Status Quo

 We can all agree that these are goals of a perfect EMS system.

1. A paramedic on every priority one emergency call
2. A run form completed before leaving the hospital
3. A living wage for every paramedic

Ever since I have been in EMS -- 24 years now -- I have heard the discussions about ambulance availability, the need to leave a fully completed documented run form before leaving the hospital, and the need to improve paramedic pay.

I recently overheard an exchange between three people, one a paramedic, one a supervisor for an ambulance service and one a hospital administrator.

Here was the rub:

The hospital wanted the paramedic to not leave for the next call before they had finished writing the run form from the first call and they wanted the paramedic on the priority one emergency call.

The ambulance supervisor wanted the run form fully completed (for billing and data reporting) and the paramedic to clear the hospital quickly to do the priority one call.

The paramedic pointed out that is was often impossible to fully complete the run form, print it out and leave it for the hospital and get to the dispatched call in a meaningful time.

The paramedic said he skipped many of the boxes on the run form so he would get the form done quickly and be able to clear. He said he sometimes cleared to take the call without leaving the run form because the patient was alert and had no issue but a cut finger. The paramedic also said many times he did fully complete the run form, but the patient was still on his stretcher when the next call came in so even though his run form was done, he couldn’t clear to take the call.

The hospital administrator told the ambulance service to put more cars on the road so the paramedic could have the time to write the run form while the added paramedic did the call.

The ambulance supervisor wanted the hospital to hire more nurses so the triage lines weren’t so long and so that when the nurse heard the paramedic’s verbal report, they wouldn’t forget it immediately because they were taking care of so many patients. And he wanted the hospital to give his company more transfers so it could make enough money to put more cars on the road.

The paramedic said while you are spending more money on hiring more nurses and putting more ambulances on the road, how about kicking a few extra dollars my way because I’m not keeping up with the cost of living despite working 60 hours a week.

The bartender interrupted the conversation then, by asking if they would all like another round, which they did. On the TV over the bar there were news stories about crumbling schools, jobs moving out of state, and other bad news.

Here’s what happened. The paramedic did the best he could to leave the run forms and get to the calls so the patients didn't suffer. Sometimes he completed the run forms, sometimes he didn’t. No nurses were hired. No cars were added. The triage lines stayed long. Calls were still dispatched before the crews had the patient off their stretcher. The paramedic did not get his raise. The three continued to drink beer together.

The Nether Zone

On TV, the paramedics are met at the ambulance bay by at least two doctors who ride the rails as the medic gives the story. The patient is moved over to the hospital bed where a team of ED staffers are ready to go to town in a seamless continuum of care.

Sometimes this mirrors real life. Except for the two doctors running alongside the stretcher.

Too often, however, I find there is a significant interruption in the care continuum. There is a nether zone where the patient who has been getting fully attended care is no longer being seamlessly cared for.

While some of this is hospital dependent, I don’t believe any hospital is immune to it.

Here are some examples.

The triage line: While you wait to be triaged, the patient’s breathing treatment runs out, their pain medicine starts to wear off, they are due for their next nitro, or perhaps they start seizing. Unless you bring your gear into the hospital, there is a gap in care.

The hallway: Your patient is left in the hallway or placed in a room, and they throw up or they need to be suctioned. If you are in a room, at least you can use the in-room suction. If you are in the hallway, and can’t shout for someone to bring you an emesis basin, you need to think fast and grab a towel or something else to try to contain the splatter, and hold them on their side to protect their airway.

The code room: The staff is there, but monitors need to be switched, tubes reconfirmed. The dopamine gets shut off and not restarted. The pacer is disconnected. The doctor is still trying to figure out what is going on. The patient maybe has gone back into arrest. An IV line is pulled out by overanxious ED staffers. No one is doing CPR or maybe the ED staffer doing it has not had the latest ACLS push hard, fast and deep lecture.

Many people believe that once you enter the hospital doors, you are no longer in charge of your patient. The problem with that thinking is who is in charge of the patient? They are in the nether zone where they may be under the care of the hospital, but have not yet been placed in the care of a medical professional with the available equipment to properly treat them.

We don’t turn off the 02 when we enter the hospital’s doors. We don’t shut off our running IV lines. We don’t turn off our heart monitor. We don’t stop doing CPR as we roll down the hallway. I argue that we should continue to care for the patient, including bringing our equipment into the ED until the ED is ready to assume complete control and care for the patient.

If we are in the triage line and our patient with CHF needs their next SL NTG, we should give it to them. If their pain scale rises back up because the fentanyl is wearing off, we should redose them (I usually redose in the ED parking lot to avoid this). If they start seizing again, we should be ready to hit them with our Versed. If our patient is post cardiac arrest, we should keep them on our monitors, and our drips running until we are sure that the receiving MD is fully aware of the care we are providing and is ready to assume seamless care. If we are doing CPR, we should insist that proper CPR and rhythm checks and defibrillations are done until we are satisfied proper transition has occurred. If it is time for the next epi, we should give it until the ED is in position to have their drug cart open and drug in hand be able to give it. We are responsible for our patient’s care and for an orderly transition to the hospital’s care. If we do not feel the transition offered is acceptable, we need to advocate for our patient. If we think our patient is too unstable to be left alone in a back hallway we need to make that clear. If a nurse is too busy to take our report, and we feel the report needs to be given, then we have to either find a doctor to give the report to or insist to the nurse that the report be given. Our patients rely on us to do the right thing by them.

Back when we first started using CPAP, I had a situation at the hospital where a nurse told me to take the patient off CPAP because her ED required an order for it to be given and she did not want to lose her license but having the patient on it without the order. I refused to discontinue the CPAP and refuse to let her discontinue it until a physician came into the room and issued the order to continue it.

And then there is the questions of what do you do when you are standing in line with your patient and there is a BLS crew in line with their patient, and their patient is having a severe asthma attack? Using every accessory muscle, diaphoretic, frightened, with declining SATs and no audible air movement. Do you run out to your ambulance and come back in with your equipment and intercept with them right there in the triage line? I will leave that discussion for another day. (But if I had to answer, I would say, you need to bring that patient to the attention of the triage nurse and be fairly insistent). 

Sickle Cell

 Sickle cell anemia is a horrible, painful disease. Over the years I have gone from viewing sickle cell anemia patients as drug-seekers (here I blame the EMS culture at the time) who I did nothing more than put on the stretcher and take to the hospital to human beings suffering from a painful disease who I aggressively treat with narcotic analgesics and fluid.

Still, I find some of these patients problematic.

Case in point. Patient calls 911. Meets us at corner and requests transport to hospital 30 minutes away. There are at least 5 hospitals closer, including one only two miles away. When asked why she did not get someone to drive her, she says she has no ride. When asked why she doesn’t want to go to the closest hospital, she has no answer. She just doesn’t want to go there. We tell her that we will medicate her, but we really would prefer not to have to take her 30 minutes, and likely more away during rush hour. She relents and agrees to go to the hospital four miles away. She says she has very poor IV access. She says they usually put an EJ in her neck to give her her pain meds. We try a 24 in her wrist with no success. We offer Fentanyl intranasally. 100 mcgs does not touch her pain, she says. We offer 100 more. She declines. It just stuffs up my nose, she says. Your choice, we say. In the hospital, we wait in triage for 20 minutes, and then then put her in the waiting room.

So, let’s analyze this. Her pain is so bad she needs an ambulance, but is willing to travel 30 miles to go to the ED. Why is that? Maybe because she knows she will not get the pain meds she wants at the closer hospital? Maybe her pain is so bad, she is willing to wait that extra length of time to reach the distant hospital for the promise of more lasting treatment. She refuses more Fentanyl IN because it stuffs up her nose. Maybe she knows the Fentanyl won’t work for her? Maybe her pain is so great that she cannot take the added discomfort of a stuffed up nose with little relief in pain?

She never appears to be in pain at any time, but I know that sickle cell patients are so used to pain that they rarely show it.

She is just in her twenties, but she does not look healthy for what should be her prime.

Some will call her a drug seeker. If I call her that I will have to qualify it that she is seeking drugs because she is in pain.

This call causes me to review my stance on sickle cell patient, but not change it. I only wish that we could have gotten an IV in her. As far as doing an EJ or an IO, our guidelines call for their use only in extremis. Is pain extremis? I wasn’t willing to go that far, but will discuss it with some ED doctors I trust for their take.

Next day, we get a man in sickle cell crisis. He is from out of state and calls from the side of the road. He looks like a homeless man. Like the young girl the day before, his arms are pocked with scars. Like the girl, his pain is also a ten and when asked where is the best place to get an IV, he points to his neck. Fortunately, we get an IV this time in his hand and give the pain meds IV along with fluid.

If I were the younger medic of years ago, I might question the older me. What are you doing giving these pain meds to these people?

And now today, as the older medic, I say to my younger self, “It is not your place to judge. If they are in pain, and you have no persuasive reason to doubt their word, you take them at their word.”

But then my stubborn and possibly lazy younger self responds. “Okay, but even if they are not a drug seeker, why medicate them because they have such a high tolerance, all the drugs we carry are unlikley to touch them.”

My older self replies, “Well, fortunately today we carry twice as much as we used to. 20 of morphine and 400 mcg of Fentanyl. And even if that is not enough to take away someone’s pain, as our ED doctors have told us, get them started on the road to being pain-free, you will make it easier for the ED to complete the job.”

“But...”

“No, buts.”

***

We pick up another sickle cell patient, requesting to go to the cross town hospital. No amount of convincing works. The patient had just been discharged from the ED two blocks from the gas station where he is calling from. He says he is still in pain. We just monitor the patient and report the story to the nurse. The patient is put in the waiting room. I don't know how they end up treating him.

Sometimes I don't know what to think. I'm glad I don't have the disease.

What I learned this week

 Experience is one of the main components of a paramedic’s smarts. Others include, but are not limited to, book learning, common sense, and mental acuity.

To put experience mathematically, a paramedic is only as smart as all the calls he has ever done minus those he has forgotten about. Thus a paramedic who is working consistently should continue to get smarter provided he continues to do new calls faster than he forgets old calls.

I am smarter this week than I was last week. Here is what I learned:

A young person who presents like a text book case of kidney stones, cool, diaphoretic, with cramping flank pain is likely having kidney stones even if their 12-lead shows mild elevation in Leads V2 and V3 with depression in III and AVF. A 12-lead, while useful, is not a perfect test.

A call that comes in as an MVA, is updated as "a person thrown from the back of a pickup truck and is now unconscious," that the dispatcher repeatedly asks for your ETA and whether or not you are a paramedic unit, and when you get there you find the patient sprawled on the sidewalk and only agonally breathing, may not necessarily be a trauma. Be thankful after you scooped and ran that you and your partner, after finding no bruising, indentations or abrasions, checked their pupils, saw they were pinpoint and gave narcan waking him up before you made it the four minutes to the hospital. Hope that next time you check the patient's pupils before you call in a trauma alert. (The patient you later learn was pulled from the back of a pickup truck by bystanders who found him unresponsive).

Do not, particularly in the midst of a bad call, let a anyone who is unfamiliar with how your stretcher works, try to unload your patient, no matter how well intentioned they may be. Be thankful that the worse did not happen, and the patient stayed on the stretcher and the stretcher did not completely tip over.

When someone tells you the woman you are treating is a “Madea”*, do not be surprised in cutting their clothes off to discover the woman has a penis. (*Madea is large grandmother character played by Tyler Perry).

While your protocol calls for you to consider termination of a cardiac arrest after twenty minutes with no success, if the patient still has a decent end tidal, it is not a bad idea to continue the resuscitation as they may come back after 30 minutes (and stay back at least until hospital admission to the ICU).

When carrying a patient on a scoop stretcher down incredibly narrow stairs with tight turning stairwells, a good approach is to stand them straight up at the bottom of each landing, pivot the scoop, and then continue carrying. This will save smashed hands, ruptured backs and much sweating and grunting.

While as a rule, confrontations should be avoided, when questioned about pain management, it never feels bad to politely point out that your dosing is correct and that the patient remains hemodynamically stable and is still in pain, and could benefit from redosing. Additionally, if the health care provider has fewer years of experience than you, it is acceptable to tell them that instead of assuming everyone is a drug seeker, the health care provider should inspect the patient for themselves before making judgments.

If you are posted at Blue Hills and Tower in the morning, don’t forget the Mount Sinai cafeteria is open in the hospital basement and the oatmeal is only 60 cents for a small.

Also, the ackee and saltfish at Sisters Restaurant north on Main Street is excellent, although you cannot get it in a small portion.

Vaginas have glands that can become swollen. They are evidently capable of being quite painful as a young person with swollen vaginal glands found them too painful to walk the two blocks to the hospital and called for us instead.

When a doctor tells you a boil on a patient’s bottom is draining and malodorous, malodorous is an apt word.

There is a new splash pad in the Sigourney Street Park that makes an excellent midday destination stop on hot humid, sweating through your clothes, ambulance AC is not getting the job done kind of days. Don’t forget to bring a towel to dry your head.

Things I forgot this week:

I don’t know, but the good thing about forgetting things is that they are not always lost forever. Some of the things I learned this week I had learned and forgotten before. Old lessons are around you all the time just waiting to be refound.

Get Another Job

 We were dropping off a regular patient at one of the hospitals the other day. A chronic PCP user. The “crusty” old nurse in the psych ward threw a fit complaining that she had just dealt with him two nights before. The fit was not good-natured banter, but clearly a I’m being imposed upon and you are a piece of shit fit. I felt like saying to her you are either (despite your age) brand new or you have been here too long. Burn out is an occupational hazard, which I have found infects either the relatively new or those whose lives outside of work have grown unpleasant. I will give everyone a period to outlast their burnout, but then you need to find another job or take time off to fix your own life Repeat patients are the territory in emergency medicine. No one likes working with miserable people. I’ll accept burnout a little more in EMS than in nursing because it seems to me nurses have more options to seek employment than EMS. Tired of the urban ER, go work in a Dr.s office or a walk-in clinic in a suburb or take a 9-5 job in endoscopy. To newer EMS burnouts, whose burnout has lasted longer than 3 months, get out now and find something that makes you less miserable because you don’t get a pass forever.

I am sitting in my ambulance outside a McDonald’s right now (using their free wi-fi). I am watching one of their employees, quite possibly even their manager, walking around the outside of the building, picking up every stray scrap of paper on the ground he can find. He has a broom and dustpan. When he is done, he will get a hose and wash the sidewalks down. He does this every morning. You can’t find a cigarette butt in his parking lot. This man has a good work ethic. I am the only one watching him, but he is performing like he is before a sellout audience in Carnegie Hall.

Who you work with is important not only to your health but the health of your organization. I have been doing this over twenty years and can say that burnout is not an isolated problem. It is an infectious contagion. At times I have seen in EMS and in EDs burnout become almost a badge of honor, as if being burnout makes you an official member of the tribe. When I first started I thought the crusty old burned out triage nurse was a great character. Some I liked to think had hearts of gold, others clearly were just plain mean. One nurse would punch everyone having chest pain, if they groaned, she put them in the waiting room. You can’t have musculoskeletal pain and a real medical problem at the same time, she seemed to think.

Recently, I heard a triage nurse chastise a patient for wasting the system’s resources. The nurse was quite nasty and aggressive about it. It took me aback because it had been years since I had heard something like that where years ago it was much more common place. I almost said to the nurse, you could get fired for talking like that to someone. EMS used to talk like that all the time. I even talked like that a few times many years ago, but I don’t do it anymore, and it is rare in my organization. There is something positive to be said for manners and correctness.

I go into many hospitals and they all have their own vibe, the same I think is true of ambulance services. A paramedic from one service recently was fired from his part-time job at another service. The reason was attitude. Doing what was permissible and part of the culture at one service was clearly not at the other service. To which I say, bravo.

If you are miserable and hate our patients, I don’t want you working with me. My best partners have always been the most pleasant people. If I have a partner who bitches all day, i find myself bitching as well and go home feeling miserable.

I wonder what the guy here at McDonald’s thinks as he sweeps up the cigarette butts. Is he thinking “f-ing slobs. I hate these f-ing people.” Or is he is thinking, “My sidewalk is glistening, the sky is blue, today is going to be a good day.”

Handsome Boy

 A handsome boy plays guitar in his garage band, thick black hair down to his shoulders. Man is he in to the music. The drummer in the background is also smiling, the kid on the bass is into it too. The photo colors are faded. I’m thinking 1970. In front of the 3X5 photo in the drug store frame sitting on the book shelf like an offering is one guitar pick. The guitar itself—-a Stratocaster--is hung on the wall like a museum piece. Next to it is a glass framed psychedelic 60’s era poster. Bright wavy yellows, purples and greens. Iron Butterfly at the Fillmore. I can hear those kids now playing at their high school dance. In-da-gadda-da-vida, baby. All the chicks digging it.

I look at the books neatly lined in the cases. Herman Hesse, Carlos Castenada, Hemingway, the Anarchists’ Cookbook, Jack Kerouac, all books I own myself. On another shelf there are others. How to Win in the Sport of Business, Effective Marketing Strategies, The Power of Habit. There is a purple bong that looks like it hasn’t been used in decades either, set up on the top shelf. Memories.

The living room is freshly vacuumed. The Electrolux sits by the door, its electric chord neatly wrapped in place. The superindendent who let us into the apartment stands there waiting patiently.

A middle-aged man in a bathing suit with his arm around three smiling children(maybe seven, twelve, and fourteen), poses on a beach, the Caribbean sea behind them. On the wall in the small open kitchenette the police officer is looking at a framed poster that says “My Kid Made This.” There is a 1st grade drawing of a man and woman and a house and a dog and a great big sun.

On the coffee table in front of the couch is a lap top computer, still open, its screen gone black, a pair of eyes glasses, neatly folded next to it. A glass of what looks like scotch with only one last drink left in it. A neatly typed sheet of paper is also laid there titled “Instructions.”

Down the hall there is a bottle of aerosol on the ground by the half open bedroom door. There is another bottle on the ground by the bed and one on the bed stand. The bed is neatly made. The man lays supine on the bedspread, his arms holding a black garbage bag wrapped around his head.

My young partner runs the strip. Six seconds of asystole. Then he looks at his watch and calls the time.

Where I Stand (Today)

I promised more columns on enhanced BLS, but I have instead been silent for the last two weeks as I have struggled to come to a clear understanding of the issue. The most successful commentators all stake out clear positions (whether they believe them or not). But I continue to struggle with this one.

Just when I think I have it settled in my mind, I talk to someone else and they convince me otherwise. Enhanced BLS will harm the advancement of paramedic services and that would harm patients. Go ahead and train and equip them, but it is going to cost dollars and there might not even be a need. Some EMTs are capable of these advanced treatments, but others, oh, no, look out! I admit I could see their points.

This week I put Enhanced BLS on the agenda of our regional medical advisory committee, and we addressed it on Tuesday. I have no set position, I told them, my position keeps changing. I am conflicted, but this is an issue we will need to address. Help me out, what do people think?

We had some good conversation. Many on the committee felt just like I did, torn and confused. But talking about it with them, and learning I was not alone in my conflicted view, helped me find some clarity. So while reserving my right to change my mind, here is where I stand today:

I believe there are a number of medications and interventions that BLS can be taught to do outside of becoming paramedics themselves that will benefit patients, enhance the public’s experience of EMS and cause little to no harm.

Having said that I believe each of these items needs to be approved by the services’s medical director and weighed carefully against any number of factors, including great benefit versus little risk to patient, cost, need, resources, service area and ability to train and oversee.

Here is my menu:

Medications:

Epi-Pen
ASA
IN Narcan
IM Glucagon
Combivent
Zofran ODT
Tylenol PO
Benadryl PO
IM Versed injector (for status epilepticus)
Morphine injector (for distant rural services)

Interventions

CPAP
Selective Spinal Immobilization
12-Lead Transmission
Supraglottic Airway

If I were to redesign the nation’s EMS system, I would expand the basic EMT course to see that all of these interventions and medications were properly and as thoroughly covered as needs be. (I would also redesign the paramedic class to make paramedics more advanced practice practioners with treat and release as part of their scope). But that is a little beyond my abilities and powers. So what will I do for the world today?

I will do a needs assessment in each particular area to see if there is an unfilled need for any of these interventions – a need that will justify the expense and training involved. I think that needs assessment might reveal some interesting answers. (While doing research on the need for BLS 12-lead acquisition, contrary to my expectation, in our region, I have found it is very rare for a BLS unit to bring a STEMI into a non-PCI center. And the likelihood of BLS bringing in a STEMI to a PCI center was actually greater for urban BLS than rural BLS, who most always eventually can meet up with a paramedic on the way to the hospital due to the length of time they have to meet up. BLS heads to the hospital and paramedics come out to greet them, in most cases far enough from the hospital for the STEMI to be identified and the PCI center notified in advance. BLS, in the city, on the other hand, is close enough to the hospital if no medic was initially available to respond, BLS may make it to the hospital before they can hook up with a medic.)

But first a diversion. In Connecticut there is a bill before the legislature to require that all BLS ambulances carry Diastat – rectal Valium. Where did the bill came from? I do not know. Certainly not from any of the EMS medical directors in the state. My guess is that it came from a mother of a child who suffers from seizures, who likely approached a powerful legislator and convinced him that requiring rectal Valium in every ambulance will ensure that her child will get relief if the child has a seizure away from home. There is also another bill that would allow school bus drivers to inject students with the student's own Epi-Pens should they suffer an anaphylactic reaction on the bus. Should we be concerned that in the confusion of the legislative process, bus drivers will end up permitted to administer rectal valium not just for seizures but also to calm down disruptive children?

While the goal of the legislation, as the goal of enhanced BLS, is laudable, we cannot lose sight of the big picture and ask the needs question? How many kids in Connecticut have suffered permanent harm from the failure of BLS ambulances to have rectal Valium? And how many kids have been spared permanent harm by not having rectal Valium inappropriately applied?

While I don’t have the answers, I can say that in the areas I work in and in the areas I oversee, it is very rare for a truly seizing child to not get treated by a paramedic. Our paramedics give medication to seizing kids very rarely. You can count the number of times in a year they give it on one hand, and this is over a sizable multi-town area. Pediatric seizure is a fairly common call, but it rarely turns out to be true status epilepticus. It more often falls into these categories: seizure over by your arrival, never a seizure in the first place or a pseudo seizure, the political correct term for a patient having a seizure for emotional reasons and not due to abnormal electrical activity in the brain. Rectal Valium costs about $300 a pop. It comes with an expiration date, would require a large amount of training, as well as requiring lock boxes and controlled substances policies. A lot of money, a fair amount of risk, many manpower hours of training, and not really a proven need – at least not in our area. Might I approve it for an area where the closest paramedic was two hours away? I possibly would. Although I would insert IM Midazolam for rectal Valium.

What I would approve in an urban setting and what I would approve for a rural area would be different depending on a multiplicity of factors. The two BLS enhancements I feel strongest about no matter the setting are the Epi-Pen and CPAP. I want to see all basics carrying these. They will save lives whether the patient is in a 3rd floor walkup apartment a block from the hospital or a hour away in a farmhouse. They are used for extremely time dependent conditions (anaphylaxis and impending respiratory failure). Both I believe have strong literature behind them supporting their benefit.

I guess if I could summarize my position it would be this: The distinction between ALS and BLS should not be an artificial one where BLS gives no medication and does nothing invasive where ALS does. The distinction should be a common sense one made by medical oversight after weighing risk/benefit, cost, and need. BLS shouldn’t necessarily carry a medicine or do an intervention simply because they can. In our current system, they should be allowed to do these enhancements only if there is a demonstrated need.

* *

Of note, Connecticut is nearing approval of CPAP for basics with the approval of the service's medical control. Epi-pen is currently mandated in all BLS ambulances. Connecticut is also nearing approval of a pilot project for the acquisition and transmission (not the interpretation) of 12-leads by BLS in the Northwest rural area of the state. IN Narcan is the next enhanced BLS issue that is expected to be taken up by our state committees.

This ends my commentary on enhanced BLS, at least until I change my mind again. 

King of the World

 I work Sunday, Monday and Tuesday, 12-hour city shifts. I took the day off today (Tuesday) to go to the monthly regional EMS meetings for my clinical coordinator job that fall on the 2nd Tuesday of every month. I was excited for the meeting because we were going to be voting of our new spinal immobilization guideline to limit the use of long boackboards for certain patients, but the meetings were cancelled due to the storm we had this past weekend. Friday night we were hit with a blizzard that dumped anywhere from two to three and a half feet on towns in the area. The storm plus the nightmare of cleanup stressed enough of us with backlogged work and still messy road conditions that the meeting was put on hold.

I woke up Saturday morning to this site in my driveway:

Fortunately, I had a good helper with the shoveling.

Sunday and Monday at work were challenging as many of the streets in the city had yet to be plowed. We got as close to the call locations as possible and then either hiked in or had the patients meet us on street corners. The mother with the sick kid and the woman with the full body rash met us on the corners, the unresponsive hypoglycemic and the weakened dialysis patients who missed their scheduled appointments we had to go get.

Monday was complicated by people trying to drive to work and by a cold rain that turned the streets to slosh and ice. We dealt with more blocked streets, and cars that were stuck on ice with skidding wheels that we had to get out and help push out of the way. All day long, it seemed I was stepping out into snowbanks and doing crazy arm whirling balance dances when my own boots failed to grip the ice.

So a part of me was relieved that instead of dealing with more of the mess today, I was in my warm office at my computer, weating a comfortable sweater and reading run forms on the computer instead of doing the actual calls myself.

…instead of doing calls myself!

I do like my office job with the nice state benefits and great boss and chance to work on systems issues, but I also like doing calls myself. Really there’s nothing like it.

I found myself daydreaming, remembering the day before, how on one call to keep from blocking the road completely and leaving room for the arriving fire truck, I was wedged up against a giant snowbank. I squeezed out of the passenger door, and started climbing. I climbed to the very top of that snow bank. I was up higher than the ambulance roof, higher than the big fire truck. I was higher than everyone on the street. I could look all the way down the avenue, at all the life of the winter city digging out. I stood on the snowbank a moment, and pounded my chest like old King Kong. I was the King of the World! Then I climbed down to follow my paramedic preceptee and our EMT partner into the apartment house where on the third floor we took care of an old man with swollen legs, carried him down in a stair chair, and out through the snow and into our warm ambulance and transported him safely to the hospital.

Homemade Soup

I am conflicted. I am having doubts about some of the benefits of medicine. Let me be more specific. In our state, we are told to advise a patient at least three times to go with us to the hospital before we can accept a refusal of care against medical advice (AMA). (For legal purposes all of our refusals are considered AMA). On the other hand, as a medical professional, we are bound by the fundamental tenet, first do no harm.

Sometimes I feel that my required recommendation of transport is actually against the patient’s best interest. (Examples to follow.) In these cases, I may say, “I am required by law to advise you to go to the hospital three times. My advice by requirement is always to recommend transport to the hospital for evaluation by a doctor.” Other times clearly I ardently believe the patient needs to go to the hospital and I will use every trick in my book to get them to go. “I believe you will die a horrible death if you don’t get to the hospital, so we are going to take you to city hospital, okay?”

So why am I losing faith in medicine and in the benefits of patients going to the hospital? Clearly, I am not in every case, but in others, I do have my doubts. The history of medicine is not a stellar one. Think blood letting and hospital acquired pneumonias. Even in my years as a paramedic, it turns out that many of the things we were doing that we thought were helping patients were harmful to them. MAST trousers, high volume fluids in trauma, lasix. A recent study of spinal immobilization in penetrating trauma showed that for the one out of every 1200 patients we were possibly helping we were likely killing one out of every 68.

1999 Institute of Medicine Report, Too Err is Human, estimated that 44,000 – 98,000 people die in hospitals each year as a result of preventable medical errors. That’s more deaths than motor-vehicle wrecks, breast cancer, and AIDS. I also think this seriously undercounts people who may die from medicine contributing to their morbidity. What about people with unnecessary operations? What about people put on meds that may not have been necessary? The tendency in medicine is always to do something. That is what we get paid for. We don’t get paid for recommending against unnecessary treatment.

Now I understand that I am not a doctor and that I do not have the battery of tests that are available at a hospital not the extensive medical education and experience of a physician. It is just that I see so many people taken to the hospital and getting workups that don’t show anything or that show what any one else could see. A patient has the flu, the patient has a GI bug, the patient is dehydrated, the patient has a muscle strain, the patient is old and has wobbly legs.

I guess what I am getting at is in the larger scale on a risk benefit ratio, I am curious the number of people who benefit from their evaluation versus those who may be harmed by the evaluation.

Here are three cases in point all that happened in one day.

A frail old man has grown weaker over the last day and has fallen twice in the last day. His family wants him evaluated, but more than that, they want our advice. We, of course, tell them the weakness could be a sign of any of number of serious illnesses, and that he should be taken by us to the ED for full evaluation by an emergency room doctor and hospital specialists. But the family really wants our advice. They are worried that if he goes to the hospital he will get the flu from all the sick patients already there (like the two we brought in earlier).

The the truth is I see their point. What if we bring him in and he does get the flu or another infection that further weakens him? What if he gets put on other meds to battle whatever irregularities they find at the hospital and he dims because of them?

If he is my father, what would I want for him? In this case, with these symptoms, I would want him to stay home where I would care for him, feed him, and see that he rests in his own bed. I would be more patient. I would wait before sending him to the emergency department. I suppose I would wait for what I saw was a true acute emergency. I think his wife and his daughter are capable of providing such care. This is what I want to tell them, but instead I am bound to follow my script. I am not upset when they decide that they will keep him home, and only call if things change.

An 88-year-old Vietnamese man passes out at the pharmacy. He lives just a few blocks away. he walked over to get his meds, but had to stand in line for over fifteen minutes. He felt woozy and was helped to a chair. He barely speaks any English. His vital signs are good and his 12-lead is normal. He doesn’t want to go, but due to language it is hard to communicate. When we finally get hold of a family member, who, on our advice, tells him he has to go, he agrees to let us take him. Maybe he has had a cardiac event and will walk out of the hospital on many wonderful meds and perhaps with a pacemaker. But maybe he just has the flu, and would better benefit from being taken care of at home by his family and hand-fed hot soup.

Nearly the same scenario plays out later in the day with a Croatian woman who collapses at the post office while waiting in line. She is old and looks pale, but everything checks out okay. We still end up transporting her for an evaluation after getting hold of an English speaking nephew. Maybe she won’t get sicker in the hospital, maybe she will be better able to rest there than in her own bed, surrounded by her family.

I know this is unrealistic, and we do need to pay for gas, ambulances, equipment, mine and everyone else’s paychecks, as the hospitals also have to pay for their staff and physical structures. Still I wonder about runaway health care costs. I wonder about the scientific evidence and if it would show we are truly making a difference but universally urging transport.

I want what I do-- what we do--to matter, and I know it does in many ways. There are just those times where I think it might be better if we could just transport someone home, set them in their own bed, with their family now gathered around them in a familar setting, and perhaps we would leave with some homemade soup as payment for our kindness. 

Risk Assessment

 This post is inspired by a book I am reading – Antifragile: Things That Gain from Disorder by Nassim Nicholas Taleb. In this fascinating book Taleb discusses risk. Take this example which I am modifying from his book:

Would you get on an airplane if there was only a 5 percent chance that the plane would crash?

While the odds may be in your favor that you will likely not crash, the outcome of those small odds is so catastrophic that you would be a fool to board the plane absent astonishing circumstances requiring your seat on the plane (to save a loved one, to prevent a war from starting, to collect a trillion dollars). The possible benefit of getting on such a risk prone plane—is insignificant when compared to the possible drawback of crashing – losing your life.

Most bets we make, according to Taleb, are asymmetrical. The amount to be gained or lost is not equal. If you are going to bet, you want to bet where the losses are minimal and the payoffs far exceed the downside. Position yourself to avoid catastrophe.

While Taleb talks a lot about economics and other subjects, let’s apply this simplified concept to EMS.

***

“Why wasn’t a 12-lead done?”

“I didn’t think it was cardiac.”

***

So your patient has syncope with a recent history of dehydration. You brought the lady in yesterday after a similar episode, and the ED sent her home after hydrating her. She is 80 and appears ill. You have been a medic for twenty years or perhaps you are a cocky brand new medic. Your gut tells you it is not cardiac. In fact you are 95 percent certain it is not, so you don’t bother with a 12-lead...

Your EMS coordinator or training officer pulls you into the office and says your patient in fact had a STEMI and went into cardiac arrest on the way to the cath lab after sitting in a room for 20 minutes until the ED did a 12-lead and spotted the anterior STEMI. If you had spotted the STEMI, the patient would have likely been cathed before going into arrest, and while resuscitated, she likely will have a significantly diminished ejection fraction as a result of the arrest and delay in treatment.

What was the gain from choosing not to do a 12-lead and going with your gut?

You didn’t have to exert yourself to do a 12-lead.

What was the worst possible outcome of not doing a 12-lead?

The patient would be having an undiagnosed STEMI and due to the delay in diagnosing her, she could die before she could be reperfused in the cath lab.

Thus the decision to withhold the 12-lead is in Taleb's view, a fragile one. If you lose, you (and the patient) can be broken. You want always to avoid the state of fragility. You want to be antifragile. Your gut may tell you it’s not cardiac, but in this situation where the possibility of failure exists, having a redundant system like a 12-lead provides you protection. At a low cost of doing a 12-lead, you prevent a catastrophe – missing a STEMI.

Minor exertion versus a patient’s death. The potential gain and the potential loss from the bet that it is not cardiac are not equal. Low upside if you are right, big downside if you are wrong.

Now for those of us who cast a wide net with our 12-leads, this may seem like much ado about nothing. There is no way despite our guts, this patient is not getting a 12-lead, but let’s apply this same reasoning to another scenario.

***

Why did you spend so much time trying to get an ET tube on that lady instead of just popping in a combi-tube?

“I thought I could get it.”

***

Obese female grabbed at her chest, and went unresponsive five minutes before your arrival. She was fortunate enough to get bystander CPR, but it doesn’t look like they are doing it very well. The seconds on her survivability clock are ticking quickly down to zero, unless you can intervene quickly and with great skill.

You put her on the monitor and see she is in a fine v-fib so you shock her X 1 and resume CPR. You want an advanced airway so you can do continuous compressions (instead of 30:2) as well as secure her airway – get more oxygen in and more CO2 out. You have two choices – an ET tube or a combi-tube.

You choose the ET tube. Why?

Well, it may be a better airway. It is the airway the hospital will use if you get her back and she remains unresponsive (under sedation) whereas if you put in a combi-tube, the hospital will eventually pull it and put in an ET. Also, you like intubating. It is a paramedic skill and one you don’t get to do as often as you’d like so you don’t want to pass up on the opportunity. Plus, when you talk about the call later, everyone will ask if you got the tube. If you are a new medic people want to know these things, and you want to show them you are worthy of the rocker on your shoulder. If you are a 20-year medic people will expect you to get it.

And most important of all – you think you can get it. You think there is perhaps an 85% chance you will get it, or maybe scale that down to 75% as you do notice, she has a thick short neck and protruding teeth. Still, you think the odds are in your favor. You go for it!

So what are the risks and benefits?

If you get the tube quickly you are a stud and the ED won’t have to switch out tubes as long as your crew doesn’t yank it. If you can do it without much interruption in CPR, all the better. Now the studies do show that ET attempts cause many interruptions of CPR, and you know that is true, but not in all cases, and sometimes you do intubate flawlessly and with great skill. No interruptions in CPR – even when checking lungs sounds. You can do it!

Now how about the risks?

If you don’t get the tube flawlessly, there could be problems. You will look bad for trying three times and not getting the tube. But wait a minute, we are not really concerned with you, we are concerned with the patient. That’s who the real risk is too.

If you are a medic working by yourself, it takes longer to get out all your equipment to intubate than it does to rip open and insert a combi-tube. If you can’t sink the ET tube on first look, CPR may be interrupted or the patient may not be ventilated well. CPR may be interrupted while you intubate, and your patient who is already on the brink of death may go to the darkness while you dick around trying to get the tube. It may not happen every time, or most times, but some tubes are, shall we say, challenging.

Reward you get the tube. Risk you cost the patients seconds if not minutes that they may not have. An asymmetrical bet. Small upside, big downside if the bet goes wrong.

Given that this patient is likely already on the razor blade edge between imminent tissue death, imminent anoxia and chance of full neurological recovery, I think we have to do everything to obtain immediate airway (oxygenation/ventilation) relief with no delay in compressions.

When seconds count, seconds should count. The risk of the most difficult airway I think is too great in this particular described patient. It is not a 75% versus 95% proposition. It is a possible loss of 10 to 60 seconds when a patient may not have those seconds left.

Wouldn’t it be great if every patient we showed up to in cardiac arrest had a visible life clock hanging on the wall above them. 0 seconds remaining, we don’t even have to go through the motions. 2 minutes remaining, we can take our time rolling up our sleeves and taking control. Or maybe 20 seconds remaining when we have to act fast and with that great skill. Deliver that jolt. Pound those compressions – they must be excellent. Secure that airway.

It doesn’t matter how well packaged the patient looks when we bring them into the ED doing CPR. ET tube, 2 IVs, run through the entire ACLS algorithm. It matters if we can get them back before that last grain of sand falls in their life clock.

We might save a human being who would otherwise pass. So what if they have to change out the Combi-tube to an ET tube later. Big upside, low downside.

***

Now I may be butchering Nasem’s points, and his book is certainly more complex and well thought out and argued than my meager post. The point is reading the book has made me look at a situation that I have struggled with in a new way. I don’t think I was adequately assessing the risks. When a life is at stake, I should err with whatever is more likely to avoid a catastrophic outcome.

Alternate Airways

Far From the Tree

 The other day was busy but boring – at least until I got the call I am going to tell you about. We were just doing EDPs, transfers and emerge-ifers (911s from nursing homes or medical clinics that go to the ED for evaluation). Then we got another EDP – a patient who had expressed suicidal ideations to a social worker. While my third rider was gathering the information from the social worker, a police officer and I were whispering to each other trying to figure out if the patient was a man or a woman. The social worker was referring to him as a he and he had a man’s name, but his voice was very feminine and he had a very feminine manner and complexion.

It wasn’t until we had begun transport and the patient answered my rider’s question about what medicine he took that I paid attention. The man said he was taking female hormones.

“You’re transgender?” I asked.

“Yes.”

“Have you had the operation or are you planning to have the operation?"

“I having it next month,” he said.

“Really? So how would you like us to refer to you? Male or Female?

“Female. You can call me Jen.”

“Okay, Jen,” I said. “I will change that on our form for you.”

“Thank you. That’s very kind.”

“I just read a fascinating book about transgender people,” I said. “Is it true that you felt you were a girl from a very young age, but you just had a man’s body?

“Yes, it’s true,” she said.

“Fascinating.”

I proceeded to tell her and my rider about the book I had read. And that is why I am writing this post -- to tell you all about this great book called Far From the Tree by Andrew Solomon.

When they say of a child, “the apple did not fall far from the tree,” they mean the child is like the parent. Thus “far from the tree” means the child is nothing like the parent. The book, which is mammoth, is about human diversity and the capacity of people to love. Each chapter consists of interviews with parents as well as descriptions of the science and cultures surrounding various disorders. There are chapters on deaf people, dwarves, Downs, schizophrenics, criminals, autistic children, severely disabled kids, and gifted children. In many of the chapters the parents say that if they were told when they were first pregnant that their offspring would be abnormal, they would likely have aborted them, but now, despite the hardships, most expressed deep abiding love and gratefulness for what the experience and their child taught them about themselves and about life. (Of note, the book includes a facinating interview with the mother of one of the Columbine shooters).

As a reader, I could not put the book down. It gave me great empathy and made me appreciate that we are not all the same tree in the forest, and that as a society we are likely better off for our diversity. It certainly gave me a window into the world of transgenders, schizophrenics, autistics, the deaf, and many of the other types of patients we encounter, as well as their families.

I remember many years ago complimenting a mother for keeping her severely disabled child, who was now in her early twenties, instead of putting her in a facility. “But how could we have sent her away?" she said to me, incredulously. "She is one of us. We love her.”

I didn’t really understand then, but I do now. Part of the reason I understand is I am older and have a family of my own now, but I think reading this book really helped me better understand it as well.

Humans are capable of deep abiding love and acceptance and this book testifies to that. I feel I am a better person for what I have read and come to understand.

Far From the Tree is one of the New York Times 10 Best Books of 2012 list.

I can't recommend it enough.