In the nursing home, Mrs. Brown sits in her wheelchair, two feet from the television in her darkened room. The blue hues illuminate her face.
Our stretcher rolls past in the hallway. Each door is open. The story on every channel.
In stillness, they watch.
We are still young, the children call to them.
Craddle us tight again, in your arms.
We had our first bid shift in several years recently. For me, it presented a dilemma. Continue working in the city or go to the suburbs in a fly car.
I have always loved the city, even when I was posted to the suburbs as a contract medic to ride as a paramedic in a volunteer ambulance, I still worked 20-30 hours a week on overtime in the city. In the past two years (I have been back in the city full time), my time in the city has been invigorating. In particular, I enjoyed the year when I was able to be in a fly car in the city, responding to any call I wished. When that experimental program ended, I still enjoyed being in a regular ambulance. Now let me be clear, not every call is “in the city.” In a regular transport ambulance, you can respond to a multiplicity of towns, but for the most part (50% of calls), you do 911s in the great city of Hartford.
So why would I consider going to a flycar in the suburbs?
Let’s go through the pros and cons.
City
Pros
Busy. Averaging 8 transports per 12 hour shift, plus additional refusals, cancels, etc.
Chance to be a paramedic. Several decent calls per day. A wide variety of calls.
Food. Great variety of ethnic restaurants.
Social/Comraderie - You interact reguarly with other crews and everyone at the hospitals
Stories – In the city, even if the call is not always medically challenging, the view of life is riveting, sometimes sad, others laugh out loud funny.
Partner-Could have a good partner
Cons
Exhausting - Of late we are constantly being called out of the hospital to take calls, and rarely even have time to post. And I'm not getting any younger. The equipment seems heavier (along with the patients), the stairs we climb steeper, and more elevators seem to be out of order.
Transfers - It’s not that I mind the occasional transfer (1-3 a day), I just mind getting them when BLS cars are doing emergencies.
Dispatch -- EMS responders and their dispatchers seem to always have different views on how ambulances should be used. Our system is perhaps no different from others. Having said that I acknowledge dispatch may not be the easiest job and I for one would not want to do their job.
Partner- Could have a Bad Partner
Now lets look at the Suburban Fly Car
Pros
You only do 911s.
Lots of good medicals that go along with the more elderly population.
You are dispatched directly by the town
Less exhausting
Lots of time to read
No transfers
Plenty of help on scene from transporting amulance crew, PD and Fire Department, who are both first responders depending on the nature of the call.
Cons
Having to sit in car all shift, and pay attention to radio (i.e. no nodding off).
Having to turn most calls over to the transporting ambulance if the transporting ambulance has a medic, and call does not necessitate two medics
No one to talk to.
Could bump longstanding medic from suburban shift
So how did it all come out?
While the time may come one day for me to settle in the suburbs, I am still a city boy. I got my first choice. Sunday, Monday, Tuesday 5:30-17:30 in the city. Moving from the 7-19 shift to the early slot may prove to be a mistake, but I figure, it gives me more time at home with the family, the chance to have a sit down dinner every night. And with age, it is easier for me to get up in the morning than it used to be. I’ll just need to make certain I get to bed at a reasonable hour. And while I know on the first wait and return transfer I am given on the new shift, I may regret my choice, I know I won’t regret it when I am in the midst of the city, its calls and its people.
I’ll let you know how it works out.
She has become a regular. She calls early Sunday morning.
“923, respond for the abdominal pain." The dispatcher gives the street and apartment number.
It’s always her. We have stopped bringing the gear in. We just wheel the stretcher in and leave it in the hallway, and then walk up the three flights of the dim stairwell to her apartment. She is always ready to go, always wearing her pink sneakers. She locks the door, and then walks down the stairs with us to the bottom where we get her comfortable on our stretcher, and then wheel her out to the ambulance.
She has a number of medical aliments, too many for someone in her twenties. While I have never had pancreatitis, I am told it is extremely painful. It is often caused by alcohol abuse, but not so in her case. Not that that should matter.
Her face doesn’t always show the pain. Most of the time, it is impassive, but sometimes she is clearly suffering. She is on Percocet and oxycodone, but it doesn’t always help. She goes to the hospital for the dilaudid, which they give her, and then send her home. Fentanyl works okay on her. It takes the edge off, certainly. Sometimes, she is nauseous and she gets zofran, too.
She has become a bit of a challenge for me. Acute pain is easy to deal with, chronic pain more difficult, and chronic pain in the frequent flyer, the hardest of all. I know that you are not supposed to correlate facial expression with pain, but I find myself doing it. If she looks like she is in pain, I don’t hesitate, even for the frequent flyer, but when she says ten and she looks normal, I ask myself questions. Do I really need to break open my narcotics for her? Can't she wait for the hospital to medicate her? She has been in pain for awhile. She is always in pain. The hospital has pain medicine and will give it to her. If I break open my kit, then after the call, I will have to go to the pharmacy and get another kit, making me unavailable for a small time. But it is Sunday morning and it is slow usually, plus if it is busy, I have enough narcotics left to handle another call if I have too.
I don’t hesitate about the Zofran because I have plenty of that. Two vials in my kit and always at least three on the shelf. It is my most used drug. If I run out, I can usually beg a vial off another car. Zofran is easy to give. Shouldn’t Fentanyl be the same? Why should I worry about having to restock at the pharmacy? True I wish restocking were not an issue. I wish Fentanyl could flow from the wall like oxygen. Wouldn’t that be nice? To have a big tank of it, and only have to change it when it gets below 500 Psi?
I have talked about her case with other medics. Most have stopped medicating her. The first, second and maybe third time were on the house, but call for the fourth or fifth time and it is a little much. I see where they are coming from, and I confess I have not always medicated her either. But for the most part, I still do. I try to keep the narrow focus. Is she is in pain? Yes. Can I make her feel better? Yes. Are there any drawbacks to her medically from getting Fentanyl from me? No, I don’t think so. So I give it. I feel bad if I don’t. I feel a little brighter about my job if I do.
And like pink sneakers, a little bit of brightness in a sometimes dim world is no small thing.
Street Lessons # 6 Don’t Always Believe Your Own Eyes
When I was a new EMT, I responded to a call for an unconscious person. In the basement of a house, I found a woman in her thirties unconscious of the floor and her husband shouting frantically that his wife was dying and that he had in fact done CPR on her for several minutes. “Help her,” he demanded. “I am,” I said. I was kneeling beside her and feeling her pulse, and watching her breathe. While she was in fact unconscious, her breathing was even and her pulse was steady. Her skin was warm and dry and she didn’t have a scratch on her.
My partners had told me stories of people doing CPR on living patients and always laughed at them, and while in my career I would encounter this phenomenon again and again, this was first time seeing it, and I thought, I am an EMT, the person is breathing and has a good pulse. This man is just a layperson who is very panicky and I think it is a good bet she did not actually need CPR when he was pounding on her chest. Perhaps she is on drugs. Her husband denied that when I asked. To this day, I am surprised he did not beat me for suggesting it. I guess he was clinging to the belief that maybe I could help her.
Well, we got her on the stretcher and out to the ambulance, and wouldn’t you know, ten minutes later, she stopped breathing and we were doing CPR.
A wise person told me once when I arrived on scene to always acknowledge the first responders or the bystander if there were no responders and get a report. Some reports would be excellent, some would be crazy. The point the wise man made was to simply show respect. “I did CPR on her for a couple minutes and then she came around,” the woman would say. “Great,” I would respond. And then get on with managing the syncopal victim with the now bruised sternum.
But let me tell you this now. I would add a caveat to the acknowledge the first responder advice, and that caveat would be “Listen to them.” I know sometimes in the past, while pretending to give my full attention, my mind has been going yadeedaa.
Now I say this because in my career, while I have had first responders or bystanders describe what seemed like crazy things compared to what my eyes were seeing when I arrived. I have had those same seemingly okay patients suddenly revert back to what the bystander or first responder described. “Sure, you were doing CPR, great Job!” I’d say, thinking that’s a laugh, only to find myself doing compressions five minutes down the road. Or to have the responder describe the crazy seizure they witnessed, only to have the patient startle me with the same earth-shaking tonic-clonic seizure later on down the road.
Don’t assume because the person is fine now, that they were fine when 911 was dialed.
I am not saying to take everything a first responder or lay person says as gospel, only to consider it. Never dismiss any information outright. If someone says the little girl with the polka dot dress’s head spun around three times and fire came out of her mouth, I will store that nugget in a small, but retrievable place.
In EMS the hierarchy on a call goes something like this. Bystander, first responder, EMT, paramedic, with each higher level of care assuming command as they arrive. The hierarchy continues at the hospital. Nurse, Doctor. Although some of us paramedics would argue the nurse is not above us, most hospitals are structured where the paramedic turns the care over to the nurse, who makes the decision where the patient goes next – a regular room or a critical care room.
Has it ever happened to you where you have described the extremely sick patient you encountered who now seems fine, and had the triage nurse or the doctor be somewhat dismissive of your account because of what their own eyes are telling them? I am sure it has if you have worked any amount of time.
Doctor, he was pale and diaphoretic. Nurse, she was in full seizure. Doctor, he was completely unresponsive. Nurse, he was blue. Doctor, I know it isn’t on yours, but I have ST elevation on my 12-lead.
Waiting room. Or a bed in the hallway.
Later, you hear: Hey your patient coded in the bathroom. Or they found your patient seizing by the coke machine. Or perhaps: Yeah, didn’t you hear? The hospital burned to the ground with only one survivor, a little girl in a polka dot dress standing in the midst of the rubble, unharmed.
Street Lessons #5 The Hand Drop Test
Anyone new to EMS is likely as amazed as I was at how many patients feign unresponsiveness. We all likely have had a moment when a more experienced responder has demonstrated the “Hand Drop Test,” where they raise the patient’s hand over their face and release it. If the hand smacks the face, they pass the test and truly are unresponsive. If the hand stops or is moved to the side to avoid contact, then the patient fails the test and is a FAKER. Or so it goes. The best FAKERS, I was told, know our tricks and so let their hands smack their faces because they are wise to what we were trying to prove. I was told to look out for these master fakers.*
There is a second more valuable lesson than the Hand Drop Test, a lesson that comes later and often comes painfully to your own performance as a paramedic. And that lesson is just because a person is aware enough to move their hand to avoid their face, doesn’t mean they can’t also be really sick.
What do you mean? They have an intracranial bleed? They failed the hand drop test!
What do you mean? They are in acute renal failure? They failed the hand drop test!
I was burned by this early in my career, but never again.
All a person needs to fail the hand drop test is a smidgeon of consciousness, and a quarter ounce of remaining strength. It merely tests for a smidgeon of consciousness and a quarter ounce of strength. It does not provide proof that a patient is not sick or injured.
Also, if the results of all your other assessment capabilities still leave you wondering, and you just have to do the hand drop test, make certain that you protect the patient. A paramedic caused bloody nose should not be considered collateral damage from having to do the hand drop test.
* I no longer feel it is my job to unmask fakers. If I suspect someone is faking, I find it easier to just pick them up, put them on the stretcher and take them out to the ambulance, than to try to prove to the surrounding crowd that the patient is conning everyone.
Street Lessons #4 Carry Your Gear
Always carry your gear into calls. I know it can be a pain to do, but nothing is worse than suddenly needing your equipment and not having it.
A woman calls 911 and says “my baby is sick!” You get dispatched for a sick baby. You think if it is a sick baby, what do you need equipment for? Most likely the baby is not really sick, but if the baby is really sick then you can, as my preceptor once said to me, “O.J. it.” This of course was when O.J. Simpson was known for running and leaping faster than any other human and not known for slashing throats. “O.J it” meant grab the baby and run for the ambulance.
Many times in my early years as a medic I “OJed” it with sick kids, sometimes doing CPR and tiny breaths as I went, hurtling toward the ambulance, my office where the gear that made me a medic was stowed. Aside from that clearly not being the ultimate way to resucitate a baby or anyone for that matter, the “sick baby” call doesn’t always turn out to be a sick baby. The sick baby can be anything from a 300-pound fifty-two-year old son in cardiac arrest to a vomiting parrot. The 300-pound son you clearly wish you had your gear for. The vomiting parrot? Well, that’s another story.
When I started there was one paramedic who always carried all his equipment in on every call. Back then we had a black hard suitcase called a biotech for the meds and IV supplies. We had an intubation kit, we had a large house bag with the oxygen and bandaging supplies, and we had the Life Pack 5 and then the Life Pack 10 monitor. We also had an orange tackle pedi-box.
Now this medic didn’t bring the pedi-box in on every call unless it sounded like it might be a pedi. For the sick baby that turned out to be the 300-pound fifty-two-year-old son, he would have had the pedi box there along with everything else where other medics would have had to send their partners running back down to the truck.
He also-- and this is what impressed me the most -- he always carried the portable battery-operated suction machine in. Every call. Me, I only bring it in to a known cardiac arrest, and I can tell you to my embarrassment, two of the last three difficulty breathings I’ve been too have turned out to be cardiac arrests where my preceptee has said, “I need suction!” when he has put the larengyscope in and seen nothing but murky waters. “I need suction now!” On its way. but not here yet.
We had a paramedic here who was fired for not bringing equipment in. She sometimes brought equipment in. Say it was a known cardiac arrest, she would put a larengyscope, a tube and a 10 cc syringe in her pocket. I kid you not. She also downgraded a stabbing because the hole in the chest was "just a little hole." Lazy paramedic. Bad paramedic.
I carry in the house bag and the monitor, and the 02 if the fire department hasn’t gotten there yet, although there have been times when I have climbed up three flights of stairs only to find the fire department also didn’t bring in their 02. I hate not being prepared.
I carry my controlled substances on me when I go into a call. While there is some lack of clarity as to what exactly the rules are in our state governing the securing of controlled substances -- it ranges from they must always be secured doubled locked in the ambulance unless you have the intention to use them to its okay to secure them on yourself as long as you are on the clock and capable of being dispatched to a call where you might need them. The issue here is: what if you respond for a person vomiting and after wheeling your stretcher down many halls and up a couple different banks of elevators in a big insurance company, you find your patient is actually seizing? You can either 1) Put the patient on your stretcher and wheel them seizing all the way back out to the ambulance. 2) Give the controlled substances keys to your BLS partner and tell him to get the kit and hurry. 3) Or you can take the controlled substances kit out of your own pocket and stop the seizure now. I hate being without my gear when I need it.
Many years ago, I was working with a partner named Steve. Good partner. We had lots of fun together. We get called to an assault in the north end. This is a pretty common call. Someone gets punched in the face or scratched -- the cops call us, we go. The patient is giving a statement. We either get a refusal or we walk the patient to the ambulance. No problem. Most of the time they are sitting on the front stoop. Anyway, we get called, and the cop coming out of the apartment building says nonchalantly, "he's up on the 2nd floor." We walk up there nonchalantly. See a cop writing up a report. He nods down by his feet where a man in laying prone with gurgling respirations and an ever growing pool of blood around his head. "He got the shit kicked out of him," the cop says -- "steel toed boots." "Uh-o," Steve says to me. "Go get the gear," I say to Steve.
We work together the next week. No "uh-o" moments we both agree. We'll bring the gear in on every call. First call of the night is for a "woman drunk wants to go to rehab." This is a call we do all the time too. We walk in, meet the patient, who says, "I want to go to rehab." And we take them to the rehab place. Piece of cake. But this time, a man meets us at the door -- also up on the second floor. "My daughter is an alcoholic," he says. "She needs to get cleaned up. I don't think she's breathing." Uh-o. Go get the gear.
I know the gear is heavy, but look at it this way, you are in physical training. Carrying all that gear up and down stairs will get keep you in shape and keep you young. Do enough calls, walk up and down enough staircases and you can skip the gym after work and spend the time with your family.
Street Lessons #3 Know Thy Patient
Ahh, the simplest things. You need the patient’s name, date of birth, and social security number if possible. The name is most important. If the name is John Smith or Juan Martinez, the date of birth helps.
I was a brand new spanking EMT and we had a patient in classic CHF -- I am talking hypertensive through the roof, bulging jugular veins, filling emesis basins with pinky frothy sputum. We had him on a nonrebreather, on a stair chair, out to the ambulance, and lights and sirens half way to the hospital before we realized we didn’t who he was, and he was still working at breathing too hard to get a syllable out. No name, no DOB, no social, just the address we picked him up at. Chalk that one up to two excited rookies.
On most calls, if you leave the house without the patient’s name, this is no problem, the patient can tell you. In the past, I didn’t often bother with this information if the patient was talking to me. I figured I could get it out in the ambulance. I look at the elderly patient and say “You know your date of birth and social security number?” The patient looks me right in the eye and says “yes, sir.” Very good.
On the way to the hospital, after I have done an IV and 12-lead, I ask the patient for his date of birth. “Yes, sir!” he says. Same answer to social security number. I ask him his name. “Yes, sir!”
Always get the name and social.
I am in the nursing home and the nurse hands me the envelope. I take a quick look at it to see if there is a name, date of birth and social security number filled in on the paperwork and that I can read it. Check. Check. The patient is unresponsive. Out in the ambulance, I am checking the patient’s meds to see if they provide a clue to their condition. I notice then that patient’s name is Mary Wilson. The problem is the patient is a man. I send the paperwork back into the SNF with my partner who comes out with an apology and the paperwork for Richard Johnson.
Here’s one. Nursing home patient is unresponsive. Ambulance crew takes patient and paperwork. Patient’s blood sugar turns out to be 29, but he is not a diabetic. They give him D50, and he comes around, but is still somewhat confused. At the hospital they keep him overnight to do tests and figure out why he dumped his sugar considering he is not a diabetic. Plus he is still confused. He won’t answer to his name. Later that night, the hospital gets a call from the nursing home to check on the patient. Who? The hospital says, we have no one by that name here. Later the hospital calls the nursing home back. We do have someone here from your facility named Edward Thomas. Ahh, no you don’t. Edward is right here next to me in his wheelchair. Whoops. No wonder the man in the hospital bed won’t answer to his name. Turns out the patient is a diabetic after all.
You have to check the name. If the patient can’t confirm it, check for a name bracelet. No bracelet? Get a nurse to verify the patient and paperwork are one and the same.
You’d think it would be easy, but it’s not. The times I’ve been on calls and had a first responder hand me a piece of paper with the patient’s name and information on it, and its been the first responder's previous patient, and not this current one. The times it has been the right patient and I have put the paper in my right pocket, but then pulled a piece of paper out of my left pocket and started typing in the name on the left pocket piece of paper. Not the patient in front of me.
I try hard now. I introduce myself to the patient and get the patient’s name or get someone to tell me the patient’s name. Mistaken identity can lead to serious errors, and those we always want to avoid.
Street Lessons #2 Troubleshooting the Monitor
In paramedic school, you are taught to apply your cardiac monitor to patients having chest pain as well as a variety of other aliments. Simple enough. If your teacher hasn’t told you, then your preceptor should be grilling it into you to always bring your monitor in to each call, as well as your house bag. Some might say you should also be bringing in your suction --anything you might need. You never know what you are walking into. But in this post we are going to just talk about the cardiac monitor, and we are going to assume you have it with you. (At least in cases A-D). Here’s where the problems begin.
Problem A
Both batteries are dead. You checked them this morning and you swear they both had four bars. Now the monitor is either completely dead or the batteries are both down to one and flashing that they need to be changed, and then they go dead. What happened? Well, you thought you turned the monitor off after you checked it at the start of your shift, but you didn’t, and all this time the machine has been sucking the batteries down. I can tell you I have on several occasions been driving to a cardiac arrest and just before I arrived, heard a sudden beeping from the back and the voice saying “Change monitor batteries.” What do you do? If you are still in the truck when the battery is beeping, you change the batteries out. Simple enough. But let’s say they are both dead and you don’t notice until you are in the house. You take the spare battery out of the back. How do you know you have a spare battery? Because this has happened to you before, so you always keep a spare battery in the back now. Always.
Problem B
The batteries are good, but when you attach the electrodes, nothing reads on the screen. You recheck the leads and connection to the monitor, which you unplug and then replug several times, all with no change. Still nothing. You take the electrodes off and apply some new ones from the same open bag, and still nothing. You blame the monitor. Is it the monitor? No, some of you may have guessed from your experience or from what I have written that reveals the clue. The problem is the electrodes are from an open bag and they are dried out. You were smart enough to switch electrodes, but you took the new ones out of the same open bag. Try to always get your electrodes from a fresh pack, or at least keep a spare fresh pack in case you have this problem. I know some medics like to preattach their electrodes, which is okay if you are very busy, but know this -- from the moment you take them out of the bag, they start to dry out, and the drier they are, the worse the ECG quality will be until you get nothing at all.
Problem C
You need to do a 12-Lead. Whoops, you have the regular cable, but the 12-lead attachment cable is missing. It fell out and no one noticed or you forgot to check carefully this morning. Either way, all you have is the four leads and your patient is having crushing pain and is cool, clammy and diaphoretic. What do you do? A modified 9-Lead. This is how we did 12-leads before we had Life-Pack 12s. Take the left leg lead -- the red lead, and move it to the V1 position. Run Lead III in diagnostic mode. Repeat with V2, V3, V4, V5 and V6. Label each lead as follows: McL (modified chest Lead)1, McL2, McL3, etc... While not exact replicas, they do passably well. You do this and see hyperacute T waves in McL3 and McL4 and McL5. Call in a STEMI Alert.
Problem D
This time you have your 12-Lead cables, but that is all you have. You don’t have the four lead cables and without those, you can’t attach the 12-Lead cables. Your patient is alert, but very clammy and you can’t feel a pulse. What do you do? Take out the defib pads, and apply them to the chest. Hit paddles on the monitor and while you won’t be able to get a 12-lead, at least you know the rythmn and if it happens to be VT, you are all set. If if is an SVT, and you want to give adenosine, go ahead, just be certain to hit print. If it is a sinus, well at least you know that.
Problem E
Okay, so this time you are dispatched to a chest pain call and when you go to grab your monitor, there is no monitor. D’oh! What happened? Who knows, but we could assume what happened to you is what happened to me as chronicled in the post D’oh! I was lucky enough that my call was not a chest pain, but a BLS call. Had it been a chest pain, I would have had no choice but to fall back on my BLS skills and call for a paramedic intercept. Even if I was revealing my lapse and subjecting myself to punishment, you can’t let the patient be harmed. Go ahead and call for a medic, and hope that your company and or medical control is lenient with you.
I am introducing a new series. I am calling it Street Lessons, but I could just as well call it any of the following:
Things They Didn’t Teach Me in Paramedic School
Things They Might have Taught Me in Paramedic School, but I Was on a Bathroom Break.
Oh Shit!
Things I Learned The Hard Way
Trial and Error
Eureka! or Light Bulb Moments
***
Street Lesson # 1
Don’t Carry Hypotensive Patients in a Stair Chair
Over the years, I have had five patients go into cardiac arrest while I carried them in a stair chair. What does that tell me? It could mean that I carry a lot of patients in stair chairs. It could mean there are not very many elevators in the city I work in. It could mean I have done a ton of calls in my twenty plus years in the field. All would be true. And I can say I have never had an ambulatory patient go into cardiac arrest on me -- at least not while I have been ambulating them. My first words to my partner on arriving at patient bedside are usually, “Get the stair chair.” The old saying "ABCs - Ambulate Before Carry" - it is not in my book of sayings.
Still five patients coding on the stair chair seems like a lot -- certainly enough for me to wonder whether their coding was in any way related to their being on the stair chair.
So why might they code on a stair chair?
They are sick and dying and called 911, and if we hadn’t arrived as soon as we did, they would have gone into cardiac arrest at that precise moment anyway.
They are sick and dying and the fact that they were being carried down steep creaky stairs scared the last bit of life out of them.
Or maybe they were hypotensive and when we sat them up, their weak hearts couldn’t compensate, and that little extra bit of stress was enough to push them into the void.
I cannot remember the details of all five cases. But I can remember each of them dropping their head back or dropping it forward in a manner that indicated they no longer had muscle control. Sometimes they took a last gasp or two, sometimes not. I am a big believer in working a cardiac arrest right where they code, not losing a precious second in poor or absent CPR. Still it is hard to just stop carrying someone mid-stair case and start rescusitation.
“You know what just happened?” I will say to my partner.
“What?
“The patient just coded.”
So what is the lesson in all of this (Besides, expect if you do enough calls and carry enough people some will code on the stair chair)?
My lesson is -- if the patient is hypotensive while supine or borderline hypotensive and they are sick, consider carrying them in a scoop stretcher.
A 20-year-old with a pressure of 80 due to vomiting may be less at risk that an 80-year-old cancer patient with altered mental status, tachycardia and a pressure of 100. If a patient gets dizzy sitting up, then don’t use the stair chair. It may not spare you having them arrest on you during extrication, but it will be less likely to cause harm.
My favorite stories are when medics talk about great medics from their past. The stories can be made up, exaggerated or true, but with telling they achieve the status of folklore and the medics in them are our Paul Bunyans and Davy Crockets, our Supermen and our Columbos (the great TV detective played by Peter Faulk).
I heard an awesome story that other day that I wanted to share. In this story the new medic (now a seasoned medic of many years) tells how he had a patient in severe pulmonary edema who was circling the drain in front of him. As his partner raced lights and sirens to the hospital, the medic told the partner to call for an intercept as he desperately needed help. The call went out and at the intercept point, the hero medic stepped in the back, eyed the patient, asked the new medic for the nitro, which was handed to him. The hero medic opened the nitro, pulled open the patient’s mouth and poured in what seemed like half the container. The hero medic closed the patient’s mouth, and then told the new medic. “You should be all set.” He stepped out of the ambulance (My work is done here), patted it on the side like they do in TV, and the new medic was back on his own with a patient who by the time they reached the ED was doing great, chatting comfortably with the new medic.
One of the reasons I like this story so much is that while it occurred probably a decade ago, it showed how the hero medic knew what is now and becoming increasingly so, the hallmark of CHF treatment. Not just NTG with our newest great gadget CPAP, but that high-dose nitro is what will likely save people. Rogue Medic has a nice recent post about high-dose nitro where he cites studies where patients are getting the equivalent of from 2-5 mg of Nitro IV every 5 minutes.
Nitroglycerin for Treatment of Acute, Hypertensive Heart Failure – Bolus, Drip or Both?
You can talk about the hero medic acting of protocol and being a cowboy, etc, but the story still resonates for me.
For more about EMS Folklore read Timothy R. Tangherlini’s great book Talking Trauma: Paramedics and Their Stories.
Some of my favorite bloggers like Rogue Medic, Ambulance Driver, Under the Lights, and Greg Friese have been discussing the topic:
"Should EMS Be Allowed to Carry Concealed Hand Guns on the Job?"
While as a rule, I try not to discuss politics, religion or guns in the interest of getting along, after thinking about it, I decided to share some of my thoughts on the topic.
First off, here are my gun credentials. I don't have any. I do not own a gun. The last time I shot a gun was in YMCA camp when I was 12 and I earned a sharpshooter’s first class certificate with a 22 rifle. I have never fired a handgun.
Perhaps I exhausted my gun desires during the cowboy phase of my early years. There are many childhood photos of me with double holstered cap guns drawn and firing. I shot many an evil hombre with them, and once, unfortunately, I El-Kabonged a neighborhood friend with one of them during a play fight when I had not yet learned that there was a difference between cartoon violence and real violence. I hit my friend in the head with my gun. Hard. His skin split open and out grew a lump just like in the toons, but unlike the toons, my momma got a phone call from my friend’s momma and I ended up getting grounded for a week, in addition to being spanked, back when spanking was not considered child abuse.
Today one of my best friends is a gun guy. I would not call him a nut as I have great respect for his wisdom and judgment, particuarly on medical issues. But I have been with him several times when he has visited with fellow gun aficionados. These meetings tend to startle me. Out of car trunks and boxes in closets and even desk drawers, these gun friendly folks always seem to produce all kinds of weaponry from German Lugars to assault rifles, which they pass around freely for admiration. For someone who is not comfortable being around guns, it is quite an experience to behold, like suddenly feeling like you are the only human among an alien race or perhaps, maybe I am the only one from another planet, and I am just an outlier among red-blooded American males. Sorry, I say, I’m good. You can go on bogarting the 9 millimeter. I don’t partake. Curiously one day of my friend’s gun buddies called him up and asked my friend to come over to the buddy's house and take his guns away (just temporarily) as he was having some difficulties with his girlfriend at the time and did not want the guns there should he feel any sudden angry impulses toward her. I am uncertain if this is an example of responsible gun ownership or a reason to fear gun ownership.
For several years, I had a rifle in my apartment within reach of my bed as well as a handgun in the nightstand. When my college girlfriend and I moved to a not the best neighborhood apartment complex in Arlington, Virginia, which at the time was all we could afford, her father gave us the guns which had belonged to her recently deceased grandfather. He said he felt safer knowing we had them for protection. I don’t even know if they worked or would have fired if I had pulled the trigger on an intruder. I don’t even know if the guns were registered or in Virginia, if they needed to be. I know I should have at least taken them to a range and fired them a time or two, as well as taken a gun safety class. But I didn't. Fortunately, I never needed them. I shot no one and no one shot me.
I developed some rules about guns over the years. Never date a woman who owns a gun (and unlike my girlfriend at the time (a gentle soul) knows how to shoot it). Also, never date a woman who’s last boyfriend owns a gun. I do read the papers and know the "one in the head two in the heart" slogan, (or is it "two in the heart, one in the head"). And I have been on more than a few gun violence calls in my years, including one where the shooter ignored the above rule and got a little more personnel. “My Dick! My Dick!" His victim cried. " He shot me in the Dick!”
I try to think back on all my years in EMS including many in a city with one of the highest murder rates in the nation (the violence seems to be largely directed at rival drug gangs and people who looked at them or their girlfriends the wrong way or innocent bystanders who were standing on the street corner doing nothing at 2:00 A.M. or innocent bystanders who were on their way to grammer school or even babes in their mother's arms) and try to imagine when if any time a concealed weapon would have benefited me or whether or not I would have ever been tempted to pull it or shoot someone.
I did recently watch a rather chilling ESPN movie about a high school basketball star in Chicago (Ben Wilson who was the number #1 prospect in the nation) who was gunned down near his school one day back in 1984. At the time, it was reported that he was a victim of a mugging. In the movie however, they interview the shooter, who claimed he had taken his father’s handgun and gone out to try to get ten dollars back from a friend who had had it ripped off from another friend. His story is when when he got there, the debt had already been settled, so he was just hanging out in front of a store with the gun still in his pants when the basketball player walked by and accidently bumped him. When he shouted at the player to show some respect, the player turned and belittled him. Words were exchanged. It was then, the boy showed the gun in his pants. But instead of having its intended effect of scaring off the taller boy, the ballplayer laughed at him and said, “What are you going to do shoot me?” And walked towards him. The boy recalled his father saying that if you ever drew a gun, you would need to be prepared to use it, since he had just then suddenly drawn the gun, he was already at that point. Boom! Boom! Boom! Two lives changed in an instant.
It is impossible for me to think of drawing a gun and then using it if the draw didn’t prevent the episode. And in EMS it is hard for me imagine drawing on a rational person, of which we encounter so few. Again, I am not gun-trained so I would have no business carrying a gun much less drawing it. But if I was qualified, I still have a hard time imagining it.
I have been lucky in that most of the violence against me has been from demented old ladies, hypoglycemics, and a few crazy people on PCP. I am also lucky that I am both six foot eight, two hundred and twenty pounds and somewhat slow moving so that when I have been rushed and I have been, I have not appeared to be either aggressive or frightened. I merely put my hands up, take a step back, and say, “Wow, Dude!” I don’t project aggression. I back off, I speak quietly and I never physically engage unless the patient is less than ten in which case, I can pick them up at arm’s length while they punch and kick, but are beyond the reach of my torso. Maybe I have just been lucky.
Some of my fellow medics have gotten into wrestling matches, and I have jumped into the back of several ambulances in response to calls for help. Fortunately there have been enough of us, along with our trusty friends Ativan and Haldol to subdue the threats. But I wouldn't want to be wrestling if I had a gun on me, but then again, I don't even know where a concealed gun goes. In my boot? Up my sleeve? I am ignorant of these things.
I can't recall any EMS people being shot on the job around here. I know one who was stabbed, but that was at very close range and by a psychiatric patient who grabbed the medic's own sissors and struck him in the leg. I do know of ambulances being shot at and occasionally hit. The last shooting I responded to involved a man who was sitting with another man in his car, doing a drug deal. A man walked up to the car and shot the driver five times. The other guy got out of the car and walked away with the shooter. An ambulance crew driving down the street, heard the shots, ducked and then the next thing they knew they were getting T-boned by the shot man, who had put his car in gear and floored it. The crew was okay and the man who had been shot five times, was lucky enough to survive himself. What if that crew had been packing? Would they have pulled their guns instead of ducking? Would one have attended to the patient while the other chased the bad men?
Many years ago in our city, a paramedic came upon a shooting as the gunmen sped away. The crowd pointed toward the car, and the paramedic seeing no one shot, (without getting out of his ambulance to check futher) immediately sped off after the get-a-way car, relaying information to the police over his radio. The police gave him a medal. His medical director almost yanked his medical control. It was quite a controversy that even played out in the newspapers. His fellow employees were not happy with him. I have always felt like we are without sides. We have free passes to wander through even the most dangerous areas. This made us targets. Not good.
I can recall a number of police officers being shot in the area. Every one of them was ambushed, and several likely never knew what hit them. Some officers have shot people who proved to be unarmed, which does not mean they did not pose immediate and deadly threats to the officers. And then there have been quite a few officers who pulled the trigger on themselves, sitting in their lonely cars, contemplating their lives gone adrift in an unpleasant world.
So given all of the above to show where I am coming from, it is no surprise that I would never carry a concealed handgun on the job. I am clearly afraid of guns in most anyone's hands. But how do I feel about others who are trained, rational and with quicker instincts and reflexes than my own carrying? I do believe EMS has the right to protect itself and I believe in a safety first culture. But let me ask this, Mr. Potential Gun Carrying EMT, how committed to safety are you? How committed are your fellows in arms?
Do you always wear gloves when touching a patient?
Do you always wear your seat belt? In the back as well as the front?
Do you work out in the gym, stretching and strengthening?
Do you eat a balanced diet?
Do you smoke?
Do you get enough sleep?
Have you had a flu shot?
Do you wear a safety helmet on duty throughout the entire shift?
Do you stop at every intersection when going lights and sirens and look both ways.
Do you wear body armor?
Do you wash your hands after every patient contact?
I do all of the above except wear the body armor and get the sleep part, and the wearing the seat belt in the back part, and the safety helmet, and sometimes the glove part and the always stopping completely at the intersection part, and remembering to wash my hands after every call, although I do wash my hands fairly regularly throughout the day, as well as use those ubiquitous foams.
If you do all these things, then you are committed to safety, and as long as you have taken the proper gun safety classes and feel you are not a threat to your patients, the public or yourself carrying a gun, then I might stop and listen to you explain why carrying a gun on you while treating patients is a good idea.
Peace and respect to all my brothers and sisters.
Thanks for all your responses to my post on Guns and EMS. A couple clarifications and further thoughts.
In Connecticut, where I practice, it is specifically illegal for EMS to carry weapons. Also, there are never supposed to be any weapons in the back of the ambulance. When we transport an injured police officer, his weapon is taken from him by other officers and secured elsewhere.
Connecticut is not a liberal gun state. We don’t see a lot of guns here, although we hear a lot of gun fire in the city. 16.2 % of our citizens own guns, ranking 46th in the nation. Curiously our death rate per person from guns statewide is also 46th. Hartford, on the other hand, is rated the 7th most dangerous city in the United States, more dangerous than New Orleans and Baltimore, but less dangerous than Gary, Indiana, and Camden, New Jersey.
http://www.morganquitno.com/cit05pop.htm
The distinction is somewhat of a misnomer as while dangerous, Hartford is also small. We respond to drug-ridden neighborhoods, and yet just minutes away in other towwns, we respond to quite proper white picket fence neighborhoods with low crime rates.
A difference, I think, in guns and EMS between us here in Connecticut and other parts of the country is perhaps that on most of ous EMS gun calls (suicides excepted), or ordinary calls for that matter, there are not a lot of guns on scene. I imagine in other parts of the country it is perhaps impossible to walk into a room or respond to a car accident where there is not a private gun within someone’s grasp. Not very likely in our state.
While I said I do not own a gun and am quite scared of guns, I am not opposed to gun ownership. I believe in an active government, but I do not believe in an obtrusive government. I will gladly pay taxes for the common good, but I don’t want government either moralizing for me or telling me I can’t own a gun if I choose to. No bazooka, I can understand, but not a hunting rifle or a personal hand gun for protection.
As far as any of my partners having concealed guns on duty, I am still against it. While I have trusted all the partners I have had over the years to varying degrees from complete trust to never let them out of my sight and never let them touch the patient lack of trust, having them also carrying a gun adds a new complicated layer. I still don't see a reason for it in our work. And, as I said before, I have trouble with the "I need it for safety" argument when on a risk/reward benefit, there are so many other things we can do to improve our's and our partner’s safety that few people use. I have always found it odd that so many young heroes I work with will strap on a bullet proof vest, but wouldn’t be caught dead wearing a crash helmet on the job when they are far more likely to be injured or killed from head trauma in an ambulance crash, than they are to be shot. I worked with one partner who even refused to buckle her seat belt while she drove (she connected the seatbelt and put it behind the seat, but oddly insisted on locking the ambulance anytime she went three feet from it because it was the rule that we were to lock it when unattended. To each his or her own, I suppose, although I argued, not wearing her seatbelt made her a danger to me should we roll over and she become a missle headed at me, where I was less concerned with our laptops being stolen.
Finally, in answer to the suggestion that my not being drawn on in 20 years is somehow a reason that therefore a cop should not carry a gun if he is not drawn on for twenty years, I can only say, our jobs are different. Let’s say they were to make a movie about a police officer and one about a paramedic. The policeman movie begins with the police officer opening a door to see a bad man drawing a gun. You have the beginning of an interesting movie. What is going to happen? How will the police officer get the man disarmed? How will the conflict resolve? Now make the same movie with the paramedic. I will happily play the role of the paramedic. I open the door, I see the man draw his gun. I close the door. Movie over. As the credits roll, you see me running down the street as fast as can. Please dispose of any empty popcorn and soda containers on your way out of the theatre.
Peace out.
An emergency doctor friend of mine has a great lecture called “It Depends…” He says that for many EMS patient care questions he is asked, the answer is “It depends…:” But there are other questions where it does not depend, he points out. For instance, when your patient suddenly goes into v-fib. There is no "It depends." You defibrillate. Your patient is in severe anaphylaxis. It does not depend, you give them epinephrine.
When I analyze a call now, I try to follow the decision making. Did it depend or did it not depend? and if it did depend, what did it depend on?
Here is a question that I recently considered. If you have a critical patient who you are worried may crash, when do you do the IV? At the patient’s side, on scene in the ambulance, or en route to the hospital? The key is that you need to have the IV when you need it. What is my thinking as I consider this question?
Well, it depends on whether or not I am going to be able to do anything for the patient and can the hospital do something that I can’t that will make a different in outcome. For instance, a gunshot to the torso. The patient needs a surgeon. My IV is not going to offer me much avenue to help. I would elect to do the IV en route once I have taken care of other priorities.
Now how about a pale, diaphoretic patient in ventricular tachycardia with a pulse? This of course raises the question of shocking or giving meds. Another it depends question. Let's say I choose to shock first and it is unsuccessful. Back to the IV question. For me there is no more it depends. It doesn't depend, I need the IV right then. I will go for the IV right at the bedside because I will be able to deliver amiodarone and if the patient codes, other ACLS drugs (for what they are worth). Bottom line, I won’t wait till the ambulance to get my IV.
Now let’s say the patient has sepsis and hypotension. Here my IV can be an avenue to give this patient needed fluid. While fluids may be life-saving the IV is less moment dependent than in the previous case, so depending on the surroundings in the home (lighting, space, etc), I may wait to the ambulance, and then depending on whether or not I think I can get the IV easily (or who is driving) I may elect to do the IV enroute or try first in the parked ambulance if the patient has poor vasculature and my partner is a rough driver.
Most every EMS call has many “it depends” moments. Here is one I am thinking about now. You are alone in back and your patient goes into sudden cardiac arrest. Ventricular fibrillation. You shock once with no success. What do you do? Do you have your partner continue to drive to the hospital while you try to manage the code or do you have him pull over and help you out in back?
What does your decision depend on? How far are you from the hospital? Can you effectively deliever quality compressions, manage the airway, and deliever quality care by yourself? How far away is help? Is it safe to pull over where you are? Does the screaming family member in the front seat affect your decision? I would lean strongly to pulling over at the first safe spot and getting assistance to work the code right there.
Tough calls. Tough questions.
And the answer? I think when deciding if it depends or does not depend, the answer must always be -- When it comes to what is best for the patient, it never depends.
Christian Schmeck passed away a few days ago at 59. I saw his obituary posted in the EMS room at a local hospital. I suspect most of the newer EMTs who saw it didn’t know who he was.
I first met Chris over twenty years ago when I worked at the state health department. He was a service chief for a local volunteer ambulance and we had invited him to an EMS Summit to discuss ways the health department could improve the EMS system. He wore his white chief’s shirt with the gold badge on it, but he came across as an unassuming man who was happy to be invited, glad that someone wanted to listen to him. I remember sitting next to him at lunch and having a long talk with him about a call he did where he came upon a family found dead in their beds from carbon monoxide poisoning and I saw how deeply it affected him.
A few years later when I left the health department and started full-time as a paramedic, he was a training officer at the service where I was hired. He gave us all our orientation on our first day, and he was reassuring in providing guidance to the group of us new hires. Over the years I worked with him a few times. He was a good solid partner. Never a know-it-all, but not afraid to direct me if I started down a wrong track. And he was kind to patients – always. He never spoke a harsh word or showed a lack of patience. He was an EMT you wanted taking care of one of your family members if they ever needed help.
Like many in EMS, he was often tired, working commercially during the day to support his family and then spending long hours as a volunteer at night, teaching classes and doing calls. As the years went by, he divorced, moved to a new town, joined another volunteer service, and suffered a slow decline in his health. Eventually, he gave up the road, and went into dispatch, and then just teaching. I saw him a few times in hospital rooms in the ED and did a double talk on seeing him on the other side of the stretcher. I'd always stop and talk and wish him well. He would tell me he was doing better, just waiting to be discharged or possibly just admitted for the night.
The last I saw him was in the aftermath of big storm we had last October. He was walking out of an emergency shelter. He wore a nasal cannula and carried a small O2 tank on his shoulder. I didn’t have time to talk, but we said hello.
For those EMTs who read his obituary, but who never knew the man, Christian Schmeck was one of us.
The call is for an unresponsive in a wheelchair on a street corner in front of a social services agency.
A woman who works at the agency flags us down. She says she has a man in a wheelchair who is unresponsive. She does not know him. He is not a client there. She says a stranger wheeled him up in the chair, said he was on some heavy duty drugs, and then bolted.
The man in the wheelchair’s eyes are closed, his head is tilted all the way back and his mouth is wide open. He is about forty years old with long dirty hair to his shoulders. He is wearing an army jacket. He is breathing, but you have to watch him for several moments to see that he is his rate is so slow. His pupils are pinpoint. I give him a shake. He opens his eyes, mutters, and then he falls back asleep.
This appears to be a narcotic overdose. We lift him out of the wheelchair and place him on our stretcher, and then get him in the back of the ambulance. While I assess him further, my partner opens the ambulance's side door, and puts his wheelchair in.
When I started in EMS we always gave narcan to heroin overdoses. You had pinpoint pupils, you got narcan. Nowadays narcan is limited to suspected opiate overdoses who are hypoventilating -- low respiratory rate and/or high ETCO2.
I debate what to do about this guy. If I stimulate him enough I can keep his respiratory rate up, but he can’t talk to me. I don’t know his name or anything about him. And I have to keep stimulating him or else he'll drop back off to hardly breathing at all. I put him on the capnography and I get an ETCO2 of 57, which is high, and suggests he is not effectively ventilating. If I stimulate him, I can get him to breathe more and the number drops down. I leave him alone, and it goes back up. His respiratory rate is 4. The end tidal climbs back up into the 50s. I finally decide to just give him a tiny dose of Narcan -- 0.4 mg to wake him up just enough that I won’t have to keep shaking him every two minutes.
No sooner do I give the 0.4 mg, then he opens his eyes, looks right at me and curses. “Shit, you just gave me that narcan shit, motherfucker.” He tries to undo his straps. “Now I have to go out and start all the fuck over again.”
“Whoa, Whoa,” I say. “You were barely breathing. I had to give it to you.”
“No, if you left me alone, I would have been fine.”
“Left you alone? I didn’t go looking for you. You want to get high and not have anyone bother you, lock yourself in a room and put a do not disturb sign on your door. You OD in public, someone is bound to call us, and if you are not breathing effectively, I hate to break it to you, but you will get narcan.”
“Where am I?”
“You were out and barely breathing. So you are in the ambulance now, headed to the hospital.”
“Where’s my money? Did you take my money?”
He frantically reaches for his pockets and is relieved when he pulls out some crumpled bills including at least a twenty.
“And we have your wheelchair with us, so don’t worry about that.”
“Wheelchair?” he says.
“Yeah, your wheelchair. Your buddy wheeled you over to the agency and they called 911. We put your wheelchair in the side. It’s right here, behind you. Safe and sound.”
“I don’t have a wheelchair.”
“Huh?”
“I don’t have a wheelchair.”
“You can walk?”
“Fuck, yeah.”
“Well, you were in a wheelchair.”
He looks puzzled, and then he says, “Wait a minute, does it say, "Property of Sam Thorpe' on it?”
“I don’t know. Maybe.”
“My roommate has a wheelchair.”
I slide over and look at the wheelchair. “Property of Sam Thorpe,” I say.
“That’s it. It’s my roommate’s wheelchair.”
“What’s wrong with your roommate?”
“He doesn’t have any legs.”
***
At the hospital, the patient continues to bitch that I gave him narcan. We put him on a bed in the hallway and tuck the wheelchair in next to the bed. No sooner have I started down the hall when a nurse takes the wheelchair and starts wheeling it away.
“Whooa, whoa,” I say. “That’s his roommate’s wheelchair?”
“Where’s his roommate?” she says.
I hold my hands out. “If only I had a crystal ball.”
I think EMS is a lot like baseball. It can be fairly slow-paced (boring, if you prefer), but it has its moments of excitement. You have your days when you don't even remember the calls you did they were so routine. Like in baseball, you can stand around all game in the outfield waiting for them to hit you a ball, and maybe on a typical day, you get a couple easy flys you can catch, or maybe a couple singles come out your way that you retrieve, and return to the infield with a crisp throw. Every so often you get a chance to make a spectacular play, and even rarer, you get a chance to make a spectacular play with the game and the season on the line. Same with at the plate, you bat your average for the season, and every now and then you get a chance to win the game in the last of the ninth, but that chance is rare. It’s a long season, and, just like in EMS, the trick is to stay ready on every play, never knowing when you will be truly tested.
The above, translated, means, its been pretty slow and non-exiting lately at the ambulance ballpark. Some days it is more like a six year old girl’s softball game than the major leagues. (In girl’s youth softball everyone bats and there are a lot of walks). (Today I’ve transported three kids from a school bus accident who had no injuries, a two day old fall and I did a dialysis transfer). The highlight of my days has been finding good things to eat. While I love a Fenway Frank as well as the next guy, after awhile regular ballpark food can taste pretty bland. One good thing about the city I work in is the food is varied, multiethnic and generally awesome. Instead of writing about calls, I have been collecting notes on restaurants. I found an excellent plantain porridge at Mr. Snapper’s on Albany Avenue last week for $2.50, some great crispy roast duck from the A Dong Supermarket on Shield Street, and later had the best jerk pork I’ve had outside of Jamaica at the Jerk Pit Café out north on Main Street just past where Windsor Street hooks back up with Main. Today, I ate the Bem Brasil Buffett on South Whitney for lunch where you pay $4.99 a pound for food. I had chicken simmered with potatoes, short ribs, rice with vegetables, and a fried stuffed green pepper. It was great. As soon as I’d finished, I wanted to go back for me, but by then we had been moved to area 16. I’m hoping later to get posted to area 10 where on the way there I can get a pizza empanada at Aqui Me Quedo on Park Street.
Oh, yeah, and I’m listening to the Red Sox on the radio right now. Unfortunately, they are down 4-1 early in the game and unless they get their act together in the next couple games, they are in jeopardy of missing the playoffs.
Heroics may be needed.
***
Postscript: The Sox lost the first game of their double-header 6-5. They rallied to win the nightcap 18-9, and they remain two games in the wildcard lead. I did another transfer, a crash with leg deformity, and a shooting to the arm. The MVA and the GSW were stable enough to get pain management (Fentanyl) from me. I didn’t get to Aqui Me Quedo, but did get a most excellent Jamaican chicken patty (chicken in a light pastry) for $1.80 at the Golden Crust Bakery at the corner of Woodland and Albany.
A reader (Lucus) queried me about what I carry on my when I am on duty:
I have a stethoscope around my neck. In my right shirt pocket, I have four small blank index cards. In my left pocket I have a pen, a pack of gum, and my I-phone.
I have trauma shears on my right side leg pocket. In that pocket I have my sealed controlled substances kit (fentanyl, morphine, ativan and versed), an IV lock, an IV flush, a 5 cc syringe and a 1 cc syringe. In my right small pocket, I have a needle, two alcohol wipes, and a nasal atomizer. I have my narc keys in the left small pocket; in the regular pocket I have a pair of exam gloves. I usually put the patient’s paperwork (W-10s, etc, med lists) in the left leg side pocket when they are handed to me on scene.
Surprisingly(Perhaps), I do not wear a watch. I stopped wearing a watch years ago because I could not afford to keep replacing my watches as I was always misplacing them. How can I work without a watch? When I feel a pulse, I feel for speed. Slow, normal, fast. Regular or irregular. I get a ballpark estimate that once I put them on the monitor is usually confirmed. There is a clock on the monitor. I also have my i-phone as a backup. All of my truly sick patients end up on the monitor.
I wish I carried a pen light more regularly, but those are hard to keep in stock. In the ambulance I have a flashlight, and someone on scene usually has a penlight if I need one.
I used to carry an EMS field guide, but now I use my i-phone to look up anything I need to check.
I am in a fly car mostly these days, so sometimes when I intercept, there are no locks or flushes on the shelves of the transporting ambulance. I find it is easiest for me if I just pull one out of my pocket. The syringes, needle and atomizer are all so I can deliver quick pain relief (IN Fentanyl) or to stop a status seizure (IM Versed). I like to have my kit at the ready to use. I don't like fumbling with the keys to open the lock box or being surprised on a call and not having my kit handy. I use my controlled substances kit, mostly for the Fentanyl fairly often -- at least every other shift, and not infrequently, two times a shift.
On my belt I have my company issued pager and when I am in the fly car, I have a portable radio.
When I enter a house, I always carry my Thomas pack and monitor. If I am the first one arriving, I bring in my oxygen bottle. If I am working the ambulance and it is for a fall, I always bring in the board and collar bag just in case. If it is for a cardiac arrest, I try to remember to bring in the suction.
I am not saying mine is the perfect set up or the recommended set up (I am not going to tell you not to wear a watch), but, based on twenty-plus years or responding, it works for me.
Note: Once upon a time, I did carry a window-punch. I only used it once, and I had a good time using it, but now I leave that to the fire department or other responders, now that we have so many others responding with us these days.
The number one treatment change in EMS in the last twenty years is the increased emphasis on painmanagement and comfort care.
Albert Schweitzer said, “Pain is a more terrible lord of mankind than death himself…. We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege.”
Like many I began in EMS with visions of saving lives everyday and then having grateful reunions filmed by the crew of the old TV show, Rescue 911.
Now over twenty years into my career, I know that true life-saving calls are few and far between. And many of those few life-saving calls you really don't do much more than you are taught:
Show up on scene, find recently collapsed patient, apply defibrillator, shock, feel restored pulse.
Show up on scene, find cool, clammy patient with chest pain, do 12-lead, see obvious STEMI, call hospital to activate cath lab, transport.
Show up on scene, find child in anaphylactic shock, eyes swollen shut, airway closing off, no blood pressure, stick them with epi, and watch them return to their normal self.
Some patients are just waiting there for us to save them.
And on other calls, you can work your tail off, do heroic things and the patient doesn't make it. It was just their day to die.
Today, I see my job not as a lifesaver, but as a comforter.
My EMT instructor told me the emergency ends when you arrive on scene, or at least that's what you have to make the patient believe.
Today, my reinterpretation of her comments is this; once I am on scene, the patient is no longer alone. I am there to care about them, to provide whatever comfort and care I can, and to try to keep them safe from further harm.
I do that hopefully with a calm voice, a caring touch, understandable words, and with if they are in pain, with everything from pillows and ice to morphine.
"My great and ever new privilege," as Schweitzer says, "is to take care of people's pain."
I can do that, in one way or another, on an almost daily basis.
When I started in EMS, I did not give morphine at all my first year. I gave it only twice for trauma in the next two years, and then in doses too small to provide relief. This is working in a busy system doing 400-500 ALS calls a year. And for vomiting patient, I never once gave an antiemetic.
“I have to hurt looking at you for you to get morphine from me,” an old school medic taught me when I started.
It's a new day.
Last year I gave Fentanyl over 50 times, more than any other drug except Zofran, which I gave close to 100 times.
I gave Fentanyl for hip fractures, and ankle fractures, and shoulder dislocations and wrist fractures, for amputated fingers, burns, for kidney stones, and for all sorts of abdominal pains. Did I get scammed a time or two by a drug seeker? Likely I did, but you know what? I don't care. I can say I didn't deny anyone in legitimate pain medication for fear they were drug seeking.
Why is pain management important? Because pain is destructive to the human body. Its only purpose is to alert patients to injury to help eliminate the source of the injury and halt damage to the affected tissue. Untreated, pain stresses the body, damages the immune system, hinders wound healing, and can lead to chronic pain. Not to mention the emotional suffering it causes.
"Prompt treatment of acute pain may prevent both short- and long-term deleterious consequences and resultant chronic pain syndromes.” – Pain Management and Sedation: Emergency Department Management, Mace Ducharme Murphy, McGraw Hill – 2006
Nearly ever study ever done on the issue has showed widespread under use of analgesics in EMS systems and emergency departments across the country.
But times are changing.
When I started as a medic, on-line medical control was required to give morphine. Today, for a 220 pound patient, I can give up to 20 mg of Morphine (over 20 minutes) on standing orders and up to 300 mcgs of Fenatnyl. Morphine for abdominal pain was prohibited. Today I can give Morphine and Fentanyl on standing orders.
I may not be able to save a life everyday, but everyday I can treat my patients with respect and dignity, and if they are in pain, I can ease their suffering.
The oldest mission of medical healers is to treat pain. I accept that mission.
And I praise paramedics and EMS systems across the country for coming to recognizie this.
# 2 AEDs
The first code I ever did I hadn’t been an EMT but a few months, and my partner had been an EMT but a few days. The man had collapsed in his kitchen. He had gasping respirations. We got him on a board and out to the ambulance, where my partner did compressions and bagged while I drove. This was in the late 1980’s, twenty years after this country had put a man on the moon. I don’t know what rhythm the man was in the field. He was asystole at the hospital -- asystole, blue and with a bloated belly. Not only did we not have an AED and no paramedic intercept, we didn’t have any intercept. We were in fact trained to do two person CPR, not two person CPR like they teach in CPR class, but two person load the patient onto a stretcher and get him out to the ambulance, load him in the back and have one EMT do CPR while the other drove to the hospital kind of two man CPR. I remember shouting to my partner the whole way “15 and 2! 15 and 2!” Our small service couldn’t afford to tie two ambulances up for one patient.
Even later, when I worked as a paramedic for a larger service, while I had a Life Pack 5, our BLS crews didn’t have defibrillators nor did the police department who was the reluctant first responder. We considered it good form if a first responder was doing CPR when we showed up as opposed to standing in the doorway, saying "he don’t look too good." For many years the only bystander CPR I saw was when someone dropped in sight of a volunteer EMT or a boy scout.
How different it is today. This year alone there have been five successful cardiac arrest resuscitations where the patient has walked out of our hospital with full neurological function. Four of those patients got bystander CPR from laypeople, three of them had pulses back before the medics even arrived thanks to the first responders’ defibrillators. The other two needed a shock from the medics before coming around after initial AED shocks. All of the five patients had pulses back before the medics intubated or put in an IV.
The 2nd most important change in EMS treatment in the last twenty years for me has been the introduction of defibrillators to all ambulances and to first responders, not to mention the widespread appearance of public access defibrillators. I wish I had one all those years ago.
# 3 STEMI Care
When I started in EMS we had Life Pack 5s, which showed only one lead at a time in a tiny window. When I went to paramedic school, no one taught us about 12-leads. Paramedics didn't do them. Early on, we did an experimental project where we had a giant 12-lead machine in our ambulance, but it was so big and we were so uncertain about how to do a read a 12-lead that we never used it (or at least I didn't) and the project soon died.
Later, another medic taught me how to do a modified 9-lead ECG. This involved putting the machine in lead III and moving the left leg electrode across the chest in the V1-V6 positions, while being certain to print in the diagnostic mode. We then had to cut and paste the strips onto a sheet of paper. We labeled the newly aquired views as MCL1-MCL6.
The first time I did one (the day after I had been taught how to do it), I had a healthy young man with crushing chest pain. His skin was warm and dry. His vitals were BP 120/80, HR-64, RR-16, SAT-100% on room air. As a lark, I tried the 9 lead ecg. When I put it in MCL4, it showed tombstone elevation. Curious, I thought. I showed it to the triage nurse, who was dismissive, but at least instead of putting the patient in the waiting room, she put him in a regular room, where the room's nurse found him in cardiac arrest when she went in to assess him. He was defibrillated successfully, taken to the cath lab and found to have a 100% blockage of his LAD.
I can remember many times when I walked through the ED waving my 9-leads, and then even later after we got 12-leads, waving those, trying to get a doctor to look at one. The regular procedure was put the patient in the room, have the nurse come over, assess, do a 12-lead and have the nurse show it to the doctor. We all soon learned to be aggressive with our 12-leads, calling in saying the 12-lead showed an MI (sure, sure, they thought), and then using the 12-lead as a ticket to the head of the triage line. Excuse me, see my 12-lead, mind if I cut ahead. Take a look at this. Where's the doctor?
Nowadays, of course, it is so much different. We see a STEMI in the field, we call the hospital from the patient's bedroom, talk directly to a doctor and activate the cath lab from the field. We often bring the patient right up to the cath lab on our stretcher. Progress.
Here's a post I wrote on STEMIs.
STEMIs (ST-Elevation Myocardial Infarctions) are my favorite EMS call. I like them as a paramedic and I like them as an EMS coordinator. They are a great test of your both your ability as a medic and the ability of your EMS/hospital system to function well. They require clinical acumen, speed, skill, and coordination of resources.
If done well, you can save a patient’s life, if done poorly, a life could be lost (although sometimes lives are lost even when everything is done right). And the lives we are talking about here are usually people in the prime of their life. These aren’t asystole codes of 95-year-old ladies whose ribs break at the first push of CPR. And these aren’t trauma patients whose bones can’t be unbroken, whose head injuries can’t be easliy unbled.
It is simple. Recognize a possible STEMI, do a 12-lead, interpret it, notify the hospital/and hopefully get the people in the cath lab ready. Think of yourself as the 911 dispatcher for the cath lab. As important as all the skills you will do is getting the cath lab team sliding down their bat poles and getting their superhero suits on and having them there ready to work their miracles when you come through the door with your patient.
Transmit the 12-lead as soon as you identify it. If you can’t transmit, call it in, as soon as you can (not after you have done your two IVs and given ASA and 3 NTGs) — as soon as you see it is a STEMI.
Give 02 if the patient is hypoxic (AHA says no longer does every STEMI get the nonrebreather).
ASA if there are no contraindications.
IV – two is best, the bigger the better.
Nitro — unless it is a inferior STEMI with right ventricle involvement or any MI with low BP.
Morphine — if pain is not controlled by NTG.
Zofran — if the patient is nauseous.
Take their clothes off if feasible. Hospital gown on top, sheet over the pants (this will save time at the ED).
Get your registration info so they can get him into the system.
Switch O2 to the stretcher tank and mount the monitor on the stretcher so there is no delay packaging once you arrive.
Hit the curb and out you pop.
Oh, yeah, and have defib pads ready in case your patient codes. The natural progression of a STEMI is to VF and cardiac arrest. We are talking high risk here!
The hospitals have been practicing their pit crew techniques on STEMIs as well. Hospitals are being rated now on Door-to-Balloon (D2B) times meaning time from when the patient hits triage to when the balloon crosses the blockage/lesion in the cath lab.
The three big hospitals in our area have been battling with each other for STEMI patients and all of them are recording both excellent door-to-balloon times and great patient outcomes. Most of these patients who may be withinin minutes of cardiac arrest walk out of the hospital in a matter of a few days with clar stented arteries, on some new meds and told to eat heart healthy diets. Years ago they would have planted in the ground. Much of the improvemt is due the medical system recognizing and encouraging the important role EMS plays. Years ago I used to have to walk through the ED waving a modified 9-lead strip trying to get a doctor’s attention that my patient was having an MI. Now the MD knows and the ED and cath lab are already readying even before I leave the patient’s house.
***
A new study in the American Journal of Emergency Medicine published in April of this year, Hospital-based strategies contributing to percutaneous coronary intervention time reduction in the patient with ST-segment elevation myocardiaI infarction: a review of the “system-of-care” approach, concluded among 8 primary strategies for reducing hospoital door-to-balloon times, “2 have substantial evidence to support their implementation in the attempt to reduce door-to-balloon time in ST-segment elevation myocardial infarction (STEMI), including emergency physician activation of the cardiac catheterization laboratory and prehospital activation of the STEMI alert process.”
#4 CPAP
This morning we had a call for a 70 year old man with dsypnea and found him guppy-breathing with a BP of 210/100, HR – 144, skin ice cool and clammy, unable to get a SAT, ETCO2 of 50, RR of 32. Wheezes and crackles in lungs. Upright CO2 wave form.
He was sitting on his front steps, probably hoping the fresh air would help, but it wasn’t. We threw him on the stretcher and got him in the back of the ambulance quick.
We put him on CPAP — first time for me (we’ve only had it a couple weeks) — and started pounding in the nitros and in no time he was warm and dry. RR down to 24, ETCO2 down to 34. HR down to 132. He was still full of fluid, but at least we weren’t having to intubate him. Neither did the hospital. They put him on bi-pap and a nitro drip. His PH was 7.25 on arrival. The doctor said he probably would have coded if we hadn’t gotten there and started treating him as soon as we did.
I was trying to imagine how the call would have gone if we didn’t have CPAP. The nonrebreather wouldn’t have helped much. We had it on for about a minute before we got the CPAP out and he was tearing it off gasping that he couldn’t breathe. We would have had to start bagging him and maybe dropped a tube – certainly much more invasive than putting the CPAP on.
I saw him later in the hospital and they had him down to a Venturi mask and he was sleeping comfortably.
I made sure to thank our medical control doctor and clinical coordinator for helping us get CPAP. It certainly made a big difference — just as advertised.
In the five years since we first got CPAP, I have used it probably two dozen times, with many just as dramatic as the above. As a region we have expanded our use of CPAP from just for pulmonary edema to any severe dyspnea. If it works, keep it on. If it doesn’t, take it off. My least favorite calls were the severe dyspnea where you had to battle with the patient just to help them, but CPAP has made it so much less stressful. We can also give Ativan on standing orders now to patients with anxiety due to their dsypnea. It makes it much easier to get them to cooperate.
Studies have shown that the use of CPAP prehospitally reduces the need for intubation by 30% and reduces mortality by 20%. – “Out of Hospital Continuous Positive Airway Pressure Ventilation Versus Usual Care in Acute Respiratory Failure: A Randomized Controlled Trial.” Annals of Emergency Medicine. September 2008
So the number to treat to save one life is 5. That means for every 5 times you use it, you are saving one patient who might have otherwise died. That speaks for itself.
In Connecticut we are pushing to make this a BLS skill with medical control approval.
#5 Capnography
Before capnography, there was nothing.
Sure, we could verify the placement of an ET tube the old fashioned way – visualization, your partner feeling the tube pass just beneath his fingertips as he gave you crick pressure, absence of epigastic sounds, positive lung sounds, mist in the tube, chest rise, and ventilation compliance. But even that was not always reliable (except for the partner feeling the tube pass). And the real problem wasn’t always just getting the tube in the right place, but keeping it there. Once you had a tube and it was good, it was nerve-racking maintaining it – and let’s say it did slip, let’s say when you arrived at the hospital and an crew anxious to help, grabbed the stretcher and yanked it out as soon as they opened the back doors for you, while you were carefully bagging, or let’s say a first responder knocked it while he was bagging for you (bad decision), you were constantly checking and if found out the tube was no longer in the right place, how long was it not in the right place? With capnography, as long as you see that beautiful wave-form, you are feeling good because you know the tube is good, and the patient is being protected.
And then there is return of spontaneous circulation. The End Tidal CO2 suddenly shoots up and walla – you have pulses! The ETCO2 suddenly drops and oh sh---!, you have to start CPR again. The key is you know right away, not at the two minute check point or longer.
There is so much capnography offers us – for both intubated and non-intubated patients, it is hard to remember what it was like without it.
#6 Termination of Resucitation Protocols
I always had a problem with it. The patient was dead. Everyone knew he was dead. He hadn’t been seen since the night before when he’d asked for a cool glass of water. They found him in the morning in his bed, still as can be. He wasn’t breathing and he had no pulse. He looked peacefully there, his head on the pillow, the half-drunk glass of water on the bed stand. He was eighty-nine years old with inoperable cancer. He’d refused hospitalization just two days before. The problem was while there was a little bit of rigor in his jaw, there was no lividity. The room was warm – how he liked it. The family knew he didn’t want any extra measures done to save his life, but they called us because they didn’t know what else to do.
How many times did this or similar scenes play out? The patient ripped from the bed, laid on the hard floor, compressions breaking the chest, tube down the throat, IV, drugs, strapped to a board, carried out of the house to the ambulance in the rain, raced lights and sirens to the hospital, only to be dismissively called dead on the stretcher on entry to the code room. And then later, unseen to us the family received bills for ambulance transport and for ED care.
Everyone was worked and everyone was transported unless they had a DNR bracelet or met the criteria of rigor mortis in the major joints with dependent lividity.
We finally instituted some changes in our system. Medics were encouraged to use their judgment and call medical control, explain a situation and get permission not to intervene. If they did work the code and the patient was asystole, we could work a patient for 20 minutes, and then cease the resuscitation at home, call the patient dead, remove the tube, lift the person back up, put them back in bed, pull the sheet up to the neck, and have the family come in to say goodbye.
For a number of years, we could presume the patient on our own, but then once we developed statewide guidelines on termination, in the interests of solidarity with the other regions, we agreed to require our medics to call a physician for permission to cease. I have never yet had a doctor disagree with my request to cease. I am somewhat bothered by the requirement that we have to initiate CPR until the doctor gives the final concurrence, although I suppose that protects us if the doctor were ever to say, no, I want you to work the patient and bring him in. It has happened to others.
Sometimes, I have the family come into the room while we were still doing CPR, and have them say goodbye before we stop. What a sight that can be. A family one by one saying good bye to the 100-year old aunt in the room where she has lived the last ten years of her life. The love you see, the things they say, the tenderness. "Auntie Mae, I'm going to look out for Junior, for you, you know that." "Auntie Mae, I love you, I love you my whole life." "You going to rest now, Auntie Mae, you going where the fields are green." Sometimes, they just give a kiss, and whisper something into the ear. A husband says, we'll be together again. Wait for me.
I have seen this scene play out a number of times and I have always considered myself privileged to be there to witness it.
We do all we can. The families know when a loved one's time has come. Their spouce, or mother or father or sister or brother, grandparent, aunt or uncle, dies at home, surrounded with their love and thoughts in their last moments, with some kind of dignity.
The National Association of Emergency Medical Physicians has termination of resuscitation rules that have a 100% predictive value for determining death. A study done at Yale showed that 54% of cardiac arrests brought into their ED met national guidelines for being called at home. They were all declared dead in the ED.
I understand that sometimes there may be reasons to transport dead people and that every scene is different. But as the American Heart Association said in its 2005 Guidelines:
“Civil rules, administrative concerns, medical insurance requirements, and even reimbursement enhancement have frequently led to requirements to transport all cardiac arrest victims to a hospital or ED. If these requirements are nonselective, they are inappropriate, futile, and ethically unacceptable.”
Termination of Resuscitation Protocols is # 6 on my list of best treatment changes in the last 20 years.
7. Decreased Use of Lights and Sirens
Ambulances in this area drove faster twenty years ago than they do today. We had some wrecks. People were killed, other injured. It happened. The longer I worked, the more unnecessary it seemed. Drive half way across the city lights and sirens only to wait half the day in the triage line with the same patient. What was the point?
The worst drivers were young men in their early twenties, all full of testosterone and invincibility, wearing bullet proof vets, but not using seat belts, much less wearing crash helmets.
In time we got mandatory seat belts and were required to come to complete stops at all intersections when responding lights and sirens, and we had the black box technology to enforce it. You “fob” in to drive so the computer knows you are driving. If you don’t wear a seatbelt, drive too fast, take a corner too sharply, or stop too suddenly, you lose points and have to listen to the ambulance beep when it happens. I resisted the black boxes at first (not the seat belts, which I always wore), and in time, I came to think they were great. People definitely drive better now.
The role of lights and sirens is much less now. EMD, which I am not a big fan of, has at least, contributed to the downgrading of some responses.
We even have a statewide policy now to help limit the use of lights and sirens. The general rule of thumb now is only go lights and sirens to a hospital if the hospital can do something for the patient that you can’t in the amount of time you would save going lights and sirens over flow of traffic that will make a difference in the patient’s outcome.
I rarely even go lights and sirens to the hospital now. Despite this, I think lights and sirens are still overemphasized. Too many town and municipal contracts are based on on-time performance as well as outcomes. All these contracts measure is what time the ambulance arrives, not whether a medic is there or not or how good the care is. How about these for performance measures instead of response times? Percentage of patients 55 and over with hip fractures, who receive pain meds, % of STEMI patients who get ASA and have their 12-lead done and successfully interpreted or transmitted to the ED, CHF patient who receive CPAP and nitro?
When I started, the Golden Hour ruled, but it has been discredited over time. Quality Care and Safe Transportation are the new watchwords. I hope this trend continues.
# 8 Selective Immobilization Guidelines
8. Selective Spinal Immobilization Guidelines
I remember this scene from a hospital triage line vividly. It is eight-thirty in the morning. A woman in her middle thirties in a nice business suit is on a backboard with a tightly applied neck collar, two body straps, and her head is immobilized with thick duct tape going from the top ends of the board, down around her collar, cranking her neck back. Her problem, besides the poor job of spinal immobilization is she needs to pee. She has been drinking coffee since she woke up and got her kids off to school, and was drinking it on the way into work when she was rear ended in traffic. She has some minor back pain. “Please,” she says for the third time to the crew and triage nurse, Let me off this board! I need to use the bathroom. Please, I can’t hold it any longer!”
The triage nurse snaps at her. “Hold still, unless you want to be paralyzed. You have to stay on that board until the doctor exams you!”
I have seen similar scenes. Triage nurses,EMS, even doctors shouting at people that they could be paralyzed unless they submit to being immobilized.
Come on, people! What about the patient? Does anyone really think that letting this lady get up to pee is going to paralyze her. Does anyone think that her jerking around on the board is good for her supposedly injured spine?
If we really cared about keeping patients still, everyone we immobilized, we would also sedate. Got neck or back pain from a minor MVA? You get spinally immobilized, and then given 5 of Versed and 100 of Fentanyl. Hell, why not RSI them all?
Actually, this is probably a bad idea because most alert people with spinal injuries have their muscles tense up, which helps them self-splint the injury to limit movement.
I remember once I was called for a motor vehicle victim in a Chinese restaurant. The patient had been in an MVA on the highway, fled the scene and finally called from the Chinese restaurant. I tried to immobilize him. He wanted no part of it. I had two cops with me. Somehow they ended up wrestling with him to try to get him to submit to being immobilized. One cop had him in a head lock. It occurred to me then that maybe it would be better for his spine if we didn’t try to force him into the collar.
We used to immobilize everyone. Every motor vehicle, every fall over three feet, every shooting. We immobilized to protect the spine based on mechanism of injury, not based on assessment. There was no science behind it; just the conjecture that keeping people with possible spinal fractures still would prevent them from suddenly becoming paraplegics with the slightest movement. In our state basics continue to c-spine everyone. Paramedics are able to follow criteria to selectively omit spinal immobilization. There is a plan that is slowly progressing through the channels to extend this to basics.
The science of spinal immobilization is more extensive than I can cover. While there is evidence that spinal immobilization causes back and neck pain, leads to decubitis in elderly and can hinder breathing, and delays transport of critical patients increasing their risk of death, to date, there is no evidence that it does what it claims to do – protect the spine. It may, in fact, make it worse.
The study I like to cite the most is the one where they studied all spinal fractures in New Mexico brought in by EMS immobilized and all those from Malaysia who were thrown into the back of a donkey cart (I am joking here) without immobilization and taken to the hospital . The patients in New Mexico did worse. Did the study prove spinal immobilization was bad? No, but it clearly did not provide any evidence that spinal immobilization was beneficial. No study ever has.
Out-of-hospital spinal immobilization: its effect on neurologic injury.
As a clinical coordinator, both at my hospital and in conversation with other coordinators, I do know of many cases where patients with cervical fractures were not immobilized (usually elderly victims of low falls), but I know of no cases where harm was done to the patient from not being immobilized. I have had several patients with cervical fractures who I did immobilize. Every one of them had significant neck pain.
Since we were able to omit spinal immobilization, countless people have been spared torture. I am unawre of any patient who suffered neurological injury from not being immobilized in our system. I would like to see the current guidelines extended to basics and I would like tto see the guidelines rewritten for paramedics to make spinal immobilization indicated only for suspicion based on assessment. If in your clinical judgment, the patient may have a spinal injury, then immobilize, and immobilize fully and properly. If you don’t believe they do, based on your assessment and judgment, don’t immobilize.
9. Alternative Airways
When I started as a paramedic – all we had was the ET tube. You brought in a code, the first question you were asked in the EMS room was “Did you get the tube?” If you got the tube, you got an approving nod. You didn’t, after you left, the other medics would shake their head. Of course, if you got the tube, nobody asked how many tries it took you to get the tube. You might hear the medic’s EMT partner later commenting it was a "hard tube,” which meant there were multiple tries. Familiar with the term “A Pass the Larengyscope Code?” I have been at a few of those and heard of many more.
Nowdays, we have alternative airways – The LMA and the Combi-tube. We may soon get the King LT. And we have limits on the number of times a paramedic or any combination of paramedics can attempt an ET. Two tries for the first medic and one for the second. No more than three tries total. And, most importantly, you don't have to try at all. You can just go to the alternative airway to start if you think it gives you the best chance to quickly secure the airway.
Here are some old posts describing my first LMA and my first Combi-tube, as well as a post called "The Battle" describing my beginning mindset when contemplating what airway to use.
I can tell you this now, based on the medical literature, and on my experiences with the LMA and Combi-tube, I no longer hesitate to use an alternative airway as my first line airway.
The goal is not to impress other medics, but to effectively ventilate the patient, and in cases of cardiac arrest, not to interrupt compressions. I can do both of those quite well with an alternative airway.
10. Chemical Restraint
I pride myself on my ability to talk to psychs. I saw a movie once about a hostage negotiator called “The Voice.” I would flatter myself that I, too, was "The Voice." I could talk anyone down, make any madman set down his hammer, sword and WWF delusions, and come peacefully. Once I was trying to talk down a kid on angel dust. I am very patient, but other responders there were not so much so. While I was talking this guy down and making what I thought was steady progress, a medic from another division, who was up helping us handle a particular rowdy concert, had had enough and jumped the guy wrestled him to the stretcher and with his partner roughly four-pointed the boy, who fought and spit and screamed all the way to the hospital. I was torqued. It seemed there was a certain class of responder who got into restraining/beating up people. I’m not saying I was always able to talk them down, but most of the time I could. If I couldn’t, sure I’d end up using the physical restraints, but I have never liked that part of the job.
Then we got Ativan and Haldol. Things are different. No more driving to the hospital with four people fighting a patient all the way to the ED. If I can’t talk them down, sure we may have to hold them down for five minutes, but I load'em up and they sleep baby dreams to the hospital.
***
This is my favorite Ativan/Haldol story - Sleepy Boy or Fetch My Dart Gun:
We get called for a violent psych at the juvenile school. Wait for PD, our dispatcher tells us.
A violent psych at the juvenile school. The last violent psych I had at a juvenile school was a fifty pound ten-year-old who was standing up on top of the cabinents in the principal's office jumping up and down screaming at the top of his lungs after already having thrown all the books that were on top of the cabinent down on the floor. I reached up, plucked him off the cabinents, tucked him under my arm, laid him on the stretcher and wrapped him in a blanket, then told him to knock it off, which surprisingly he did.
When we arrive, a staff member meets us in the hall and asks us if we are familiar with Andy.
I am not.
Big kid, thirteen years old, autistic, out of control today. They have six people holding him down, he says.
Six people, I think, right. Talk about overkill.
I enter the room, nod to the cop, who is standing by the door. I look about the room, then look down on the ground, where there are indeed six people holding Andy down. Andy is two hundred fifty pounds minimum, maybe two-seventy. He has the muscled shape of a big bear. There is a grown man on each limb, a large grown man leaning over his torso, and another man holding his head down. He looks up, despite the hold the man has on him, and roars. I swear the room shakes.
"You're just one crew?" the cop asks. "You have restraints?"
***
Now when I first took my EMT class many years ago, I wasn't too keen on the section of the course where we practiced restraining patients. I mean I wasn't certain I wasn't going to vomit at the first sight of gore, and I wasn't certain how good I was going to be at wrestling patients. I was as tall as I am now, but not nearly in the shape I am in now. I was sort of skinny and flabby at the same time.
I was lucky that one of my partners when I first stared working was a black belt karate instructor, but other times I worked with tiny women. In the same way I hoped that I never had to deal with the massive chemical hazmat train wreck mutlicasulaty plane crash call, I hoped I wouldn't get called for the big guy who wanted to kick my ass.
I cultivated a calm approach, and learned to rely on my voice and on the trait of patience, which I have in fair abundance, and when faced with being patient or getting pummeled, I am always happy to be patient. But there are always some patients who patience doesn't work on. That's why we have cops, but cops don't like to get worked up any more than paramedics.
In recent years, restraining patients has also gone somewhat out of favor due to some tragedies -- patients dying of asphxia. A couple years ago, our protocols were rewriten to address issues of restraint. In the case of Andy, in my mind, I flip through the first two pages of the protocol to half way down the third page, under the title "Chemical Restraint."
***
"We're going to sedate him," I say. (If this was movie, I would have said to my partner, "Fetch my dart gun.")
2 mg Ativan and 5 mg Haldol IM.
He screams when I stick him in the thigh. He presses against his restrainers, tries to spit, but they quickly put a face shield over him. He calls me nasty names.
Then we sit and wait. He settles down for a moment, but any time anyone moves or tries to talk to him, he starts fighting again.
Ten minutes go by. He is still angry and yelling.
I excuse myself and go out to the ambulance and call medical control. The doctor approves my request for a second dose. "By all means," he says.
Andy nearly throws everyone off him when I hit him in the other thigh.
I sit back down in a chair and wait.
A staffer asks what the plan is now.
"I'm going to sit here until he's asleep," I say.
Five minutes later, he starts to snore.
One by one I have each of the restrainers get up. We nudge Andy, and he opens his eyes, and sleepily gets up and lays down on the stretcher like a little boy who has stayed up past his bedtime.
He snores all the way to the ER.
#12 No More Lasix
In our 2012 Regional Protocols, Lasix has been removed from our med kits. I stopped using it several years ago -- even when I was reasonablely sure my patient had CHF. I had CPAP and I had nitro and I relied on them, as I do now.
The first rule of medicine is "Do No Harm." Lacking chest x-rays and the ability to do BNPs in the field, time and again, EMS (myself included) has done harm to our patients by giving patients we thought we in CHF, Lasix when in truth they had sepsis or pneumonia.
Below is excerpted from a 2010 post about Lasix.
Dear EMS Medical Control-
I am an 87-year -old man with pneumonia and sepsis laying in a hospital bed, feeling rather miserable. Two days ago one of your paramedics gave me Lasix believeing the junky sounds in my lungs were a sign of pulmonary edema. He was wrong. As a consequence my blood pressure dropped from 170/90 at my house to 90/40 in the ED where they gave me two liters of fluid in addition to several very strong antibiotics, and I am told my kidneys are not functioning so well. I know I am old and approaching the end of my life, but I was once a vibrant man who taught school for many years and often demonstrated for various causes such as civil rights and against the slaughter of baby seals. If I were able, I would make a sign and demonstrate in front of your house. I would lean against my walker and hold my sign up for passing cars and the news cameras to see. "Stop the Horror! Ban Lasix!" I know I am not the first victim. I wish to be the last. Those of us with pneumonia and sepsis are sick enough without Lasix making us worse.
Respectively
Patient X.
***
As you know for the last year I have been a clinical coordinator at a local hospital. Our EMS Medical Director and I have had lengthy discussions about taking Lasix off our sponsored services's trucks. The problem is we are part of a larger region and we try to do all our protocols regionally. The region just finished up its 2009 protocols, and won’t be addressing changes until later this year with an implementation target date of sometime next year. We both agree we should take Lasix away. We don’t want to act unilaterally. But I am thinking (with each imaginary letter we recieve) that maybe we ought to act now.
In 2006, a study appeared in Prehospital Emergency Care that revealed that Lasix was given inappropriately to 42% of prehospital patients.
Evaluation of prehospital use of furosemide in patients with respiratory distress.
For the last two years I have been keeping track of all prehospital use of Lasix from our various sponsored services using similar criteria to the mentioned study. I have found a 37% inappropriate rate, a rate that has improved only marginally with education.
Looking closely at the patient data, it is clear just how difficult the diagnosis can be (lacking a chest X-ray and a BNP blood test). The indicators that many of us were taught in paramedic school don’t always hold up. Some patients with fevers had CHF, while some patients who were not febrile had pneumonia. Some patients on Lasix had pneumonia and some patients not on Lasix had CHF. Some pneumonia patients had significant edema and some CHF patients didn’t have any edema. The only sign that at all was suggestive of CHF was blood pressure. In general if a patient had a BP over 170 systolic they were more likely to have CHF (Except for patient X here). Speaking of blood pressures when I tracked BPs in the ED, nearly every patient, CHF or not, who received Lasix prehospitally experienced a huge (although sometimes transient) BP drop in the ED.
I know about misdiagnosing CHF myself. In 2006, the very day after reviewing the before mentioned article at a journal club meeting, I had a patient in severe respiratory distress who sounded like a washing machine. I gave Lasix. She turned out to have pneumonia. D’oh!
When I was a newer medic in the last 1990’s, one year I gave Lasix 21 times. If I thought I heard rales, I gave Lasix. I was told by another paramedic (be careful of your infomation sources) that Lasix was basically harmless. How many of those patients had pneumonia or sepsis? At least 40% is probably a close starting guess. This past year I didn’t give Lasix at all.
Several years back, we added the following caution to our regional protocols:
CHF vs. Pneumonia: If the clinical impression is unclear and transport time is not prolonged, consider using Nitroglycerin and withholding Lasix or Bumex or contact medical control.
Yet people continue to give Lasix to patients who are not in CHF. I think it stems from our natural incliniation to want to do something to help, particuarly if the patient's respiratory distress is severe.
With CPAP and Nitro now the hallmarks of CHF treatment, I think it is clearly better to deny Lasix to someone who might have CHF than give it to someone with pneumonia or sepsis.
13. Permissive Hypotension
In the mid 1990s and before then, you were a stud if you could swoop down on a shooting victim, toss him on a board, get him in the back of the ambulance, and take off before the mobile TV news crews arrived (even better if you were gone before the PD arrived). Then in the three or four minutes you were in the back of the ambulance as your partner flew (we’re taking airborne on the rises) to the Level one trauma Center, you slammed in two large bore IVs and had the fluid running fast and wide. Two 14’s was an A plus. A 14 and a 16 was good. Two 16’s was border line. Anything less was not worthy of the patch on your shoulder. You were a god if the 1000 liter bags had less than 100 cc by the time you hit the trauma room.
It really sucked if your victim had bad veins. A 20? That was all you could get? A 20? But in most cases your shooting victims were young strong males with bulging pipes, who just happened to be on the wrong street corner doing nothing at the wrong time.
I remember one time I put a 14 in a man’s AC and the fluid ran like Niagara Falls. I noticed then the cot was soaking wet under his upper arm. He had another huge bullet hole there that had completely taken out the vein. The fluid entered the AC, run upstream for four inches and then ran right out tinged with pink. Pink was often the color on the sheets after we’d unloaded the patient. And back then, we didn’t just run the fluid when the BP was low. We ran the fluid regardless of the BP. We were medics and aggressive and taught to stay ahead of the game. We ran fluid in anticipation of the BP dropping.
Many medics started the day by hanging and prespiking two 1000 cc bags of fluid. One of Saline; one of Ringers. Some medics hung the bags, but just taped the drip sets unspiked to them. I usually just laid two bags on the bench seat, ready to open and spike. A few medics may have just left the fluid in the cabinets until needed. I guess it all depended on what degree of spark you were.
Of course we know better today. Aggresive fluid resucitation in absence of controlled bleeding can damage the body's ability to clot off the bleed, create hypothermia, and impair the delievery of oxygen. While there is still some discussion about just how much fluids trauma patients should get prehospitally, permissive hypotension seems to rule the day. Our regional protocols calls for blood pressure to be titrated to 100 systolic. I know some would argue that blood pressure limit should be much lower – just enough to produce a pulse and no more.
14. Expanded Medication Routes, Less IV Emphasis
When I was going through paramedic school (1982), another student told me, if you can’t get an IV, you can’t be a paramedic. If your IV skills are not second nature, you will spend too much time worrying about getting an IV, he said, and not be calm enough to keep the big picture in mind. Plus, he said, if you can’t get the IV, you can’t fully treat the patient or give most of the medications you carry.
I worked hard on my IVs during school, taking many extra shifts on the IV rotation where I accompanied the IV nurse around the hospital and jumping to do every IV I could on my ED rotations. I was already an EMT-Intermediate, but I worked for a small volunteer service and was lucky to get three IVs a month. When I was cut loose as a paramedic (now working for a city 911 ambulance company), I was assigned an EMT-Intermediate as a partner for my first six months as a condition of my medical control. On my calls, I insisted on doing most of the IVs and I put IVs in most of my patients. My reasoning was if the person was going to get an IV in the hospital, I was going to give them an IV in the field. At the time, we also drew four tubes of blood for the hospitals, so bringing in a patient with an IV and labs drawn was a great way to earn nurses’ favors.
Back then, if a patient was in status epilepticus, we had to have an IV to give them Valium. If a patient was in CHF or having an MI, we had to have an IV to give them nitro. If they were in pain, we had to have an IV to give them morphine. Even most heroin ODs got an IV. True, if you had a patient in cardiac arrest, you could give drugs down the tube if you didn’t have an IV, but even then, we did not think that was the most effective way to deliver the drugs. And, of course, trauma patients didn’t just need an IV, they needed two large bore IVs so you could run the fluids wide open.
Things are very different today in 2012. You still need to be good at IV to be an effective paramedic, but there are more drug delievery options, which is better for the paramedic and, most importantly, better for the patient. Also, the IV has less importance in cardiac arrest and trauma as studies have shown IV meds don’t improve and may worsen outcomes in cardiac arrest and the old practice of pouring fluids into trauma patients was, in fac,t helping kill some of them.
Today with a patient in status epilepticus, we can give Versed not just intramuscularly (IM), but intranasally (IN). Same with patients in pain. IM, or even better IN with Fentanyl. Heroin ODs get Narcan IM or IN as well. We can give patients with chest pain NTG without an IV as long as we use caution. Someone sick and vomiting, we can give Zofran IM, and very soon, we may be able to give it sublingually. With Benadryl we now have a PO option. And for those patients who absolutely need an IV, no more sweating and shaking hands, the eyes of everyone on you as you poke and poke and fail to get an IV on a critical person who continues to deteriorate or who may already be dead, you now have the EZ-IO drill to fall back on.
I want to thank all the thousands of patients who let me put IVs in them over the last twenty years and who helped give me the confidence I have today in my IV skills. I no longer follow the rule that if a patient is going to get an IV in the hospital, they will get one from me in the field. I still do my fair share of IVs – but I now appreciate there may be times when it may be necessary in the ED, but it is not as necessary for us prehospitally to do it. There is also that factor that some hospitals routinely either DC prehospital IVs or put in their own. Some have said it is for infection control reasons, others have said it allows the hospital to add another charge to the bill. I don't know, but when transporting a patient to a hospital following such a policy, I tend to be more selective about when I establish IV access.
15. Narrower Use of Narcan
When I started we used narcan for opiate overdose and coma of unknown etiology. Today we only use narcan for respiratory depression or inadequate ventilation associated with opiate overdose.
The following is excerpted from a post "That Narcan Shit" from December of 2008.
When I was in paramedic school one of my instructors boasted of fellow medics bringing junkies into ERs with a loaded narcan syringe in the junkie's IV, and slamming the Narcan as they'd go through the ED door so the junkie would sit up and puke all over the medic's nemesis -- the evil nurse at triage. We all thought that was funny in class, and while I have heard versions of this story told by many people from many parts of the country, I never did it and never saw anyone do it or even heard of it really truly happening.
I did, however, slam Narcan into lots of junkies and wake them up. When I say slam, I'm not taking about pushing the Narcan in like I push Adenosine, but I probably pushed it as fast as I would push a routine flush. In other words, too fast for narcan.
I'd slam it. They'd puke, curse, rip their IV out and stalk off. One guy I found in an abandoned building. His brother had flagged us down. The man had been missing for a day until his brother discovered him. He was out cold, but he was still breathing. I was real new and excited and so I am sure I pushed the Narcan way too fast. I probably gave the full 2.0 dose all at once as well. The next thing I knew the man who was now semi-awake was in such severae pulmonary edema that I was hitting him with Lasix (a drug for another blog post). The sudden pulmonary edema was completely unexpected. I asked a doctor at the ED about it, and she said, it can happen when you push Narcan. I'd had no idea.
Over the years my practice has changed. Maybe I was improperly instructed at the beginning, but I went from putting an IV into every junky and slamming the Narcan to doing it IM or SQ and pushing it very slowly and just a small amount (0.4 mg) at a time. Just enough to get their respirations going and not even wake them up fully.
Slamming a full dose of Narcan is not a good thing to do. Its puts them into sudden withdrawal and that is not good. Nor is the violence that may ensue.
It used to be if I was called for an OD and the patient had used Heroin, they got Narcan even if they were breathing okay. As long as they were slightly altered, I'd hit them with it. Even if they were talking to me. I thought that was what I was supposed to do.
"Did you do drugs?"
"No."
"Then why do you keep dropping asleep?"
"I didn't do drugs."
I'd push the Narcan. They are wide awake and puking. Stupid. Them and me.
"Did you do drugs?"
"No."
"Then why are you wide awake now and puking?"
I don't give narcan now as much as I used too because I don't work in the city nearly as much, plus now, like I said, I only give Narcan if I suspect an opiate overdose and the patient's respirations are extremely depressed. Sometimes I bring Heroin users in to the hospital and the first thing the hospital staff does is give the patient Narcan. Wake them up and make them puke. I shake my head. That's just no way to treat people. Put them in a hallway and let them sleep it off -- as long as they are breathing okay.
We also used to give Narcan as a diagnostic for coma of unknown etiology. That was an indication listed in our protocols. We removed that indication several years ago, and I think it is a good thing.
Here's two cases where I gave narcan to coma of unknown origin with bad consequences.
1. I had just started as a medic and found a paraplegic unresponsive in bed. He was a young guy who had been shot a few years before and ended up like he did -- living in a small room with a bed, a big screen TV and stacks and stacks of DVDs. He was stuporous when I found him. I should also point out he had a bad fever. Knucklehead that I was, seeing his pin point pupils and all the prescription pain pills -- opiates -- I zapped him with Narcan. So now I went from a patient in a semi-coma due to a fever to a patient in a semi-coma due to a fever in excruciating pain. He became extremely agitated with good reason. I'd just zapped all the pain medicine he needed to tolerate living into the ether. My bad.
2. Called for a possible stroke, I found an 80-year-old female with altered mental status of sudden onset, unable to speak or respond. I loaded her quick, raced toward the hospital, calling in a stroke alert. I then happened to notice her pupils were pinpoint so, as a stab in the dark, I gave her Narcan. Amazingly she woke up within a minute. I told the driver to slow down and called the hospital back to say never mind about that stroke alert. I had woken granny up with narcan. The odd thing about it was I couldn't find any opiates on her list of meds and she denied taking any drugs or even having a secret stash of cough syrup. Strange. At the hospital, her whole family was gathered around laughing with her when suddenly she gorked out again. She had a head bleed and her waking up (her lucid interval) had just happened to correspond with my giving her Narcan. So narcan as a diagnostic had actually led me to the wrong diagnosis.
Rogue Medic and Ambulance Driver have some excellent material on this whole issue of the inappropriate use of Narcan.
Narcan Solves the Riddle, Part I
Ambulance Driver Article "Naloxone: The Most Abused Drug in EMS"
I particularly like this quote from a Boston Medic that Ambulance Driver cites in his article:
"Addicts take opiates and other sedatives specifically to induce a pleasant stupor. If they’re lethargic and hard to arouse, but still breathing effectively, it’s not an overdose. It’s a dose.” – experienced Boston paramedic
Rogue Medic sites an excellent study done years ago in LA.
The empiric use of naloxone in patients with altered mental status: a reappraisal.
The study asked the following questions:
# 1 - Can clinical criteria (RR of 12 or less, pinpoint pupils, and circumstantial evidence of opiate abuse) predict response to naloxone (Narcan) in patients with acute alteration of mental status (AMS)?
# 2 - Can such criteria predict a final diagnosis of opiate overdose as accurately as response to naloxone?
-Hoffman JR, Schriger DL, Luo JS. The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med. 1991 Mar;20(3):246-52
730 patients with Altered Mental Status received narcan prehospitally from paramedics brought to two LA hospitals over 1 year period
Only 25 patients (3.4%) demonstrated a complete response to narcan
32 (4.4%) manifested a partial or equivocal response.
673 (92%) had no response.
19 of 25 complete narcane responders (76%) were ultimately diagnosed as having overdosed
2 of 26 partial responders (8%) (with known final diagnosis)
4 of 195 non-responders (2%) (with known final diagnosis). Note: They only reviewed 195 of the 673 non responder charts.
Of the 25 complete responders to Narcan
19 had opiate overdose
6 had seizure or closed head injury.
Their conclusion was:
“The study indicates that there is no diagnostic benefit derived from the administration of naloxone to all AMS patients.”
“In addition, response to naloxone created a substantial amount of diagnostic confusion...”
-Ann Emerg Med. 1991 Mar;20(3):246-52
That study came out when I was still as EMT.
Good lessons, as I had learned the hard way.
The bottom line:
Just because they woke up after you gave them narcan doesn't mean they woke up because you gave them narcan.
In the last month I have responded to three calls of a person passed out in a car in the middle of the road. All three had pinpoint pupils and only seemed to be breathing on prodding. All three had just done opiates (two heroin and one had swallowed a 20 mg Morphine pill). I thought about giving one of them a slight squirt of intranasal Narcan (We can do this now), but as soon as he saw me go fro my yellow medical kit, he snapped awake. (So how unresponsive was he even though he was breathing at 6 a minute?) Don't, he said. I won't as long as you keep breathing, I said. Deal?
I so much prefer the new approach. I am for love and happiness and as long as someone can support their own ventilations, I am oppossed to being a buzz-kill or for practicing bad medicine for that matter.
16. Increased Standing Orders
When I started as a paramedic 20 years ago, we had to call medical control for permission to give medications far more than we do today, including anytime we wanted to give controlled substances. If a patient was in status epilepticus or had bones sticking out of their leg, we had to call to talk to a doctor for permission to give Valium for the seizure or morphine for the broken leg. What doctor would say no? We did this because at the time in Connecticut there was a law requiring "simultaneous communication" with a physician for a paramedic to give controlled substances.
We had also had to call in many other situations. often whether you got permission or not depended on which doctor answered the phone. Some moonlighters or new doctors didn’t even know our guidelines or would tell us to give drugs we didn’t carry. Recently we had torodol as a medical control option. The problem was some doctors said no to torodol no matter the scenario, while others thought ti was a great drug and always said yes. There was little consistency. In the end, we decided to remove the drug altogether and just up the amount of fentanyl and morphine would could give instead.
We hardly ever have to call for anything now. Our region has decided that if our guidelines are reasonable, we ought to be able to lay out situations where paramedics can do what they need to do on standing orders. For instance, if a medic needs to call in for permission to give a drug like dopamine, he likely has a patient sick enough to demand his full attention and requiring him to get on the phone to talk a doctor, who likely is busy himself, is not an ideal situation. While medics are always encouraged to call if they have any question, as long as they are within our general guidelines they are free to follow them on their own. The only two major situations we call for now are for STEMI alerts to get the doctor to activate the cath lab and on cardiac arrests if we want permission to cease a resuscitation on scene. Overall, the standing order system works great and is a vast improvement over the old “Mother, May I?" days.