A young doctor I know, who used to be a street paramedic, says the reason paramedics have standing orders is because no two doctors can agree on anything so they let the medics decide based on written guidelines. Otherwise there would be chaos.
Where I work I transport patients to any of eight hospitals, but there are four I regularly take people to. With the exception of the hospital's EMS medical directors, hardly anyone on the medical staff are familar with our prehospital protocols. They may know the outlines (ASA for chest pain, D50 for hypoglycemia, narcan for heroin OD, albuterol for asthma wheezing, etc.) but they don't know the particulars. I have been castigated for not RSIing a patient with trismus (We don't carry RSI meds), for calling medical control when faced with an 68 year-old man who had a syncopal episode and was refusing to go to the hospital despite being clammy and having a heart rate of 36(I'm supposed to call so you can help persuade the patient who needs to go and not yell at me for bothering you), and questioned on the appropriateness of giving Cardizem prehospitally for rapid a-fib (it's why we carry it).
This doesn't happen a lot. I site it only to demonstrate people don't know the protocols or, in many cases, the drugs we carry. Of the few things we do have to call for, I could probably go ahead and just give and have no one blink an eyelash at because they don't know I'm not supposed to give it on standing orders.
A number of years ago, I was quite proud that I had won the right on our medical advisory committee for paramedics to now give up to 15 mg morphine(weight dependent) on standing orders for fractures (previously we had to call after 5 mg). Two medics told me, "I do that anyway." They had been doing it and no one had questioned them.
There is not a lot of QA in our system.
But my point here is not about taking advantage of the system, it is about inconsistency.
One doctor likes Cardizem, another hates it. One doctor never gives Lasix, another gives it all the time. One doctor likes nitro paste, another says its worthless.
I recently heard about a call where a medic responded to an elderly woman who had been hit by a car at a low speed in a parking lot of a supermarket. When the medic arrived, she found the woman alert, ambulatory with only a small head lac. She said she had been brushed by the car and bumped her head against her own car. Never the less she boarded and collared the woman, and took her to the hospital, which happened to be both the woman's choice and the closest hospital.
Many hours later, the woman developed mental status changes and it was discovered she had a broken leg. Also, additional witnesses came forward and described a different story that the medic, in her best efforts, had obtained at the scene. The family also arrived and said their relative was clearly not her usual self. That happens. You can hardly do a full investigation in your ten minutes on scene. Nor can you be expected to know the patient's norm. The medic was later questioned on why she hadn't taken the woman to a trauma center. Given the circumstances I probably would have done just what the medic did. An alert, ambulatory patient, a minor mechanism of injury were hardly enough to deny the patient's choice of hospital.
Shortly thereafter I read a new study that showed that the elderly are often under-triaged when it comes to trauma. One reason sited was confusion is harder to spot in an elderly person where absent-mindedness and slowness of response are often taken for the norm. Another reason is their bones are much more brittle and prone to breaking at even the smallest mechanism. A young person acting confused and moving with a limp is easy to spot. In an elderly person it is the norm if you are unfamilar with their baseline.
Keeping this in mind, I had two patients in two days who were very similar. Each, an elderly woman who had sustained a fall, striking their head in the morning and then were not themselves afterwards, displaying serious and gradually worsening mental status changes. In both cases, the staff at their facilities waited hours to send them out.
I board and collared both of them, and gave them the full ALS workup, although niether did I transport lights and sirens. Both went to a trauma center. One patient went into the trauma room, the other was immediately taken off the board and I was questioned as to why I had collared her since she had been up and walking after the fall. I didn't think either patient had a spinal injury, but since they had both fallen, struck their heads and had altered mental status and were elderly I was following out liberal spinal immobilization policy that as liberal as it is, still requires me to immobilize a fall head injury patient with altered mental status. Had I not immobilized the first patient, I would have had to stand there while the doctor call for a collar to be applied in the trauma room. It's happened to me before. All trauma room patients at this one hospital get a collar if they are to have a head scan. I'm not disputing the motives of either doctor. I wouldn't want to be on the back board. It is just that doctors view things differently. That's why we have standing orders. We need consistency to keep us from being as unpredictable as the doctors. While our education is fairly extensive, it is not broad enough to allow us to practice beyond the norm.
Sunday, August 31, 2008
Saturday, August 30, 2008
Solo Again
Yesterday my preceptee didn't come to work. He told me he might not come in. That was okay because he is pretty much done. We're just waiting for the hospital coordinator (who officially cuts him loose) to come back from vacation and sign the paperwork.
The truth is it was great being the medic again. While I love precepting, I also love being a solo medic. You get tired of standing back watching someone else handle the call. I like talking directly to the patient, putting my hand on their forehead, feeling their skin temperature, then holding my finger tips at their wrist, feeling the pulse waves from their beating hearts. I like having them look to me to help them.
It was a busy day, back to back to back to back calls. Nothing out of the ordinary, but all with their own unique challenges. A possible broken arm, a case of vertigo, an elderly fall with change in mental status and a rapid afib causing weakness and lightheadness.
I carefully splinted the woman's arm, which wasn't deformed, but had point tenderness near the elbow and was causing her to wince when she moved it. I used a cardboard splint, some towells as padding and an ice pack. Her pain wasn't great when she was still -- only a 2 on the 0-10 scale so I held off on morphine.
The woman with vertigo and nausea I gave Zofran, making certain to push it nice and slow. Her nausea cleared up and she only felt a little dizzy.
The elderly man who fell had severe kifosis so we had to really pad him to get him comfortable on the board. He ended up in the trauma room. It was an unremarkable fall, but he wasn't the same person afterwards as he was before so he really did need the special attention that comes with being an alert. I am curious what his CAT scan showed.
The man with rapid afib was on a beta blocker so I got to use Metoprolol for the first time. Our new protocol calls for Metoprolol for rapid afib before Cardizem if the patient is already on a beta blocker. I felt the excitement I always do at pushing a new drug or using a new devise for the first time. I pushed it slow -- over five minutes, but it didn't seem to have any effect. He was still cranking along in the 160's-170's. We were at the hospital in a short time so I was still waiting to see if the Metoprolol would kick in by the time we rolled through the doors. They ended up giving him Cardizem and that did the trick.
He and his family thanked me afterwards. When I was walking out the woman who'd had the vertigo was in the hallway with her husband who was getting ready to take her home. She thanked me also, and introduced me to her husband, who shook my hand, placing his other hand on top of mine as we shook.
Back at the station, I restocked the truck, and then punched out. Driving home, I thought I would surely miss this work if I couldn't be a paramedic anymore.
The truth is it was great being the medic again. While I love precepting, I also love being a solo medic. You get tired of standing back watching someone else handle the call. I like talking directly to the patient, putting my hand on their forehead, feeling their skin temperature, then holding my finger tips at their wrist, feeling the pulse waves from their beating hearts. I like having them look to me to help them.
It was a busy day, back to back to back to back calls. Nothing out of the ordinary, but all with their own unique challenges. A possible broken arm, a case of vertigo, an elderly fall with change in mental status and a rapid afib causing weakness and lightheadness.
I carefully splinted the woman's arm, which wasn't deformed, but had point tenderness near the elbow and was causing her to wince when she moved it. I used a cardboard splint, some towells as padding and an ice pack. Her pain wasn't great when she was still -- only a 2 on the 0-10 scale so I held off on morphine.
The woman with vertigo and nausea I gave Zofran, making certain to push it nice and slow. Her nausea cleared up and she only felt a little dizzy.
The elderly man who fell had severe kifosis so we had to really pad him to get him comfortable on the board. He ended up in the trauma room. It was an unremarkable fall, but he wasn't the same person afterwards as he was before so he really did need the special attention that comes with being an alert. I am curious what his CAT scan showed.
The man with rapid afib was on a beta blocker so I got to use Metoprolol for the first time. Our new protocol calls for Metoprolol for rapid afib before Cardizem if the patient is already on a beta blocker. I felt the excitement I always do at pushing a new drug or using a new devise for the first time. I pushed it slow -- over five minutes, but it didn't seem to have any effect. He was still cranking along in the 160's-170's. We were at the hospital in a short time so I was still waiting to see if the Metoprolol would kick in by the time we rolled through the doors. They ended up giving him Cardizem and that did the trick.
He and his family thanked me afterwards. When I was walking out the woman who'd had the vertigo was in the hallway with her husband who was getting ready to take her home. She thanked me also, and introduced me to her husband, who shook my hand, placing his other hand on top of mine as we shook.
Back at the station, I restocked the truck, and then punched out. Driving home, I thought I would surely miss this work if I couldn't be a paramedic anymore.
Friday, August 22, 2008
My ETA/ The Triage Zone
You call in for orders and medical control asks "What's your ETA?"
That's an interesting question.
There are several answers.
I am fifteen minutes from the hospital grounds.
I am eighteen minutes from my back door opening.
I am twenty minutes from arriving at the triage desk.
I am anywhere from twenty-five to fifty minutes to getting through registration/triage.
I may be as far as an hour from putting my patient on a bed.
My patient may be an hour and a fifteen minutes to an hour and a half away from being assessed by a nurse.
My patient may be two hours away from being seen by the doctor asking for my ETA.
So what's my ETA?
***
Every system and every service is different and has its unique challenges. I know some medic services that practice load and go on most patients, rarely treating anything within ten minutes transport unless urgently needed because they have no wait at their EDs and can quickly clear for another, potentially more urgent call. I know other services whose medics will in some cases spend ten minutes or more in their hospital parking lot, providing care and treatment because time to care is not the thirty second distance to the ED door.
Just last week we had a patient with suspected kidney stones and generous orders to give the patient 5 mg of morphine every ten minutes X 3. We had given the morphine X 2 when our wheels came to a stop in the visibly crowded ED parking lot. We talked about our options, and included the patient in our discussion. He was still 9 out of 10 on the pain scale. We can bring you in now, or we can sit here for another five minutes until it is time to give you your last dose. He wanted us to sit. We did. We gave him the last 5 mg of Morphine and then rolled through the ED doors. We were in triage 22 minutes. By the time we had the patient in his room thirty minutes later, his pain was down to a 3.
***
I had an interesting conversation with a doctor the other day. We were talking about nitro paste, which he said was really a bad drug for us to carry because its absorption rate was so variable. I always defer to doctors on these types of questions that are beyond my education, but I raised the one merit of nitro paste was that it provided the patient nitro continuously while they worked their way through the triage zone -- the time between exiting our ambulance door and a doctor's arrival at the patient's bedside in the ED.
Our conversation lead to his opinion that it was completely acceptable for us, as long as we had the patient on the monitor and an ability to take their blood pressure, to continue to give the patient sublingual nitro while in the triage line, and if we felt that the patient needed care that urgently, it was our duty to cut the line if necessary to get the patient the care needed.
I have often cut the line, and have often allowed others to cut in front of me, and I have never seen anyone object to this practice which we all agree is in the patient's best interest. I have, on the other hand, heard of medics being scolded for giving meds in the triage line because we are then on the hospital's turf and not our own. But I would agree with the doctor, and argue that until the patient is put on a hospital bed and care discussed with a nurse or doctor at the patient's side, there is nothing wrong with continuing to treat. We don't take them off oxygen. We don't turn our drips off. What's wrong with nitro spray?
I wonder if we had wheeled the kidney stone patient in, and syringe in hand, proceeded to slowly push morphine in through the IV port, while we waited in the line of stretchers, if it would have created a stir?
That's an interesting question.
There are several answers.
I am fifteen minutes from the hospital grounds.
I am eighteen minutes from my back door opening.
I am twenty minutes from arriving at the triage desk.
I am anywhere from twenty-five to fifty minutes to getting through registration/triage.
I may be as far as an hour from putting my patient on a bed.
My patient may be an hour and a fifteen minutes to an hour and a half away from being assessed by a nurse.
My patient may be two hours away from being seen by the doctor asking for my ETA.
So what's my ETA?
***
Every system and every service is different and has its unique challenges. I know some medic services that practice load and go on most patients, rarely treating anything within ten minutes transport unless urgently needed because they have no wait at their EDs and can quickly clear for another, potentially more urgent call. I know other services whose medics will in some cases spend ten minutes or more in their hospital parking lot, providing care and treatment because time to care is not the thirty second distance to the ED door.
Just last week we had a patient with suspected kidney stones and generous orders to give the patient 5 mg of morphine every ten minutes X 3. We had given the morphine X 2 when our wheels came to a stop in the visibly crowded ED parking lot. We talked about our options, and included the patient in our discussion. He was still 9 out of 10 on the pain scale. We can bring you in now, or we can sit here for another five minutes until it is time to give you your last dose. He wanted us to sit. We did. We gave him the last 5 mg of Morphine and then rolled through the ED doors. We were in triage 22 minutes. By the time we had the patient in his room thirty minutes later, his pain was down to a 3.
***
I had an interesting conversation with a doctor the other day. We were talking about nitro paste, which he said was really a bad drug for us to carry because its absorption rate was so variable. I always defer to doctors on these types of questions that are beyond my education, but I raised the one merit of nitro paste was that it provided the patient nitro continuously while they worked their way through the triage zone -- the time between exiting our ambulance door and a doctor's arrival at the patient's bedside in the ED.
Our conversation lead to his opinion that it was completely acceptable for us, as long as we had the patient on the monitor and an ability to take their blood pressure, to continue to give the patient sublingual nitro while in the triage line, and if we felt that the patient needed care that urgently, it was our duty to cut the line if necessary to get the patient the care needed.
I have often cut the line, and have often allowed others to cut in front of me, and I have never seen anyone object to this practice which we all agree is in the patient's best interest. I have, on the other hand, heard of medics being scolded for giving meds in the triage line because we are then on the hospital's turf and not our own. But I would agree with the doctor, and argue that until the patient is put on a hospital bed and care discussed with a nurse or doctor at the patient's side, there is nothing wrong with continuing to treat. We don't take them off oxygen. We don't turn our drips off. What's wrong with nitro spray?
I wonder if we had wheeled the kidney stone patient in, and syringe in hand, proceeded to slowly push morphine in through the IV port, while we waited in the line of stretchers, if it would have created a stir?
Saturday, August 16, 2008
Links
Here are some links worth checking out.
***
Rogue Medic has some excellent things to say on the recent subject discussed here of drug administration:
Not So Rapidly
***
Katherine Howell, author of the EMS thrillers Frantic and The Darkest Hour, recently had a nice article published in the London Daily mail:
The Day a Paramedic made the Difference
***
The American Heart Association has published a new article:
Pre-Hospital ECGs in ACS Management
***
Check out the Normal Sinus blog, which is published weekly featuring an array of contributors. Sometimes all the posts are themed, others open.
***
Rogue Medic has some excellent things to say on the recent subject discussed here of drug administration:
Not So Rapidly
***
Katherine Howell, author of the EMS thrillers Frantic and The Darkest Hour, recently had a nice article published in the London Daily mail:
The Day a Paramedic made the Difference
***
The American Heart Association has published a new article:
Pre-Hospital ECGs in ACS Management
***
Check out the Normal Sinus blog, which is published weekly featuring an array of contributors. Sometimes all the posts are themed, others open.
Summer Report
I apologize for no posts for a week. It's summertime after all. I have been busy playing with my seven-month-old baby girl, staying up watching the Olympics, while channel-surfing to the Red Sox games (including their epic 19-17 win over the Rangers), and celebrating my fiftieth birthday by running my first triathlon of the year (I did 6 last year).
Here's an account of my 50th Birthday triathlon:
Winding Trails Triathlon Report
And here's some pictures of a proud dad with his baby daughter:
Hope everyone is having a happy and safe summer!
Here's an account of my 50th Birthday triathlon:
Winding Trails Triathlon Report
And here's some pictures of a proud dad with his baby daughter:
Hope everyone is having a happy and safe summer!
Saturday, August 09, 2008
Drips, Slow Pushes
I was watching my preceptee give Zofran the other day and I thought that he gave it a little too fast. I didn't have the stop watch on him, but I was looking for maybe 30 seconds to a minute for the small 4 mg in 2cc injection, and what I saw was about ten seconds. It wasn't a rapid adenosine push, but it was more rushed than it should have been.
Now let me confess that I have done the same thing. I have pushed drugs that I know are supposed to be pushed slow maybe a little faster than I should have. In the 911 world time can easily become compressed. 1-2 minutes becomes 10-15 seconds maybe in the same way that for some providers 8-10 ventilations in a minute become 20-30 ventilations.
After the call I cautioned him on pushing the drug slower and when I turned to the protocol page to show him that the drug was supposed to be pushed slowly, I saw in plain black and white that the drug is supposed to be pushed "over 2-5 minutes."
Surprised by this, I went to the drug insert and read:
"The recommended I.V. dosage of ZOFRAN for adults is 4 mg undiluted administered intravenously in not less than 30 seconds, preferably over 2 to 5 minutes."
My first reaction, was, well, I can at least go with "Not less than 30 seconds," but when I discussed the matter with an ED doctor, his reaction was I should do it in 2-5 minutes. Why? I asked. Because it says "preferably" over 2-5 minutes, he answered.
Good point.
Now I suppose if all hell is breaking loose - the patient is vomiting, having a massive MI, I'm by myself, trying to patch to the hospital as well as put in another line, maybe I could get away with 30 seconds. But if I was a regular patient with nausea and vomiting and I read that insert, would I want the drug over 30 seconds? or over 2-5 minutes?
I think 2-5 minutes. It's hard to argue with black and white.
I love reading drug inserts. You can find all sorts of fascinating information. For example it was a drug insert that confirmed a reader's tip that Nitrolingual spray can be sprayed on the tongue if you can't get the patient to lift up his tongue. I read in a drug insert that I had to dilute Ativan at least 1-1 before pushing it IV. And long ago I learned giving Lidocaine to a patient with a bifasicular block will kill them -- all things I hadn't known.
There is all kinds of information in drug inserts -- information about drug trials, side effects. Very interesting stuff. My only problem is the print is a little small for my aging eyes.
Anyway, this all has me thinking about drips. When I give Zofran in the future, I will give it by drip. If the patient needs fluid anyway, I'll just put it in a 250 saline bag and open it up. If they don't need fluid, I'll let 200 cc out of the 250 bag and put the Zofran in the remaining 50. (We're out of 100 cc bags right now).
Back in November 2007, the following article appeared in JEMS:
Is D50 Too Much of a Good Thing?
The point was when faced with a hypoglycemic patient, instead of giving them D50 through an IV and risking tissue necrosis and too rapid an absorption of Dextrose, it would be better for the patient to put the D50 in a 250 cc bag (you would have to let out 50 cc first) and then run the whole bag in as D10. The other good part of this is it makes it much easier to titrate to effect. Some patients won't need the whole D50. (I can't find the D50 insert, but an internet site suggested D50 needs to be pushed much slower than I think many people push it -- as fast as it will push).
For peripheral vein administration: Injection of the solution should be made slowly. The maximum rate at which dextrose can be infused without producing glycosuria is 0.5 g/kg of body weight/hour. About 95% of the dextrose is retained when infused ata rate of 0.8 g/kg/hr.
I've asked a couple brittle diabetics about their preference between the thick syrupy D50 and the more watery D10 and they have said they would prefer getting the D10 to the D50 which often leaves them with a headache and rubbing their veins.
I'm trying to view things from the patient's point of view, which I do sometimes, but maybe not as much as I should. I'm also going to try over the next couple weeks to look at all the drugs we carry and find the proper push method and maybe compile a best practices list. While each situation will be somewhat patient/scene driven, I'd like to follow the "preferable" method as much as I can. I just read the Benadryl insert and it says no quicker than 25 mg/min, which would be two minutes for someone getting a 50 mg dose. I'm going to need to slow that one down, too.
***
Update: We had a chemo patient today with nausea. I watched to see how my preceptee would give the Zofran after we had talked about it. He gave it slow IV push over two and a half minutes. It was a fairly straight foward call so after he had put her on the monitor and gotten the IV there wasn't much else to do. He chatted with the patient as he pushed it slowly. She soon felt better.
Now let me confess that I have done the same thing. I have pushed drugs that I know are supposed to be pushed slow maybe a little faster than I should have. In the 911 world time can easily become compressed. 1-2 minutes becomes 10-15 seconds maybe in the same way that for some providers 8-10 ventilations in a minute become 20-30 ventilations.
After the call I cautioned him on pushing the drug slower and when I turned to the protocol page to show him that the drug was supposed to be pushed slowly, I saw in plain black and white that the drug is supposed to be pushed "over 2-5 minutes."
Surprised by this, I went to the drug insert and read:
"The recommended I.V. dosage of ZOFRAN for adults is 4 mg undiluted administered intravenously in not less than 30 seconds, preferably over 2 to 5 minutes."
My first reaction, was, well, I can at least go with "Not less than 30 seconds," but when I discussed the matter with an ED doctor, his reaction was I should do it in 2-5 minutes. Why? I asked. Because it says "preferably" over 2-5 minutes, he answered.
Good point.
Now I suppose if all hell is breaking loose - the patient is vomiting, having a massive MI, I'm by myself, trying to patch to the hospital as well as put in another line, maybe I could get away with 30 seconds. But if I was a regular patient with nausea and vomiting and I read that insert, would I want the drug over 30 seconds? or over 2-5 minutes?
I think 2-5 minutes. It's hard to argue with black and white.
I love reading drug inserts. You can find all sorts of fascinating information. For example it was a drug insert that confirmed a reader's tip that Nitrolingual spray can be sprayed on the tongue if you can't get the patient to lift up his tongue. I read in a drug insert that I had to dilute Ativan at least 1-1 before pushing it IV. And long ago I learned giving Lidocaine to a patient with a bifasicular block will kill them -- all things I hadn't known.
There is all kinds of information in drug inserts -- information about drug trials, side effects. Very interesting stuff. My only problem is the print is a little small for my aging eyes.
Anyway, this all has me thinking about drips. When I give Zofran in the future, I will give it by drip. If the patient needs fluid anyway, I'll just put it in a 250 saline bag and open it up. If they don't need fluid, I'll let 200 cc out of the 250 bag and put the Zofran in the remaining 50. (We're out of 100 cc bags right now).
Back in November 2007, the following article appeared in JEMS:
Is D50 Too Much of a Good Thing?
The point was when faced with a hypoglycemic patient, instead of giving them D50 through an IV and risking tissue necrosis and too rapid an absorption of Dextrose, it would be better for the patient to put the D50 in a 250 cc bag (you would have to let out 50 cc first) and then run the whole bag in as D10. The other good part of this is it makes it much easier to titrate to effect. Some patients won't need the whole D50. (I can't find the D50 insert, but an internet site suggested D50 needs to be pushed much slower than I think many people push it -- as fast as it will push).
For peripheral vein administration: Injection of the solution should be made slowly. The maximum rate at which dextrose can be infused without producing glycosuria is 0.5 g/kg of body weight/hour. About 95% of the dextrose is retained when infused ata rate of 0.8 g/kg/hr.
I've asked a couple brittle diabetics about their preference between the thick syrupy D50 and the more watery D10 and they have said they would prefer getting the D10 to the D50 which often leaves them with a headache and rubbing their veins.
I'm trying to view things from the patient's point of view, which I do sometimes, but maybe not as much as I should. I'm also going to try over the next couple weeks to look at all the drugs we carry and find the proper push method and maybe compile a best practices list. While each situation will be somewhat patient/scene driven, I'd like to follow the "preferable" method as much as I can. I just read the Benadryl insert and it says no quicker than 25 mg/min, which would be two minutes for someone getting a 50 mg dose. I'm going to need to slow that one down, too.
***
Update: We had a chemo patient today with nausea. I watched to see how my preceptee would give the Zofran after we had talked about it. He gave it slow IV push over two and a half minutes. It was a fairly straight foward call so after he had put her on the monitor and gotten the IV there wasn't much else to do. He chatted with the patient as he pushed it slowly. She soon felt better.
Sunday, August 03, 2008
Family
Sometimes it takes back-to-back calls to help you understand lessons you might not otherwise have thought about.
There are family members on scene of most of all calls and they often ask if they can ride along with us. In most cases, we are not traveling to the hospital lights and sirens so we might suggest that they follow in their own car so they will have a ride home. Some do this, but in other cases when there are more than one family member, one will drive their car and the other will want to travel with us. “Fine,” we say. Out in the driveway, they may wait by the back ambulance doors while we load their relative and then they look a little uncertain about what to do. Some try to step up into the back, and we say, “No, you’ll ride up front.” If they ask why they can’t ride in the back, we usually answer “Safety reasons,” or “Insurance reasons,” or “It’s required.” We rarely get a hassle. If the patient is a pediatric, I usually have the parent ride in back. I have them sit in the seat across from me or if I am in a smaller van ambulance, I have them sit next to me. All I ask is that they put their seat belt on.
Every now and then I have a bad experience with someone in the back, but it is usually pretty rare.
Sometimes I have noticed and thought it odd that a relative will want to ride in the ambulance even if it means leaving their car at a doctor’s office or shopping center or at their home – wherever the call happened. I might ask “How will you get home?” or “How will you get your car?” and they say, “I’ll worry about it later.” “Okay, your choice.” They sit in the front and the patient may ask for them or they may call from the front to the back to ask how they are doing, and I will play the intermediary. “Your wife is sitting up front,” I’ll tell the patient. “Your husband’s doing fine,” I’ll call up to the wife.
This week I had two calls in a row where the family member was either an EMT or a paramedic who I knew. The first was a man who had fallen and broken his shoulder. Since he had also hit his head and had some neck tenderness, in addition to splinting him and we also had to c-spine him. The EMT was very helpful in giving us a full history of the event, and helping us board and collar his father. We stayed on scene quite awhile because the man was in pain, so we made certain to premedicate him with morphine before we moved him on to the board and then out to the ambulance. The son rode in the front, after reassuring his father as we loaded him in.
The very next call was at a doctor’s office for an elderly woman with increased fluid retention. As we approached the room I recognized an area paramedic in street clothes standing by the door to an exam room. She turned out to be the patient’s daughter. While the doctor gave my preceptee a report, the medic filled me in on her mom’s history. We put the mother on the stretcher, gave her a touch of 02 by cannula and went out to the parking lot. The daughter said she’d like to come along. We asked about her car, and she said it wasn’t important, she could get a ride back out to the doctor’s office later. I asked her if she wanted to ride in the back with us, and she deferentially said it was up to me. “Please, it's no problem,” I said. We had her sit across from us, and we had a nice conversation – all of us with her mother -- on the way in while my preceptee did his paramedic thing, putting the woman on the monitor and putting in an IV.
Both the EMT and the medic were very respectful of us as responders with a job to do, and at the same time, we used them not just for history but to help with the care. In both cases, the parent was reassured having their child near them.
It all made me think what I would like if my father were sick. I would certainly be deferential with the responders as long as they weren’t demonstrating gross incompetence. I would hope they would show some respect to me. I have heard other medics tell me of terrible experiences they had had with responders coming for their parents. And I know medics have had bad experiences with relatives with health care backgrounds. It can clearly go both ways.
So what is the lesson? It’s that these two calls made me think for the first time in awhile that we are not just dealing with patients and their relatives, we are dealing with mothers and fathers and sons and daughters just like ourselves, and we should always treat them as we would want to be treated -- with respect and courtesy. That doesn’t mean letting everyone ride in the back. It just means treating everyone like family -- as you would want your own to be treated. Not a complex lesson, but one that can be easily forgotten in the daily grind of EMS.
There are family members on scene of most of all calls and they often ask if they can ride along with us. In most cases, we are not traveling to the hospital lights and sirens so we might suggest that they follow in their own car so they will have a ride home. Some do this, but in other cases when there are more than one family member, one will drive their car and the other will want to travel with us. “Fine,” we say. Out in the driveway, they may wait by the back ambulance doors while we load their relative and then they look a little uncertain about what to do. Some try to step up into the back, and we say, “No, you’ll ride up front.” If they ask why they can’t ride in the back, we usually answer “Safety reasons,” or “Insurance reasons,” or “It’s required.” We rarely get a hassle. If the patient is a pediatric, I usually have the parent ride in back. I have them sit in the seat across from me or if I am in a smaller van ambulance, I have them sit next to me. All I ask is that they put their seat belt on.
Every now and then I have a bad experience with someone in the back, but it is usually pretty rare.
Sometimes I have noticed and thought it odd that a relative will want to ride in the ambulance even if it means leaving their car at a doctor’s office or shopping center or at their home – wherever the call happened. I might ask “How will you get home?” or “How will you get your car?” and they say, “I’ll worry about it later.” “Okay, your choice.” They sit in the front and the patient may ask for them or they may call from the front to the back to ask how they are doing, and I will play the intermediary. “Your wife is sitting up front,” I’ll tell the patient. “Your husband’s doing fine,” I’ll call up to the wife.
This week I had two calls in a row where the family member was either an EMT or a paramedic who I knew. The first was a man who had fallen and broken his shoulder. Since he had also hit his head and had some neck tenderness, in addition to splinting him and we also had to c-spine him. The EMT was very helpful in giving us a full history of the event, and helping us board and collar his father. We stayed on scene quite awhile because the man was in pain, so we made certain to premedicate him with morphine before we moved him on to the board and then out to the ambulance. The son rode in the front, after reassuring his father as we loaded him in.
The very next call was at a doctor’s office for an elderly woman with increased fluid retention. As we approached the room I recognized an area paramedic in street clothes standing by the door to an exam room. She turned out to be the patient’s daughter. While the doctor gave my preceptee a report, the medic filled me in on her mom’s history. We put the mother on the stretcher, gave her a touch of 02 by cannula and went out to the parking lot. The daughter said she’d like to come along. We asked about her car, and she said it wasn’t important, she could get a ride back out to the doctor’s office later. I asked her if she wanted to ride in the back with us, and she deferentially said it was up to me. “Please, it's no problem,” I said. We had her sit across from us, and we had a nice conversation – all of us with her mother -- on the way in while my preceptee did his paramedic thing, putting the woman on the monitor and putting in an IV.
Both the EMT and the medic were very respectful of us as responders with a job to do, and at the same time, we used them not just for history but to help with the care. In both cases, the parent was reassured having their child near them.
It all made me think what I would like if my father were sick. I would certainly be deferential with the responders as long as they weren’t demonstrating gross incompetence. I would hope they would show some respect to me. I have heard other medics tell me of terrible experiences they had had with responders coming for their parents. And I know medics have had bad experiences with relatives with health care backgrounds. It can clearly go both ways.
So what is the lesson? It’s that these two calls made me think for the first time in awhile that we are not just dealing with patients and their relatives, we are dealing with mothers and fathers and sons and daughters just like ourselves, and we should always treat them as we would want to be treated -- with respect and courtesy. That doesn’t mean letting everyone ride in the back. It just means treating everyone like family -- as you would want your own to be treated. Not a complex lesson, but one that can be easily forgotten in the daily grind of EMS.
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