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.