I wanted to show how these manifest themselves in the EMS world and how a lapse has real consequences. We all know this. We’ve all seen it. It’s part of the job.
Anyway, I wanted to write about the hurdles for a rookie medic, and to have him make some mistakes and start going down the wrong path, but in the end, good does conquer evil, the main character does the right thing and comes out on the other side of his struggles, and will go on trying to do the right thing longer because of his past crises. The endpoint, I hope, is a hard won battle for the rookie medic, and a new respect for medics in general and the struggles they go through to do their job. If this isn’t the impression the book gives, then…I failed in my goal. But that was my intent.
And, just as an aside, I know the NYC system has a reputation of being a hostile environment, and it’s hard for me to say if it’s worse than other places because I have nothing to compare it to, but I can say with all certainty that the burnt out medics I wrote about in the book are less burnt out and do less bad things than what the real bad guys I knew did in my first six months on the job. It’s possible I just stumbled into a dysfunctional situation, but I swear to you that what I wrote is an understatement rather than an exaggeration, and anyone who was working out of the old Station 18 back in the nineties can back me up on this. There was some wild shit going on and everybody knew it.
Thanks for the insight into your writing.
I would like to add, as someone who has written fiction, both EMS and non EMS (without the success of Burke), that Black Flies
is a tremendous achievement. It is a "good" book -- a page-turner with an ultimate moral message that brings light to a dark place. I encourage you to buy it and if you do, after you have read it (it won't bore you), please send your comments in. I would be interested to know what you all think about it.
***
Black Flies (4-13-08)
Comments and Followups 4-20-08)
Sunday, April 20, 2008
Comments and Follow Ups
I wanted to thank everyone who has posted comments. I always read them and have learned a lot from many of them.
I want to use this post to followup on comments and some recent entries.
***
I particularly want to thank the commentator who brought up the tidbit that Nitro spray (NitroLingual) doesn't have to be sublingual.
I have heard from many of you on this issue and have asked lots of medics and doctors about it. It is surprising how many people like me were unaware that nitro could be sprayed on the tongue. The consensus now seems to be if you can spray it under the tongue, this is best. It may work slightly faster and has less unpleasant taste, but if you can't get it under the tongue, and don't want to have to go through all the contortions of 29 Ways to Lift Your Tongue just go ahead and spray it on the tongue.
***
Thanks to those posters who have picked up on my occasional patient gender shifting in stories. In light of HIPPA privacy fears, I use a randomized method of disguising patient identities that sometimes includes writing about a man when the patient was actually female. Sometimes in the heat of writing "the he" who I am writing as "a she", sometimes slips back into being "a he."
***
Thanks also to everyone who wished me better health after reading Medicine for Paramedics. I am feeling much better now. Spring is here and I have even been back out running.
***
In a recent post about ceasing a resuscitation (Faces of Death), I mentioned that we took the tube and IVs out after we have presumed the patient. Some commentators thought that odd. As I noted in a comment:
Our discontinuation protocol reads: "Tubes and Iv lines may be removed if patient is being transported to or by a funeral home. If the patient is deemed a medical examiner's case. leave tubes and lines in place."
Most patients that will end up being medical examiner's cases usually fall in the transport category. We rarely, if ever, work and discontinue a trauma. Our tubes are documented for the record by capnography print outs, both wave form and trend summary.
I sit on the regional medical advisory committee and have fought for the right for medics to remove tubes in certain cases. It is not rare in a town like the one I work in most regularly to have a wife or husband summon 911 when their longtime spouse has just passed on. We often find the patient warm and asystole with no DNR paperwork. The people are in their eighties or nineties and are living in the homes in which they have raised their families and spend most of thier lives.
We put the patient on the floor, work them for twenty minutes, giving them full ACLS (CPR, intubation, IV, epi, atropine) get no response, and then presume them. We often pick them back up and put them back in bed, their head resting on a pillow, close their dead eyes and pull the sheet up to their neck. Afterwards I often see the husband or wife come in and give them a kiss on the cheek or lips or hug them or sit with them while waiting for the medical examiner.
I think it is more humane for the patient to lie in their bed looking as peaceful as possible and not have a big tube sticking out of their mouth. Fortunately, the committee agreed with me and so we have have this provision. Again, we can only remove the tube for those patients where the police, who are on usually on scene with us, will be calling for the funeral home to come instead of calling the Medical Examiner.
***
I have thought more about the novel Black Flies by Shannon Burke that I reviewed. I know many EMSers are upset or disturbed by our continual portrayal as burned out stereotypes who no longer care about our patients, but I still think this is a worthy effort.
I reread an interview with the author and he mentions that his book is a "story of good and evil." And it certainly is. Burke presents a stressful environment where weaker individuals (new medics) can fall prey to bad influences.
The older medics represent an array along the spectrum of good and evil, including the good, a medic who struggles to grow a garden in a small strip of earth next to the Harlem ambulance headquarters, the burnout, a once decent medic who is having trouble caring and who is descending into despair, and another medic (pure evil) who carries a picture of himself holding the head of a decapitated girl like a bowling ball (pretty nasty stuff).
I have found myself thinking about this novel weeks after I have read it, and that I think is a mark of a good book -- it makes you think. I hope Burke writes another EMS novel that while dealing with as important issues (good and evil) as this book deals with, can do it without leaving a lay reader with a distasteful impression of your average paramedic.
***
In My Death I railed against ambulance safety and posted a link to the Ambulance Crash Log.
The most recent news on the log concerns a young EMT in New York state who lost her arm in an ambulance crash and is still in critical condition. Prayers and thoughts go out to her and her family.
The streets aren't getting any safer.
I want to use this post to followup on comments and some recent entries.
***
I particularly want to thank the commentator who brought up the tidbit that Nitro spray (NitroLingual) doesn't have to be sublingual.
I have heard from many of you on this issue and have asked lots of medics and doctors about it. It is surprising how many people like me were unaware that nitro could be sprayed on the tongue. The consensus now seems to be if you can spray it under the tongue, this is best. It may work slightly faster and has less unpleasant taste, but if you can't get it under the tongue, and don't want to have to go through all the contortions of 29 Ways to Lift Your Tongue just go ahead and spray it on the tongue.
***
Thanks to those posters who have picked up on my occasional patient gender shifting in stories. In light of HIPPA privacy fears, I use a randomized method of disguising patient identities that sometimes includes writing about a man when the patient was actually female. Sometimes in the heat of writing "the he" who I am writing as "a she", sometimes slips back into being "a he."
***
Thanks also to everyone who wished me better health after reading Medicine for Paramedics. I am feeling much better now. Spring is here and I have even been back out running.
***
In a recent post about ceasing a resuscitation (Faces of Death), I mentioned that we took the tube and IVs out after we have presumed the patient. Some commentators thought that odd. As I noted in a comment:
Our discontinuation protocol reads: "Tubes and Iv lines may be removed if patient is being transported to or by a funeral home. If the patient is deemed a medical examiner's case. leave tubes and lines in place."
Most patients that will end up being medical examiner's cases usually fall in the transport category. We rarely, if ever, work and discontinue a trauma. Our tubes are documented for the record by capnography print outs, both wave form and trend summary.
I sit on the regional medical advisory committee and have fought for the right for medics to remove tubes in certain cases. It is not rare in a town like the one I work in most regularly to have a wife or husband summon 911 when their longtime spouse has just passed on. We often find the patient warm and asystole with no DNR paperwork. The people are in their eighties or nineties and are living in the homes in which they have raised their families and spend most of thier lives.
We put the patient on the floor, work them for twenty minutes, giving them full ACLS (CPR, intubation, IV, epi, atropine) get no response, and then presume them. We often pick them back up and put them back in bed, their head resting on a pillow, close their dead eyes and pull the sheet up to their neck. Afterwards I often see the husband or wife come in and give them a kiss on the cheek or lips or hug them or sit with them while waiting for the medical examiner.
I think it is more humane for the patient to lie in their bed looking as peaceful as possible and not have a big tube sticking out of their mouth. Fortunately, the committee agreed with me and so we have have this provision. Again, we can only remove the tube for those patients where the police, who are on usually on scene with us, will be calling for the funeral home to come instead of calling the Medical Examiner.
***
I have thought more about the novel Black Flies
by Shannon Burke that I reviewed. I know many EMSers are upset or disturbed by our continual portrayal as burned out stereotypes who no longer care about our patients, but I still think this is a worthy effort.I reread an interview with the author and he mentions that his book is a "story of good and evil." And it certainly is. Burke presents a stressful environment where weaker individuals (new medics) can fall prey to bad influences.
The older medics represent an array along the spectrum of good and evil, including the good, a medic who struggles to grow a garden in a small strip of earth next to the Harlem ambulance headquarters, the burnout, a once decent medic who is having trouble caring and who is descending into despair, and another medic (pure evil) who carries a picture of himself holding the head of a decapitated girl like a bowling ball (pretty nasty stuff).
I have found myself thinking about this novel weeks after I have read it, and that I think is a mark of a good book -- it makes you think. I hope Burke writes another EMS novel that while dealing with as important issues (good and evil) as this book deals with, can do it without leaving a lay reader with a distasteful impression of your average paramedic.
***
In My Death I railed against ambulance safety and posted a link to the Ambulance Crash Log.
The most recent news on the log concerns a young EMT in New York state who lost her arm in an ambulance crash and is still in critical condition. Prayers and thoughts go out to her and her family.
The streets aren't getting any safer.
Thursday, April 17, 2008
Equipment? (Brain) Malfunction
It doesn't happen often, but every once and while, there we go again.
***
Where I work in the contract town, we have three ambulances that all look pretty much the same. Box Type. Red stripe along the side. AMBULANCE written on it. We have four medics (but only one on at a time). Every six months or so, our ambulance assignments are switched. I'm moved from 80 to 92 or to 70. Sometimes I share an ambulance with another medic. Sometimes I have one to myself. We also have two sets of medic house bags. One black. One red. I share the red bag with another medic.
Every morning when I come in, I move into my ambulance, making certain all the gear gets changed over. Red bag, monitor, spare med kit, pedi box, EZ-IO, and narcs.
The other morning I come in and take the gear out of of 92 (the one that this morning has the black house bag in the back) and move it across the bay into the other ambulance -- the one with the red bag in the back. Then I realize, wait a minute, I'm moving into 80 when I have just been reassigned to 70, which is sitting behind 80. I am about to move the ambulances around when a call comes in. Its a code (the nursing home code I had the other morning that I wrote about in Faces of Life and Death). The other medic hasn't left yet so he comes along with me. Two medics is better than one.
When we get back, I move the ambulances around and get my stuff into 70. The EMT relief is already in, sitting watching TV. He asks how the ambulance is? I say everything's fine.
A couple hours later we get a call. I start into the bay, but then realize my backpack is still in my car outside. In it are baby pictures of my daughter. When I was at the hospital one of the nurses asked to see them, and I said I had left them in my car, but would bring them if I came back, so I tell my partner to pull the ambulance out, and I'll meet him out front.
I get my backpack. He pulls the ambulance out. I meet him out front and get in the ambulance. And off we go to the chest pain.
We arrive on scene. I go around to pull the stretcher out and there sitting on the stretcher is the black bag. Not good. No monitor. I look at the ambulance number 92, not 70. My gear, along with the narcs, is all in 70.
F-me.
Well, it turns out the patient is a 20-year-old with I'm guessing pleuritic chest pain, but she is moaning and groaning up a storm like she is about to die and her mamma is very upset.
The call is in between the hospital and the ambulance quarters. No chance to make a quick stop on the way for a pickup. No one else is on duty.
We get her on the stretcher and head for the hospital, BLS style. An oxygen cannuala at 2 lpm. When I radio the hospital, I give my assessment, and add due to a malfunction, I haven't been able to run a strip.
The first thing I do at the hospital is put her on their monitor and am relieved to see a normal sinus.
I call dispatch and tell them we are out of service until we can get back to the bay to fix our equipment problem.
Here are some similar episdoes from the past.
Paperwork? Paperwork?
The Stretcher
Credit
One of these days, its not going to work out so well.
***
Where I work in the contract town, we have three ambulances that all look pretty much the same. Box Type. Red stripe along the side. AMBULANCE written on it. We have four medics (but only one on at a time). Every six months or so, our ambulance assignments are switched. I'm moved from 80 to 92 or to 70. Sometimes I share an ambulance with another medic. Sometimes I have one to myself. We also have two sets of medic house bags. One black. One red. I share the red bag with another medic.
Every morning when I come in, I move into my ambulance, making certain all the gear gets changed over. Red bag, monitor, spare med kit, pedi box, EZ-IO, and narcs.
The other morning I come in and take the gear out of of 92 (the one that this morning has the black house bag in the back) and move it across the bay into the other ambulance -- the one with the red bag in the back. Then I realize, wait a minute, I'm moving into 80 when I have just been reassigned to 70, which is sitting behind 80. I am about to move the ambulances around when a call comes in. Its a code (the nursing home code I had the other morning that I wrote about in Faces of Life and Death). The other medic hasn't left yet so he comes along with me. Two medics is better than one.
When we get back, I move the ambulances around and get my stuff into 70. The EMT relief is already in, sitting watching TV. He asks how the ambulance is? I say everything's fine.
A couple hours later we get a call. I start into the bay, but then realize my backpack is still in my car outside. In it are baby pictures of my daughter. When I was at the hospital one of the nurses asked to see them, and I said I had left them in my car, but would bring them if I came back, so I tell my partner to pull the ambulance out, and I'll meet him out front.
I get my backpack. He pulls the ambulance out. I meet him out front and get in the ambulance. And off we go to the chest pain.
We arrive on scene. I go around to pull the stretcher out and there sitting on the stretcher is the black bag. Not good. No monitor. I look at the ambulance number 92, not 70. My gear, along with the narcs, is all in 70.
F-me.
Well, it turns out the patient is a 20-year-old with I'm guessing pleuritic chest pain, but she is moaning and groaning up a storm like she is about to die and her mamma is very upset.
The call is in between the hospital and the ambulance quarters. No chance to make a quick stop on the way for a pickup. No one else is on duty.
We get her on the stretcher and head for the hospital, BLS style. An oxygen cannuala at 2 lpm. When I radio the hospital, I give my assessment, and add due to a malfunction, I haven't been able to run a strip.
The first thing I do at the hospital is put her on their monitor and am relieved to see a normal sinus.
I call dispatch and tell them we are out of service until we can get back to the bay to fix our equipment problem.
Here are some similar episdoes from the past.
Paperwork? Paperwork?
The Stretcher
Credit
One of these days, its not going to work out so well.
Tuesday, April 15, 2008
The Tree
The husband awakes to an empty bedroom. He reads the note his wife has left him on the kitchen table and then goes out into the backyard and finds her in the backyard at the edge of the woods, hanging from the big tree.
When we arrive, an officer in the driveway tells us they already cut her down and are doing CPR out back, but she is cold and riggored. We still push our stretcher and gear across the wet soft grass.
She is laying on the ground wearing a man’s blue flannel pajamas. There is a deep thin red gash that runs across her throat. I kneel by her head. She is cold and blue, but her jaw is limber as are her fingers. I look at the other medic. We both shake our heads. She’s asystole, but we can’t call this one. Continue CPR. I intubate while the other medic puts in the line. He gives a round of drugs, and then we lift her up onto board, a collar around her neck. It is a hard go doing CPR and pushing the stretcher across the yard.
As we approach the house the husband comes out. I pause the stretcher a moment for him to put his arms around her, kiss her face and crying, tell her he loves her. An officer gently pulls him away and says they have to keep going.
In the ambulance when we are about five minutes out, I patch to the hospital. “Female in cardiac arrest. Found hanging from a tree by her husband. Unknown when she hung herself. She’s cold and blue and asystole, but her body is still limber. No rigor. We have her intubated and have given a round of meds with no response. We’re bringing in her because she’s hypothermic.”
At the hospital, the trauma team waits for us. A member of the team says, “Oh, she’s really cold.”
“She’s not dead till she’s warm and dead,” a doctor says.
“She’s still limber,” I add. “We don’t know how long she was out there. Ten minutes or an hour. There’s quite a chill out there this morning.”
Her rectal temp is a surprising 97.0. I guess she wasn’t out there that long after all. They call the time.
Later I hear she just got out of the psychiatric hospital. She’s been trying to kill herself for ten years. She told her husband once, “One day you’re going to find me hanging from that tree.”
Hell. If my wife ever told me that, I’d cut the damn tree down.
When we arrive, an officer in the driveway tells us they already cut her down and are doing CPR out back, but she is cold and riggored. We still push our stretcher and gear across the wet soft grass.
She is laying on the ground wearing a man’s blue flannel pajamas. There is a deep thin red gash that runs across her throat. I kneel by her head. She is cold and blue, but her jaw is limber as are her fingers. I look at the other medic. We both shake our heads. She’s asystole, but we can’t call this one. Continue CPR. I intubate while the other medic puts in the line. He gives a round of drugs, and then we lift her up onto board, a collar around her neck. It is a hard go doing CPR and pushing the stretcher across the yard.
As we approach the house the husband comes out. I pause the stretcher a moment for him to put his arms around her, kiss her face and crying, tell her he loves her. An officer gently pulls him away and says they have to keep going.
In the ambulance when we are about five minutes out, I patch to the hospital. “Female in cardiac arrest. Found hanging from a tree by her husband. Unknown when she hung herself. She’s cold and blue and asystole, but her body is still limber. No rigor. We have her intubated and have given a round of meds with no response. We’re bringing in her because she’s hypothermic.”
At the hospital, the trauma team waits for us. A member of the team says, “Oh, she’s really cold.”
“She’s not dead till she’s warm and dead,” a doctor says.
“She’s still limber,” I add. “We don’t know how long she was out there. Ten minutes or an hour. There’s quite a chill out there this morning.”
Her rectal temp is a surprising 97.0. I guess she wasn’t out there that long after all. They call the time.
Later I hear she just got out of the psychiatric hospital. She’s been trying to kill herself for ten years. She told her husband once, “One day you’re going to find me hanging from that tree.”
Hell. If my wife ever told me that, I’d cut the damn tree down.
Sunday, April 13, 2008
Black Flies
I just finished reading a new EMS novel called Black Fliesby Shannon Burke, who also wrote Safelight.
The novel is about a young paramedic in Harlem who, trying to fit in, falls under the influence of some seriously burned out medics.
Black Fliesis a much better read than Burke's first book, which while well-written, seemed to rely more on craft than emotion, and was a slow go for me. This new book is a page turner, and at times, is quite moving.
Burke does an excellent job in describing EMS scenes. His character portrayals are also well done. He really shows how easy it is for an impressionable young person to be molded in all the wrong ways by poor role-models. His portrayal of the gradual unraveling of an older medic is unsettling.
I think most medics and EMTs will enjoy the book although some may be turned off by some of the actions of certain medics in the book. Burnout unfortunately seems to be the universal theme of EMS fiction, i.e. Joe Connelly's Bringing Out the Dead as well as the movie Broken Vessels.
I've worked inner city EMS and I've seen burned out medics, but the characters in this book are well beyond my experience. Nevertheless, the book itself while diving into EMS's darkest corners, is ultimately redeeming. There is a particularly good scene when the young medic, on his own, visits the family of a patient who was left to die by the medic and his partner.
It is my understanding the novel is being made into a movie to be released by Paramount in January 2009.
Here's an old New York Times profile of the author who worked as an EMT/paramedic in Harlem in the 1990s.
On the Way to the Hospital, A Novel is Born
by Shannon Burke, who also wrote Safelight.The novel is about a young paramedic in Harlem who, trying to fit in, falls under the influence of some seriously burned out medics.
Black Flies
is a much better read than Burke's first book, which while well-written, seemed to rely more on craft than emotion, and was a slow go for me. This new book is a page turner, and at times, is quite moving.Burke does an excellent job in describing EMS scenes. His character portrayals are also well done. He really shows how easy it is for an impressionable young person to be molded in all the wrong ways by poor role-models. His portrayal of the gradual unraveling of an older medic is unsettling.
I think most medics and EMTs will enjoy the book although some may be turned off by some of the actions of certain medics in the book. Burnout unfortunately seems to be the universal theme of EMS fiction, i.e. Joe Connelly's Bringing Out the Dead
as well as the movie Broken Vessels.I've worked inner city EMS and I've seen burned out medics, but the characters in this book are well beyond my experience. Nevertheless, the book itself while diving into EMS's darkest corners, is ultimately redeeming. There is a particularly good scene when the young medic, on his own, visits the family of a patient who was left to die by the medic and his partner.
It is my understanding the novel is being made into a movie to be released by Paramount in January 2009.
Here's an old New York Times profile of the author who worked as an EMT/paramedic in Harlem in the 1990s.
On the Way to the Hospital, A Novel is Born
Friday, April 11, 2008
Faces of Life and Death
Earlier this week I did a cardiac arrest at a nursing home. I arrived to find an elderly patient apniec and pulseless. The patient was quite large and had a lifeless face with a small amount of facial hair that made it difficult to ascertain gender. The nursing home staff had last seen her (she was a woman, they confirmed) alive an hour before. I put her on the monitor and she was asystole. We resumed CPR. I intubated her, while my partner put in an IV. We gave her four epis and two atropines. Still asystole, we presumed her dead after 20 minutes of ACLS per our protocol. We detached her from our monitor, removed the ET tube and IV line, covered her with a sheet and cleaned up the assorted medical wrappers that were laying about. On the way back to the ambulance, the nurse handed me a W10, which I could use to write up my paperwork back at the base.
After we'd restocked and cleaned our gear, I called dispatch for times and then sat down to write my form. I pulled the W-10 out of my pocket and looked at the patient's name.
I was shocked. She was someone I knew. I had in fact transported her to the hospital on many occasions and often saw her sitting in the hallway in her wheelchair. We always said hello to each other as I wheeled my stretcher past. She had a big, mischievous smile and often cracked jokes. I was startled that I hadn't recognized her.
Cardiac arrests I find are relatively easy to work from an emotional standpoint because the patient is simply dead. More than dead -- they are lifeless without a personality. It is much harder when your patient codes in front of you(you have after all just been talking to them), and it is certainly much harder if you have known the patient a long time.
During the arrest, I wasn't working on "Hilda." I was working on the corpse of a stranger. Not that I didn't do my best. It just wasn't very emotionally involving. After 20 minutes, I announced my intention to presume the patient unless there were objections. Hearing none, I called the time. Not at all like the TV codes or even real-life codes where the medical staff is working on a loved patient and while the tearful doctor or nurse won't stop CPR, another doctor puts his hand on their shoulder and says, "She's gone. She's gone. You have to let her go."
I thought about all of this this morning as I came across the following on the internet. It is an art exhibit of black and white portraits of hospice patients, before and after their deaths.
Life Before Death
After we'd restocked and cleaned our gear, I called dispatch for times and then sat down to write my form. I pulled the W-10 out of my pocket and looked at the patient's name.
I was shocked. She was someone I knew. I had in fact transported her to the hospital on many occasions and often saw her sitting in the hallway in her wheelchair. We always said hello to each other as I wheeled my stretcher past. She had a big, mischievous smile and often cracked jokes. I was startled that I hadn't recognized her.
Cardiac arrests I find are relatively easy to work from an emotional standpoint because the patient is simply dead. More than dead -- they are lifeless without a personality. It is much harder when your patient codes in front of you(you have after all just been talking to them), and it is certainly much harder if you have known the patient a long time.
During the arrest, I wasn't working on "Hilda." I was working on the corpse of a stranger. Not that I didn't do my best. It just wasn't very emotionally involving. After 20 minutes, I announced my intention to presume the patient unless there were objections. Hearing none, I called the time. Not at all like the TV codes or even real-life codes where the medical staff is working on a loved patient and while the tearful doctor or nurse won't stop CPR, another doctor puts his hand on their shoulder and says, "She's gone. She's gone. You have to let her go."
I thought about all of this this morning as I came across the following on the internet. It is an art exhibit of black and white portraits of hospice patients, before and after their deaths.
Life Before Death
Wednesday, April 09, 2008
Minimally Interrupted CPR
There is another new study out (published in the March 12 Journal of the American Medical Association that may change the way we do CPR, continuing the emphasis on "Minimally Interrupted CPR."
Minimally Interrupted Cardiac Resuscitation for Out-of-Hospital Cardiac Arrest
Here the jist of the protocol:
This novel approach, aimed at maximizing cerebral perfusion, involves:
an initial series of 200 uninterrupted chest compressions;
rhythm analysis, with a single defibrillator shock if indicated;
200 immediate post-shock chest compressions before pulse check or rhythm reanalysis;
administration of epinephrine as soon as possible, repeated with each cycle of compressions and rhythm analysis;
delay of intubation until after three cycles of chest compression and rhythm analysis.
I haven't read the full research article, here is the abstract:
Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest
The article suggests the study needs to be validated by a randomized study.
What I find interesting is the high profile of epi, which has not performed well in the past. One physician told me that the reason epi may not have made a difference in the past is because the CPR was too poor. By improving the CPR we change the entire dynamics of all the other elements.
What I love about medicine is it is never stagnant, always changing, and hopefully get closer to, not farther from, the best course for the patient.
***
As a side note, I wish there was a way to better(quicker) communicate at least the new CPR's emphasis on compressions to other health personnel. I did another code this morning (I have had quite a rash of them this year) and again arrived to find two nursing home personnel trying to figure out how to bag properly) and no one doing CPR. I have also seen this with sanctioned first responders. While I can't find it in the abstract -- it may be in the text of the article, I believe either this study or another protocol somewhere calls for the application of a non-rebreather on the apneic patient until time for intubation. I know one the commentators on a recent post mentioned doing that.
Minimally Interrupted Cardiac Resuscitation for Out-of-Hospital Cardiac Arrest
Here the jist of the protocol:
This novel approach, aimed at maximizing cerebral perfusion, involves:
an initial series of 200 uninterrupted chest compressions;
rhythm analysis, with a single defibrillator shock if indicated;
200 immediate post-shock chest compressions before pulse check or rhythm reanalysis;
administration of epinephrine as soon as possible, repeated with each cycle of compressions and rhythm analysis;
delay of intubation until after three cycles of chest compression and rhythm analysis.
I haven't read the full research article, here is the abstract:
Minimally Interrupted Cardiac Resuscitation by Emergency Medical Services for Out-of-Hospital Cardiac Arrest
The article suggests the study needs to be validated by a randomized study.
What I find interesting is the high profile of epi, which has not performed well in the past. One physician told me that the reason epi may not have made a difference in the past is because the CPR was too poor. By improving the CPR we change the entire dynamics of all the other elements.
What I love about medicine is it is never stagnant, always changing, and hopefully get closer to, not farther from, the best course for the patient.
***
As a side note, I wish there was a way to better(quicker) communicate at least the new CPR's emphasis on compressions to other health personnel. I did another code this morning (I have had quite a rash of them this year) and again arrived to find two nursing home personnel trying to figure out how to bag properly) and no one doing CPR. I have also seen this with sanctioned first responders. While I can't find it in the abstract -- it may be in the text of the article, I believe either this study or another protocol somewhere calls for the application of a non-rebreather on the apneic patient until time for intubation. I know one the commentators on a recent post mentioned doing that.
Monday, April 07, 2008
Zen Masters and Gizmos
I've been precepting a new part-time intermediate. He needs 15 IV starts in the field. He may have five or so. (We only work together once a week.) He doesn't quite have the hang of it yet. I tell him not to worry about missing because when you miss you learn what not to do the next time. The more you miss, the more you learn. That's how it was when I started. I poked a lot of holes in people, spilled a lot of blood, but with time, I became pretty good at it.
IVs are, in fact, my secret pride. I consider myself an IV War Lord Zen master, capable of putting an IV into a stone. I get so good sometimes that I feel like I don't even have to look for a vein, I just stick the needle in anywhere and the next thing I know I have blood flowing into the chamber. I am one with the vein. If I were an oil driller, Jed Clampet and JD Rockefeller would have nothing on me. So whenever I stick the catheter in and don't see blood flashing into the chamber, I am a little shocked. I adjust it a little, pull back and then forward at a slightly different angle and blood flows into the chamber and all is right with the world again.
Now I am exaggerating a little. I don't always get the IV, but I am really good at it. If you were to rate my various paramedic skills. I might be below average or average in some, above average in others, but in IVs, I rate nothing less than very good, even excellent. Like I said, I missed a lot in the early days to get as good as I am.
So my preceptee goes down to the EMS Conference and comes back with all these IV vein finder gadgets. He even buys one for me. I think he is expecting me to thank him graciously and be his pal, but what I am thinking is: "Grasshopper, how dare you insult your master this way?" IV Gizmo? I don't need no stinking IV Gizmo! If I were Darth Vader, I would simple crush the insolent private with a blow to the top of the head.
I put the gizmo -- an contricting band something or other -- in my IV tray, but leave it in the package. There it sits all day long. I have three patients with relatively poor IV access, but I don't even think about picking it up. First patient I miss my first try, get my second. Next patient I miss twice before I get a tiny 24 on my third try on the underside of the wrist. The patient is in failure, and needs Lasix, so the third try was okay, plus like I said, I always get the IV, so there was no question I would miss the third time. The first two misses were, ah...aberrations. Still, though, I no longer feel one with the vein.
And then the next day -- first patient -- I miss the first one, get the second try, and then go to put in a 2nd IV -- the patient is critical -- and I miss again. Next patient -- I miss on the first attempt. Get a 22 on the second try. The third patient is in a rapid a-fib. I need a line so I can give Cardizem. I can't even find a vein. I can't see one, can't feel one, and when I do my anatomy checks, there is not even the slightest hint of a vein hiding in the usual places. I have no confidence at all that if I just stick the catheter where I think a vein might be hiding that I will hit anything.
Note: While we have the EZ-IO, this patient isn't sick enough for me to drill a needle into her leg bone.
I eye the tourniquet constricting gizmo. I'm thinking all right -- this will be a good entry for the blog. Veteran Zen master IV man casts hubris aside and uses grasshopper's gizmo, gets IV and learns lesson in swallowing pride.
I take the thing out of the package. It takes me a little while to figure out how it works. I finally strap it on the patient and she starts screaming. I am pinching her skin. I apologize profusely and manage to free her skin from the device. Following the instructions I roll it down the arm. I think I spot a possible vein -- a small rubbery spot near the AC. I tap it a few times, run an alcohol wipe over it, and then take out a 20 catheter. I slide it right in. Nothing. No flash.
"Did you get it?" the patient asks.
"No," I say, sounding more like a homeless man whose dog has just run than any Zen Kung Fu IV master.
"Why don't you wait for the hospital and let the professionals do it?" she says.
Now, normally this would get me all fired up, challenging me to uphold the honor of my profession, but today, my confidence is shot. I hang my head and say, "Yeah, I guess you are right."
I'm losing my powers.
I'M MELTING!
IVs are, in fact, my secret pride. I consider myself an IV War Lord Zen master, capable of putting an IV into a stone. I get so good sometimes that I feel like I don't even have to look for a vein, I just stick the needle in anywhere and the next thing I know I have blood flowing into the chamber. I am one with the vein. If I were an oil driller, Jed Clampet and JD Rockefeller would have nothing on me. So whenever I stick the catheter in and don't see blood flashing into the chamber, I am a little shocked. I adjust it a little, pull back and then forward at a slightly different angle and blood flows into the chamber and all is right with the world again.
Now I am exaggerating a little. I don't always get the IV, but I am really good at it. If you were to rate my various paramedic skills. I might be below average or average in some, above average in others, but in IVs, I rate nothing less than very good, even excellent. Like I said, I missed a lot in the early days to get as good as I am.
So my preceptee goes down to the EMS Conference and comes back with all these IV vein finder gadgets. He even buys one for me. I think he is expecting me to thank him graciously and be his pal, but what I am thinking is: "Grasshopper, how dare you insult your master this way?" IV Gizmo? I don't need no stinking IV Gizmo! If I were Darth Vader, I would simple crush the insolent private with a blow to the top of the head.
I put the gizmo -- an contricting band something or other -- in my IV tray, but leave it in the package. There it sits all day long. I have three patients with relatively poor IV access, but I don't even think about picking it up. First patient I miss my first try, get my second. Next patient I miss twice before I get a tiny 24 on my third try on the underside of the wrist. The patient is in failure, and needs Lasix, so the third try was okay, plus like I said, I always get the IV, so there was no question I would miss the third time. The first two misses were, ah...aberrations. Still, though, I no longer feel one with the vein.
And then the next day -- first patient -- I miss the first one, get the second try, and then go to put in a 2nd IV -- the patient is critical -- and I miss again. Next patient -- I miss on the first attempt. Get a 22 on the second try. The third patient is in a rapid a-fib. I need a line so I can give Cardizem. I can't even find a vein. I can't see one, can't feel one, and when I do my anatomy checks, there is not even the slightest hint of a vein hiding in the usual places. I have no confidence at all that if I just stick the catheter where I think a vein might be hiding that I will hit anything.
Note: While we have the EZ-IO, this patient isn't sick enough for me to drill a needle into her leg bone.
I eye the tourniquet constricting gizmo. I'm thinking all right -- this will be a good entry for the blog. Veteran Zen master IV man casts hubris aside and uses grasshopper's gizmo, gets IV and learns lesson in swallowing pride.
I take the thing out of the package. It takes me a little while to figure out how it works. I finally strap it on the patient and she starts screaming. I am pinching her skin. I apologize profusely and manage to free her skin from the device. Following the instructions I roll it down the arm. I think I spot a possible vein -- a small rubbery spot near the AC. I tap it a few times, run an alcohol wipe over it, and then take out a 20 catheter. I slide it right in. Nothing. No flash.
"Did you get it?" the patient asks.
"No," I say, sounding more like a homeless man whose dog has just run than any Zen Kung Fu IV master.
"Why don't you wait for the hospital and let the professionals do it?" she says.
Now, normally this would get me all fired up, challenging me to uphold the honor of my profession, but today, my confidence is shot. I hang my head and say, "Yeah, I guess you are right."
I'm losing my powers.
I'M MELTING!
Sunday, April 06, 2008
Epistaxis-Syncope, SYNCOPE-HYPOTENSION-epistaxis
The call is for a nosebleed. Person unconscious in a car. We get updated that the patient is now conscious, but still some bleeding from the nose.
The first responder tells us the man has had a nose bleed all day and finally called a neighbor to drive him to the hospital. On the way, he passed out. The responder says the bleeding is down to a trickle.
We are at the side of a busy road so my partner and I lift the thin, frail man out of the front seat of his neighbor's car and right onto the stretcher and then we wheel him over to the ambulance and get him in the back.
He is extremely diaphoretic and asks repeatedly if he locked his door. I try to tell him that we just picked him up from his neighbor's car. He is in his eighties and I am guess he may some dementia. I take a blood pressure and just barely hear it at 90. While my partner tries for an IV, I do a quick 12-lead, but the electrodes just won't stick. The man holds a Kleenex in his hand that is just dabbed with blood. There is no way a nosebleed would cause this kind of diaphoresis. Maybe it is posterior bleed, but there is no sign of throwing or spitting up clots. The man can tell me his date of birth, but not the names of his medicine. The only medical history I get is hypertension. I ask if he is on a beta blocker, but he doesn't seem to know what I am talking about. I ask because his heart rate is only in the 80's.
My patch to the hospital is brief, "We're seven minutes out with an 80 year old with a supposed uncontrolled nose bleed earlier, had a neighbor drive him to the hospital, on the way he had a syncopal episode so they called 911. The nose bleed has stopped. He's alert, but slightly confused, very diaphoretic with a BP of 90/50. Heart rate 88. Denies any pain. Only history I can get from him is hypertension."
Not the best patch, but it's about what I said. Generally to this hospital, they want short and sweet, just so they have an idea of what is coming in, so they know where to make room in ED. A major medical or trauma room, the Main ED, a Less Acute Wing, the psych ward or the waiting room, and whether or not this will need a doctor at the ready.
His skin looks a little mottled to me now and his hands are very cold. I try to take another pressure, but can't hear anything. When I use the electronic cuff on the monitor I get 74/40 and then 66/38. I have by now popped in a second line -- a 16 this time and am running the fluid in wide open. At triage I have to emphasize the syncope and the hypotension and deemphasise the nosebleed. We get the patient in the room. I give another quick report to the nurse. The nose bleed's been stopped for me. He's really cold and clammy and the last pressure I got was 66/38. When I come back to the room with my report, I see their monitor also has his pressure in the 60's and the bag of saline is just about empty. The doctor in the room is asking the patient about his nosebleed. I give him the report then, and he listens attentively.
Then we clear the hospital and life continues on.
Two things happen this morning. First the night medic, who I recently precepted, tells me that it is her feeling that it really important that medics work patients up as thoroughly as possible because at least some of the hospitals(because they are so overcrowded) tend to listen to what we have to say. If we say the patient is sick, they take it seriously. If we don't, they may put the patient in the hall or out in the waiting room. We are the patient's advocate and we need all the information we can get in order to advocate most effectively. And after all, it is only one patient we are taking care of, while the ED is taking care of easily a hundred -- with each nurse having seven or eight patients. For all we might bitch about it when we are ignored, the hospitals abd nurses do tend to rely on us. I really like what the medic is saying and how she is saying it, and I am pleased that she takes her responsibility as a medic seriously.
It makes me think about how in patches to the hospital or reports at triage, it is very important how I frame the information, and the order I put it in. If I had to do the patch over again, I might not even mention the nose bleed over the radio, while giving less weight to it in the direct paramedic-to-nurse report. Syncope. Hypotension. Also Epistaxis.
This morning I am at the hospital and a nurse comes over to me and tells me the man had a dissecting aneurysm. He lived in the ICU for five days till he expired. She theorizes that the nose bleed was from the hypertension. When the aneurysm ripped, his pressure plummeted and the nose bleed stopped.
Since few people with a ruptured aneurysm survive, I don't know if a more urgent patch would have made much of a difference. Perhaps, if I had been more urgent, he would have gone into a major medical room with a doctor right there with a true sense urgency -- not one pondering the nose bleed. At least, I suggested there was something more than a nosebleed at play. Nevertheless, it illustrates the point. We have to fight for our patient. The patients deserve it, and for the most part the hospitals expect us to do it. In many cases, a full assessment and an articulate, and at times passionate report will do as much or more for an ill patient than any actual care we render.
The first responder tells us the man has had a nose bleed all day and finally called a neighbor to drive him to the hospital. On the way, he passed out. The responder says the bleeding is down to a trickle.
We are at the side of a busy road so my partner and I lift the thin, frail man out of the front seat of his neighbor's car and right onto the stretcher and then we wheel him over to the ambulance and get him in the back.
He is extremely diaphoretic and asks repeatedly if he locked his door. I try to tell him that we just picked him up from his neighbor's car. He is in his eighties and I am guess he may some dementia. I take a blood pressure and just barely hear it at 90. While my partner tries for an IV, I do a quick 12-lead, but the electrodes just won't stick. The man holds a Kleenex in his hand that is just dabbed with blood. There is no way a nosebleed would cause this kind of diaphoresis. Maybe it is posterior bleed, but there is no sign of throwing or spitting up clots. The man can tell me his date of birth, but not the names of his medicine. The only medical history I get is hypertension. I ask if he is on a beta blocker, but he doesn't seem to know what I am talking about. I ask because his heart rate is only in the 80's.
My patch to the hospital is brief, "We're seven minutes out with an 80 year old with a supposed uncontrolled nose bleed earlier, had a neighbor drive him to the hospital, on the way he had a syncopal episode so they called 911. The nose bleed has stopped. He's alert, but slightly confused, very diaphoretic with a BP of 90/50. Heart rate 88. Denies any pain. Only history I can get from him is hypertension."
Not the best patch, but it's about what I said. Generally to this hospital, they want short and sweet, just so they have an idea of what is coming in, so they know where to make room in ED. A major medical or trauma room, the Main ED, a Less Acute Wing, the psych ward or the waiting room, and whether or not this will need a doctor at the ready.
His skin looks a little mottled to me now and his hands are very cold. I try to take another pressure, but can't hear anything. When I use the electronic cuff on the monitor I get 74/40 and then 66/38. I have by now popped in a second line -- a 16 this time and am running the fluid in wide open. At triage I have to emphasize the syncope and the hypotension and deemphasise the nosebleed. We get the patient in the room. I give another quick report to the nurse. The nose bleed's been stopped for me. He's really cold and clammy and the last pressure I got was 66/38. When I come back to the room with my report, I see their monitor also has his pressure in the 60's and the bag of saline is just about empty. The doctor in the room is asking the patient about his nosebleed. I give him the report then, and he listens attentively.
Then we clear the hospital and life continues on.
Two things happen this morning. First the night medic, who I recently precepted, tells me that it is her feeling that it really important that medics work patients up as thoroughly as possible because at least some of the hospitals(because they are so overcrowded) tend to listen to what we have to say. If we say the patient is sick, they take it seriously. If we don't, they may put the patient in the hall or out in the waiting room. We are the patient's advocate and we need all the information we can get in order to advocate most effectively. And after all, it is only one patient we are taking care of, while the ED is taking care of easily a hundred -- with each nurse having seven or eight patients. For all we might bitch about it when we are ignored, the hospitals abd nurses do tend to rely on us. I really like what the medic is saying and how she is saying it, and I am pleased that she takes her responsibility as a medic seriously.
It makes me think about how in patches to the hospital or reports at triage, it is very important how I frame the information, and the order I put it in. If I had to do the patch over again, I might not even mention the nose bleed over the radio, while giving less weight to it in the direct paramedic-to-nurse report. Syncope. Hypotension. Also Epistaxis.
This morning I am at the hospital and a nurse comes over to me and tells me the man had a dissecting aneurysm. He lived in the ICU for five days till he expired. She theorizes that the nose bleed was from the hypertension. When the aneurysm ripped, his pressure plummeted and the nose bleed stopped.
Since few people with a ruptured aneurysm survive, I don't know if a more urgent patch would have made much of a difference. Perhaps, if I had been more urgent, he would have gone into a major medical room with a doctor right there with a true sense urgency -- not one pondering the nose bleed. At least, I suggested there was something more than a nosebleed at play. Nevertheless, it illustrates the point. We have to fight for our patient. The patients deserve it, and for the most part the hospitals expect us to do it. In many cases, a full assessment and an articulate, and at times passionate report will do as much or more for an ill patient than any actual care we render.
Saturday, April 05, 2008
A Choice
A couple years ago I decided I wanted to become a triathlete. Call it a middle aged crisis, but I started training regularly and last year completed six triathlons. These triathlons were not the same distance as the famous Ironman triathlons, which include a 2.4-mile swim, a 112-mile bike and a full 26.2-mile marathon at the end. My triathlons were called “sprint triathlons”, which at their longest involved a 1/2 mile swim, 12-mile bike and 3.1-mile run. Believe me they seemed long enough to me. While others used them as sprint races, they were every bit endurance contests to me.
I continued training vigorously over the winter and then in February laid out my race goals for the year with the pinnacle being an Olympic distance triathlon in late July with a one mile swim, 24-mile bike and 6.2 mile run. The next day, as if to penalize me for my hubris, I hurt my foot running (I think I ruptured a tendon in one of the toes of my left foot as I can no longer flex the toe), and I was left limping for a couple weeks until the pain went away. When it started to feel better I went running on a very cold day without properly warming up. I ran a full 3.1 miles, and then had to rush off to pick someone up without doing a proper cool down and then, sure enough, I found myself hobbled with a sore ankle.
Just when my ankle started feeling better I came down with a cold, which turned into bronchitis. Twenty-one days later I finally made it back to the track for a two-mile run. The next day the big toe on my right foot, which had been mysteriously slightly swollen the morning of my run was now fully swollen and inflamed. I don’t think I injured it running. My best guess is it is an attack of gout. This has not been confirmed by a doctor, just my best guess from reading on-line medical wed sites. I have had similar big toe swellings a couple times in the past, always spaced a few years apart and think gout is likely. It feels better today and I need to show some sense and not push it too much although I really want to go out running.
Today I was supposed to run my first ¼ marathon at the nearby reservoir, but my training has suffered to the point I would not only come in last, but would likely finish walking. I have managed to work through all of this without missing a scheduled work day, but have had to cut back significantly on overtime to heal.
I was talking to an older medic last week and he confesses he eats Motrin daily just to make it through the day. I know my old partner Arthur used it quite a bit as well. I have on occasion, but may need to amp up my dosing.
Being a paramedic is my great love and at times like this when I am sick and hobbled, I wonder if I will be able to make it until the end -- age 65 is my target -- or whether I will have to find something safer, less stressful on my body. It seems in a way at times like it is a choice between the woman you passionately love and the one who would make a securer marriage – a woman from a respectable family with a fine dowry. I am always encouraged when I see older medics and EMTs out working the streets with vigor, and I am discouraged when I have patients who I discover on their W-10s are younger than I am.
It is cold and rainy here today and I cannot wait for warmer weather's arrival and to be back out on the road running, feeling like a young man with illness and injury far from my unworried mind.
My Triathlon Quest
I continued training vigorously over the winter and then in February laid out my race goals for the year with the pinnacle being an Olympic distance triathlon in late July with a one mile swim, 24-mile bike and 6.2 mile run. The next day, as if to penalize me for my hubris, I hurt my foot running (I think I ruptured a tendon in one of the toes of my left foot as I can no longer flex the toe), and I was left limping for a couple weeks until the pain went away. When it started to feel better I went running on a very cold day without properly warming up. I ran a full 3.1 miles, and then had to rush off to pick someone up without doing a proper cool down and then, sure enough, I found myself hobbled with a sore ankle.
Just when my ankle started feeling better I came down with a cold, which turned into bronchitis. Twenty-one days later I finally made it back to the track for a two-mile run. The next day the big toe on my right foot, which had been mysteriously slightly swollen the morning of my run was now fully swollen and inflamed. I don’t think I injured it running. My best guess is it is an attack of gout. This has not been confirmed by a doctor, just my best guess from reading on-line medical wed sites. I have had similar big toe swellings a couple times in the past, always spaced a few years apart and think gout is likely. It feels better today and I need to show some sense and not push it too much although I really want to go out running.
Today I was supposed to run my first ¼ marathon at the nearby reservoir, but my training has suffered to the point I would not only come in last, but would likely finish walking. I have managed to work through all of this without missing a scheduled work day, but have had to cut back significantly on overtime to heal.
I was talking to an older medic last week and he confesses he eats Motrin daily just to make it through the day. I know my old partner Arthur used it quite a bit as well. I have on occasion, but may need to amp up my dosing.
Being a paramedic is my great love and at times like this when I am sick and hobbled, I wonder if I will be able to make it until the end -- age 65 is my target -- or whether I will have to find something safer, less stressful on my body. It seems in a way at times like it is a choice between the woman you passionately love and the one who would make a securer marriage – a woman from a respectable family with a fine dowry. I am always encouraged when I see older medics and EMTs out working the streets with vigor, and I am discouraged when I have patients who I discover on their W-10s are younger than I am.
It is cold and rainy here today and I cannot wait for warmer weather's arrival and to be back out on the road running, feeling like a young man with illness and injury far from my unworried mind.
My Triathlon Quest
Wednesday, April 02, 2008
Hands-Only CPR
The AHA has issued a new Hands-Only (Compression Only) CPR advisory. The advisory applies to bystanders, not professional rescuers.
When you see an adult suddenly collapse, use Hands-Only CPR: that's CPR without mouth-to-mouth breaths. And it can help save lives.
Hands-Only CPR is CPR without mouth-to-mouth breaths. It is recommended for use by bystanders who see an adult suddenly collapse in the "out-of-hospital" setting. It consists of two steps:
Call 911 (or send someone to do that).
Begin providing high-quality chest compressions by pushing hard and fast in the center of the
chest with minimal interruptions
The American Heart Association recommends conventional CPR (that is, CPR with a combination of breaths and compressions) for all infants and children, for adult victims who are found already unconscious and not breathing normally, and for any victims of drowning or collapse due to breathing problems.
-AHA
AHA Hands-Only Advisory
***
I've posted these strips before. It is an ETCO2 readout while the patient has just been intubated during CPR, but before the ambu-bag has been attached and ventilation begun. (I always attach the capnofilter to my ET tube before I intubate.) The tiny bumps are CPR, each compression creates a small tidal volume that releases CO2, ventilating the body by compression only. The large wave is from the first ambu-bag ventilation on the just placed ET tube.
***
Based on a code I did yesterday at a nursing home, I would add some nursing home workers to the bystander category. Even with multiple hands and an ambubag, it is rare to see ventilations done properly, and even when they are done well, they are often at the expense of good compressions.
When you see an adult suddenly collapse, use Hands-Only CPR: that's CPR without mouth-to-mouth breaths. And it can help save lives.
Hands-Only CPR is CPR without mouth-to-mouth breaths. It is recommended for use by bystanders who see an adult suddenly collapse in the "out-of-hospital" setting. It consists of two steps:
Call 911 (or send someone to do that).
Begin providing high-quality chest compressions by pushing hard and fast in the center of the
chest with minimal interruptions
The American Heart Association recommends conventional CPR (that is, CPR with a combination of breaths and compressions) for all infants and children, for adult victims who are found already unconscious and not breathing normally, and for any victims of drowning or collapse due to breathing problems.
-AHA
AHA Hands-Only Advisory
***
I've posted these strips before. It is an ETCO2 readout while the patient has just been intubated during CPR, but before the ambu-bag has been attached and ventilation begun. (I always attach the capnofilter to my ET tube before I intubate.) The tiny bumps are CPR, each compression creates a small tidal volume that releases CO2, ventilating the body by compression only. The large wave is from the first ambu-bag ventilation on the just placed ET tube.
***
Based on a code I did yesterday at a nursing home, I would add some nursing home workers to the bystander category. Even with multiple hands and an ambubag, it is rare to see ventilations done properly, and even when they are done well, they are often at the expense of good compressions.
Tuesday, April 01, 2008
Driver's Seat
We're called for an unresponsive at the movie theatre, but are soon updated that the patient is conscious and breathing. As we pull into the parking lot, we see a police car next to a green Oldsmobile, and the officer looking in the passenger door.
The officer comes over and talks to me as I step out of the ambulance. "He doesn't want to go," the officer says, "But his wife says he wasn't breathing and she gave him rescue breaths and did CPR."
I look at him dubiously. He shrugs as if to say, "I'm just giving you the information."
The man, in his seventies, has good color and is fully alert. He looks good for someone who had CPR done on him. I introduce myself by name to him and his wife and ask how he is feeling.
"I'm fine," he says quickly. "I just passed out for a moment in the theatre, but I'm fine now, really."
His wife starts to speak, but he cuts her off. "This really isn't necessary," he says.
"Well," I say. "I understand you don't want to go to the hospital, but anytime someone has what you had -- what we call a syncopal episode -- someone passing out -- it is very important that you go to the hospital to get checked out. If it happened once, it can happen again, and the next time with a different, perhaps more ominous outcome."
"No, really, thank you for coming, but I am fine," he says.
"He didn't just pass out," his wife says. "You weren't breathing. I had to breath for you. You were dead and I had to push against your chest."
He looks at me and rolls his eyes. "I just want to go home."
"He had no pulse," a woman standing by me now says. I turn to look at her. She appears also to be in her seventies.
"His wife and I are nurses. He wasn't breathing. She saved his life."
"You couldn't feel a pulse?" I hint.
"He had no pulse."
I don't argue with her. I have my opinion, but I wasn't there. And I suppose anything is possible.
"How long did this episode last?"
"I don't know. It was all so scary. Maybe thirty seconds. Maybe a minute. His eyes rolled back into his head. He was gone and then she brought him back. He must go to the hospital."
"I was only out thirty seconds," the man says. "I just want to go home."
"If you were out. How do you know how long you were out for?"
"It was at least a minute," the wife says. "I gave him two rescue breaths and pressed twice against his chest." She looks right at her husband. "You were dead. My breath...." She tears up. "...my kiss -- brought you back. Please, for me, go to the hospital."
"How long have you two been married?" I ask. I am clearly expecting her to say in excess of fifty years.
"Three months," she says.
He looks at me, pleadingly. I get the sense that this young marriage seems much longer than three months to him. "I just want to get out of here and go home," he says.
"You wife is really concerned about you. I'm concerned about you. How about just going in the interest of marital bliss?"
He shakes his head again.
"You won't do it for me?" she says, and she begins to cry in earnest. "Please, do it for me."
I have a vision of her, dressed in black, grieving in another empty home.
I check him out from top to bottom. His vitals are good. His EKG is normal. He just tells me he felt weak at the knees and got lightheaded and passed out briefly. It happened to him ten years ago and they never found anything wrong. He was at the doctor this week and everything checked out fine. Please, can he just go home?
"My advice, as it is in every episode of syncope, is to go to the hospital. We don't really know what happened. We'll take you down there and they can either give you a clean bill of health or else find out what the problem is and hopefully correct it." I turn to the tired standard line. "Better be safe than sorry."
"I'm not going," he says.
"You must take him," the other woman says again. "He should have no choice. He must go. Think of his poor wife."
I explain that we can't take him against his will. If, despite our strongest medical advice, he refuses, there is nothing we can do. We cannot kidnap him.
"Thank you," he says. "Now, can we leave?"
He signs a refusal and she reluctantly signs as a witness. I remind her she can call us back if anything happens or she has any more concerns.
But then, I say, "And don't forget, right now you are sitting in the driver's seat. He is in the passenger seat. There's nothing to keep you from driving right to the ER."
I see one of her eyebrows raise. He looks at her as if to say, don't you dare.
We leave the two newlyweds to decide their own course.
***
Later, I hear from a woman who happened to be in the theatre when the episode occurred. She laughs when I describe the account of the wife's heroic efforts. "He just passed out," she says. "There was no CPR."
The officer comes over and talks to me as I step out of the ambulance. "He doesn't want to go," the officer says, "But his wife says he wasn't breathing and she gave him rescue breaths and did CPR."
I look at him dubiously. He shrugs as if to say, "I'm just giving you the information."
The man, in his seventies, has good color and is fully alert. He looks good for someone who had CPR done on him. I introduce myself by name to him and his wife and ask how he is feeling.
"I'm fine," he says quickly. "I just passed out for a moment in the theatre, but I'm fine now, really."
His wife starts to speak, but he cuts her off. "This really isn't necessary," he says.
"Well," I say. "I understand you don't want to go to the hospital, but anytime someone has what you had -- what we call a syncopal episode -- someone passing out -- it is very important that you go to the hospital to get checked out. If it happened once, it can happen again, and the next time with a different, perhaps more ominous outcome."
"No, really, thank you for coming, but I am fine," he says.
"He didn't just pass out," his wife says. "You weren't breathing. I had to breath for you. You were dead and I had to push against your chest."
He looks at me and rolls his eyes. "I just want to go home."
"He had no pulse," a woman standing by me now says. I turn to look at her. She appears also to be in her seventies.
"His wife and I are nurses. He wasn't breathing. She saved his life."
"You couldn't feel a pulse?" I hint.
"He had no pulse."
I don't argue with her. I have my opinion, but I wasn't there. And I suppose anything is possible.
"How long did this episode last?"
"I don't know. It was all so scary. Maybe thirty seconds. Maybe a minute. His eyes rolled back into his head. He was gone and then she brought him back. He must go to the hospital."
"I was only out thirty seconds," the man says. "I just want to go home."
"If you were out. How do you know how long you were out for?"
"It was at least a minute," the wife says. "I gave him two rescue breaths and pressed twice against his chest." She looks right at her husband. "You were dead. My breath...." She tears up. "...my kiss -- brought you back. Please, for me, go to the hospital."
"How long have you two been married?" I ask. I am clearly expecting her to say in excess of fifty years.
"Three months," she says.
He looks at me, pleadingly. I get the sense that this young marriage seems much longer than three months to him. "I just want to get out of here and go home," he says.
"You wife is really concerned about you. I'm concerned about you. How about just going in the interest of marital bliss?"
He shakes his head again.
"You won't do it for me?" she says, and she begins to cry in earnest. "Please, do it for me."
I have a vision of her, dressed in black, grieving in another empty home.
I check him out from top to bottom. His vitals are good. His EKG is normal. He just tells me he felt weak at the knees and got lightheaded and passed out briefly. It happened to him ten years ago and they never found anything wrong. He was at the doctor this week and everything checked out fine. Please, can he just go home?
"My advice, as it is in every episode of syncope, is to go to the hospital. We don't really know what happened. We'll take you down there and they can either give you a clean bill of health or else find out what the problem is and hopefully correct it." I turn to the tired standard line. "Better be safe than sorry."
"I'm not going," he says.
"You must take him," the other woman says again. "He should have no choice. He must go. Think of his poor wife."
I explain that we can't take him against his will. If, despite our strongest medical advice, he refuses, there is nothing we can do. We cannot kidnap him.
"Thank you," he says. "Now, can we leave?"
He signs a refusal and she reluctantly signs as a witness. I remind her she can call us back if anything happens or she has any more concerns.
But then, I say, "And don't forget, right now you are sitting in the driver's seat. He is in the passenger seat. There's nothing to keep you from driving right to the ER."
I see one of her eyebrows raise. He looks at her as if to say, don't you dare.
We leave the two newlyweds to decide their own course.
***
Later, I hear from a woman who happened to be in the theatre when the episode occurred. She laughs when I describe the account of the wife's heroic efforts. "He just passed out," she says. "There was no CPR."
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