I want to use this post to followup on comments and some recent entries.
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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.
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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."
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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.
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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.
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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.
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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.
