Footprints

 Three sets of footprints in the snow. Two with fully defined treads. Mine barely register. I’m twelve years older than the two of my partners combined. This is my fifth pair of boots and the soles have gone smooth. I walk carefully. We do a call and I can’t make it up the icy driveway. I keep slipping down the incline. I have to hike up through the snow to get to the door. I have had this pair of Fort Lewis’s seven years, and they have stood me well. I order a new pair that night and they arrive on Christmas eve. I put them under the tree so I it will look like there are even more presents when my daughter awakes in the early hours and checks to see if Santa has come. In life we give way to youth, all of us do. We fade away. But I hope this new pair of working boots won’t be my last. I have more earth to tread on, more inclines to climb.

Pain Myth

 In my standard talk urging paramedics to be generous with pain management, I have a section called pain myths. One of the myths is entitled Fear of Creating Addicts On the powerpoint I have two pictures, one of an all-American housewife, the other of a skanky drug-addled prostitute.

Here is the text from the slide:

"4 patients out of 11,882 patients treated with opioids at Boston University developed opioid dependence."
-Research from Boston University
http://www.emedmag.com/html/pre/fea/features/121501.asp

***

Imagine my pain and surprise when I read recently that this study, which in various sources has been hailed as a landmark study, etc, was in fact just an obscure letter to the editor in The New England Journal of Medicine consisting of no more than a paragraph, written in longhand. The man who wrote it, Dr. Hersel Jick, kept a database of medication side effects suffered by patients hospitalized at the University Hospital. Curious about the opiate addiction question, he had an assistant run the data, which prompted him to write the letter. Little did he know, but his letter, which was titled Addiction Rare in Patients Treated with Narcotics, initially forgotten, was later found and trumpeted by the pharmaceutical companies who were trying to convince the world their oxycontin and other opiates were not addictive, and should be given liberally to those in pain.

As most in EMS know the country is in the midst of an opiate overdose epidemic never seen before. Here is the narrative of how that epidemic has come to play out, according to an excellent book I just finished called Dreamland, the True Tale of America's Opiate Epidemic by Sam Quinones.

Drug companies pushed oxycontin on well-meaning doctors as the panacea for patients's pain at the same time the medical establishment was coming to recognize pain as the fifth vital sign, and that pain was what the patient said it was. Using landmark studies such as the Jick letter, they encouraged the prescription and represcription at even higher doses of oxycontin. While the meds helped countless patients, others quickly became addicted, and they required more and more of the drug to keep from being drug sick. Pill mills sprouted up across the country where easy money was made charging $250-$500 cash for an exam with a resulting prescription for opiates. Many of the patients at these clinics, faked pain to get the prescriptions to sell the drugs to addicts. In time, the pill mills were shut down and the drugs became much harder to acquire. For those without insurance the pills could cost $200 a day on the street. With the advent of safer tamper resistant oxycontin drugs, it was harder and harder to be an oxy junkie. In the meantime, the cost of heroin dropped drastically at the same time its quality improved. (A dual narrative in the book describes the Mexican retail trade in black tar heroin that is fascinating reading.) With heroin cheaper and easily accessible and working on the same receptors, the switch from oxycontin to heroin was a no brainer.

Hartford, where I work, has several methadone clinics, and it is quite an education to respond there in the morning and see the lines stretching down the block. The addicts are not predominantly young minority men from the inner city as they were years ago. Today, they are of all ages and races, from the city and the suburbs, high school athletes, grandmothers and housewives. The same with the heroin calls we get. Last week, I picked up a man sleeping the bushes, who had come to the city looking for heroin and pills. He wore a jacket with the name of a construction business on it. We asked if that was where he worked. He said he used to own the business.

The book explains that the patients in the Boston University database were cancer patients getting small amount of opiates under strict control, not patients with chronic pain. No real study has been done on how many people get addicted to opiates, but the number of deaths suggest it is much larger than the number quoted in the letter.

There is an ongoing health care battle in the country today between two opposing and well-meaning groups -- those whose primary goal is to provide pain management to those who need opiates to function and those whose primary goal is to stop the deaths. It is hard to find the proper balance between the two.

Where do we as medics fall in it? I don't see but we have any choice but to continue to provide pain relief to those in need, and let the hospital sort out any addiction problem. I do ask now if patients have pain contracts and if they say they do, but are requesting transport to a second hospital, then I am hesitant to dose them. I continue to treat acute pain, even possible faked acute pain (I have pancreatitis!) as I always do. If their pain is greater than a 4, I ask "Would you like some pain medicine?"

I can't say definitively that there is no risk that I am starting them on the road to addiction and ruin. I doubt the number is great, but maybe I am giving them their first taste of an opiate and they really like it (I'm not certain what they gave me for my colonoscopy, but I left the procedure feeling great!), and they are cursed with the addiction gene. Maybe the same business owner today who hurts his shoulder in a fall and gets fentanyl from me, I might find on a future day laying in the bushes in his tattered work coat, an addict who lost his wife and children and home and business, ruled now by the opiate lust.

But then again, promptly medicating the business owner with the damaged shoulder, I am, as others have argued, intervening quickly and sparing him the physical changes that acute pain can cause that often lead to chronic pain. Perhaps, I am sparing him from ever having to go on oxycontin in the first place.

Here is another slide from my presentation that is a bedrock of my pain management philosophy:

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

I just hope someday I don't read that that is a phony argument too.

Same Old Song and Dance

 When couples get old, they communicate with fewer words or sometimes just a look.

I am feeling that way about my EMS reports at the ED.

Where I used to rattle off every detail I could think of (from brand of cereal they had for breakfast to the number and locations of the moles they had removed a month prior), nowadays I try to keep it short.

Here are some examples:

"Last drink two days ago, got the shakes. 2 of Ativan and some fluid."

Low speed, belted, neck and back.

History of seizures, had a seizure.

 Curtis, same old

Sugar of 20, forgot to eat, gave her D10.

He thinks he's the Devil, gave him 10 of Versed.

"Cold and flu."

They shot him in the leg.

Eight years old. Acting up in school.

ETOH.

Coughing up green phlegm for two weeks.

2 of Narcan IN.

Sometimes, I don't say anything at all. I just point to the patient. Every picture tells a story.

It helps if the nurse or doctor I am giving the report to has been around as long as I have. They just nod like all those times before.

Legends

 On Sports Radio this morning they were talking about the decline of three sports legends – Tiger Woods, Peyton Manning and Kobe Bryant. The radio host, a retired athlete himself, was saying how no one who hadn’t played professional sports could possibly understand what these three were going through. He said they dedicated their lives and heart to a sport. They were the center of everyone’s attention. And now their bodies were betraying them. They could no longer perform at the level they were accustomed to performing. They couldn’t be the hero anymore. It was like they were suddenly staring into a void, left with nothing.

I love sports, but seriously…

I thought today of all the paramedics past I have known, men and women, who stood tall, who were the center of attention, who performed at the height of their abilities when human life and death were on the line, when people were sick or injured and in need of someone special to walk through their doors and make things better, and these men and women did. EMS was their life and their identity, and then the day came when their powers started to fade. They grew old or got hurt and they could no longer do the job they loved. They were no longer the center of attention; they no longer had the power to heal.

I think of all the medics I saw over the years, who instead of riding the ambulance, were consigned to the light-duty chairs, consigned to paper work, washing ambulances, or delivering supplies. I think of the others who went out on injury and never came back.

They might not have been known to the world as Tiger, Peyton or Kobe, but they were known to those who worked with them, and to those they took care of.

You don’t have to be a professional athlete to understand what age does to people or to yourself.

We all one day vanish.

Thoughts on Lights and Sirens: Stroke

 I hardly ever go lights and sirens to the hospital. I feel so strongly about not going lights and sirens unless absolutely necessary, I wrote what became our statewide policy on lights and sirens. Although it was toned down through the various committees it went though, the gist of it remained the same. You should only go lights and sirens to the hospital if the hospital can do something in the minutes saved by going lights and sirens that you can’t do that will make a difference in the patient’s mortality or morbidity.

Here’s how it was eventually worded:

When transporting the patient utilizing lights and sirens, the need for immediate medical intervention should be beyond the capabilities of the ambulance crew using available supplies and equipment and be documented on the patient care report.

I used to go lights and sirens quite a lot when I first started, but then I began to wonder. Here I am going lights and sirens, making cars veer out of my way, and running the risk of someone slamming into me, or someone else and for what? To get ahead in the triage line? Or to get to a room to turn the call over to a nurse, who I can’t even find to be seen by a doctor who has four other patients to see first?

Sometimes when I worked at night years ago, we went lights and sirens on bullshit calls, just to drop the patient off in the waiting room to clear to take the next holding call. That seemed more reasonable to me than going lights and sirens to wait in the line.

I posted that once on an early internet EMS list serve and got slammed for it -- and with good cause. I don’t do that anymore. I recognize now getting into an accident going lights and sirens for a patient with a smashed toe is not good form. Mea culpas galore.

Here’s what I have been going lights and sirens in 2015:

STEMI
Major trauma with physiological changes. Decreased GCS, penetrating trauma, hypotension or tachycardia, amputations.
Refractory anaphylaxis.
Pale, cool diaphoretic, abdominal pain. Thinking AAA or ischemic bowel or another surgical emergency
Refractory seizure
Refractory CHF not responding to CPAP and NTG
Major stroke*
Others depending on unique circumstances (like someone who I think is going to crash)
Cardiac arrest (only sometimes).
Seriously impending childbirth. (Some people like to deliver babies, but I think the baby deserves an OB team more than just a paramedic, particularly when things go bad.)

I call your attention to itme 7 on the list -- major stroke. Why not minor stroke? Good question. I acknowledge that I should be going lights and sirens on these patients, but I have been having a hard time, actually doing it. I make excuses. “Let’s just get going I will tell my partner, but keep it on a two. I’ll do everything on the way.” My partner on this day is new and drives rough and doesn’t always know where he is going. I justify my decision that it is a safety issue, which trumps all.

I have a dual role when it comes to stroke. I work at a stroke center and collect data. One of the data fields I collect is whether or not the ambulance went to the hospital lights and sirens. I was shocked to discover EMS only transports a little more than half of stroke patients on a priority, even though we have all been taught -- time is brain. They say you lose 32,000 brain cells every second in stroke. I am not talking about unresponsive Cincinnati 3 here. I am talking about the patient with a mild facial droop and arm weakness, who is hemodynamically stable. I ask medics who have called in stroke alerts why they didn’t go on a priority. 32,000 brain cells a second. I remind them. We are on the clock --the patient is still in the tPA window. They shrug. Maybe it’s the fact it takes hospitals so long to give tpa -- the goal benchmark is 60 minutes. The time it takes to give it is not unreasonable -- the patient needs to be scanned, thoroughly evaluated by Neurology and then have a conversation on the risks and benefits of tPA (IT MIGHT KILL YOU!). If they get tpA within 52 minutes instead of 50, does it matter?

If you buy into tPA (not everyone does) and you buy into our stroke system (which is build around tPA) then we all should be going lights and sirens on even minor strokes. It was shocking to me that 60% of our EMS patients who were recognized strokes and got tPA, were transported nonpriority.

Like many time sensitive interventions the data shows the sooner people get it the better it works. The longer time passes, the greater the risk until the point at 3-4.5 hours (depending on patient) when the risk exceeds the benefit.

Based on the data I collected (showing area medics reluctance to go on priority) we added the following to our regional stroke guideline:

Try to limit scene time to 15 minutes or less, and transport rapidly. Transport should be equivalent to trauma or acute myocardial infarction calls.

I haven’t had a stroke for awhile, so I haven’t been tested, but other medics keep resisting. It’s odd.

Looking at the dispatching side, we noticed early on that only 70% of strokes were being dispatched on a priority, but in certain areas, it was even lower. We looked into those towns and found their dispatch centers were dispatching STROKE (Card 28) in Medical Priority Dispatch non lights and sirens. Reading the card was somewhat shocking.

"STROKE must receive an immediate response that is not subject to delay, lights and sirens are not recommended; however there should be a sense of urgency.”

It is important to note that someone having a massive stroke, leading to say, being unconscious, would be coded out under another dispatch card such as UNCONSCIOUS (card 31) and receive automatic lights and sirens response.

The way EMD works is the EMD system makes recommendations but the medical director makes the final decisions. Stroke coded out as a C or Charlie response and our medical director had ambulances going cold on most of the Charlie calls. We had our medical director, who to his credit is very conservative with calls he will have ambulances go lights and sirens on, change the possible stroke response to lights and sirens. We saw an almost immediate change in times. It seems the historic rationale for the non lights and sirens response on hemodynamically stable strokes is that while stroke was time sensitive, the few minutes saved by going lights and sirens was not worth the risk.

I know there are studies that say using lights and sirens only saves a few minutes. True, maybe when all responses are combined, but there are times of the day when without lights and sirens, you wait forever at strings of lights. There are clearly outliers where lights and sirens will save you 10-20 minutes. That is a lot of brain cells when it comes to possible stroke, and can be the difference in whether or not someone gets tPA. Not only that but tPA, if you believe the studies, shows a better effect the sooner it is given. 1 hour is better than 2, 2 hours is better than 3. After that, the considerable risks outweigh the benefits.

Maybe EMS is reluctant to go lights and sirens on milder strokes because EMS doesn’t get the follow-up on stroke patients. With STEMI, you either go up to the cath lab or you learn the door to balloon time. With trauma, you see the response and when you come back from writing your form, they are up in the OR. Maybe if we provide better followup to EMS, we will come in quicker? I have been a medic over twenty years and I cannot point to one of my patients that I know got tPA. I am sure some of them did, but no one told me, and I never followed up. And it is not like every stroke patient gets it. Our best quarter 20% of ischemic strokes got it, which is quite good. Some hospitals only 1-2% of stroke patients get the drug.

And maybe EMS is reluctant to go lights and sirens because the outcomes are so poor. Even if you believe tPA works, all it means is that the patient has a 10-30% chance of being moderately disabled versus severely disabled. The push tPA and there is the sudden hallelujah moment where the patient can walk and see and talk is largely a myth. Sure, some people can suddenly become better, but it is more likely if they are waking at that moment that it is the natural progression of their individual stroke/TIA and their reperfusion is spontaneous. Even the positive tPA studies show no difference at 24 hours between those who get it and those who don’t.

Over the years I’ve had a number of patients who were completely stroked out, who awoke after I had called in my stroke alert. They just had giant TIAs with spontaneous reperfusion. What if they had been given tPA? Would it have been the tPA or the natural reperfusion? And what if, in getting tPA, it caused them to bleed in their brains and die?

Bottom line, despite my reservations about tPA, I am going to try to go lights and sirens on my future stroke patients, because that is how our system is setup, (tPA is considered a Level I AHA intervention) and 32,000 brain cells a second is our responsibility. I say get them to the hospital quick, and let the neurologists do what they think is best. And if they get tPA long after I am on another call, I hope my lights and sirens transport, made a difference, even if small, to a fellow human’s outcome. I also hope I didn’t cause any accidents on the way to the hospital. Some of the newer people I work with are not the most experienced drivers. I have had a number of intercept medics tell me they won’t go lights and sirens strictly because they don’t trust the driver. I admit to being in that situation at times.

***

Update: I responded the other day to an elderly man with dementia who had suddenly lurched to the right, and then while he did not fall, was observed unable to move his right arm. I palpated all along it for trauma and elicited no response. He could squeeze his left hand on command, but not the right. He failed the pronator drift, but had no facial droop or speech problems. He was elderly and was hypertensive -- 180/100. I would have been more confident in my assessment if I could have had a conversation with him, but I was stuck with his limited ability to converse. His watchers said the right arm was completely not normal for him. I was only a couple miles from the hospital, but I did call it in as a stroke alert, and I did go lights and sirens, although I told my partner to make is an “easy 1”. The patient got a quick neurological exam, and then was sent right to CT scan as a possible stroke. I left for another call, and never got any follow-up.

* Now modified to stroke

Changes

 People are always asking me what changes I have seen over the years.  Here are four changes I have been thinking about lately.

More paramedics.  When I started we had anywhere from two to six paramedics on to cover the entire city of Hartford and backup the other three large towns we covered.  On many days I was the only medic for the northern half of the city.  I never did transfers unless they were ALS, I was rarely deliberately dispatched to drunks or psychs, and I intercepted constantly with BLS cars.  Today, we have anywhere from five to twelve medics on, and I believe if we could do it, we would put a medic in every car.  How do I feel about this?  I miss the old days, but if I was a patient and I was sick, I would want a paramedic taking care of me.  Going along with this, I think today it is much easier to be a paramedic.  Today’s medics have capnography, CPAP, combitubes and other backup airways, EZ-IOs, and much wider array of drugs that no longer require an IV.  Intranasal Fentanyl, oral Zofran, IM Versed area examples.  Gone are the days when you had a cardiac arrest that you couldn’t get an airway and IV access on.  Someone having a horrible time breathing and you don’t know why?  Slap the CPAP on.  I don’t mean this as a criticism, I think this is great for all medics and patients.

More calls at Dr.s offices and walk-in clinics.  We have always done these calls, but the numbers have increased to the point that a shift rarely goes by that I don’t do at least one call and often more at these offices.  For years, the complaint had been people were using emergency rooms as their primary care.  Now with the proliferation of these walk in clinics and more people covered by insurance now having doctors, they go there first.  Blood pressure high?  Short of breath?  Or an odd looking ECG?   911 is called.  Some are true emergencies, others not.

Safer equipment for moving patients.  Power stretchers and stair chairs with treads.  The days of the two person dead-lift and the back-breaking carry downs are largely gone thanks to these wonderful improvements.

More Fire-based EMS.  At least around here, we rarely saw fire departments on our calls.  In Hartford, the PD was the first responder -- their 02 tanks were empty, and they did not like touching patients.  Now, the Fire Department goes to all priority one calls.  And since we have fewer cars in the city than we used to, they are almost always there before us.  It is a big help -- everything from seeing the big red truck to help us pinpoint the location of the call to all the help they give us on scene, particularly with carrying.  In one town we respond in -- West Hartford -- we have seen the Fire Department go from only going to car crashes needing extrication, to going to priority ones, to going to all calls, to starting in January, actually providing paramedic care as the first responders in town.

What do these four changes all have in common?  Money.  The ambulance services make more money through the added paramedic assessment charges.  Walk-in clinics are much more profitable to health care organizations than EDs.  Safer equipment means reduced worker’s comp costs and less employee turnover.  The only outlier here is the fire involvement, which could be argued costs more, but when properly spun, comes out as getting more bang out of the fire personnel for the buck than when they were just firefighters.

I am not criticizing this.  Money has always driven change.  It is the way of the world, and not necessarily a bad thing.

The next big change coming down the pike driven by dollars. --  Mobile Integrated Health Care, aka, paramedic community medicine.  For years, nurses have used their political power (nursing organizations, power of the vote, donations, numbers), as all groups do, to keep paramedics off their turf in hospitals and home care settings, but in today’s world, the dollars to be saved by using medics to fill gaps in the health care system, are too great.  Many states have already gone to this new model of care.  Here in Connecticut, a law was passed to study the issue and consider regulatory change to make it happen.

Here’s how it might happen.  After a medic has completed the additional education, he comes to work and is given a list of appointments.  He takes the ambulance or a fly car and visits people recently released from the hospital for say CHF.  He takes vitals signs, does an ECG, weighs the patient, makes certain they have been taking their medicine, and calls the patient’s doctor with his report, and may either give the patient Lasix and make a followup appointment with him or, if necessary, call for an ambulance to transport.  If all goes well, the patient doesn’t have to use the ED, doesn’t need a costly readmission to the hospital, is healthier for the interventions, and saves the system a ton of money.  A win for everyone.

A patient calls 911 because they took two of their beta blockers by mistake.  Under community paramedicine (which if done properly will pay EMS not to transport), the paramedic calls the patient’s MD and is able to tell him to skip his next dose.  An elderly patient is short of breath because she ran out of her combivent.  The community paramedic will give her a breathing treatment, and then go to the pharmacy to get her refills.  Another patient is a little short of breath and due for dialysis in a hour.  The medics calls the MD, and gets permission to transport the patient right to dialysis, instead of the ED, and the ambulance service now gets paid for this transport.  

Now I did not get into EMS just to do home care, but I also didn’t get into EMS to take people to the hospital who didn’t need to go.   Times change, and thanks to better equipment, my back has made it this far.  Maybe community paramedicine, and all it promises, can keep my paycheck coming long after I would have otherwise retired.  When money and what’s best for the patient and the provider can go hand and hand, it’s all good.

 

Surprises

 I work in a high volume system.  It is not unusual to do 10 transports in a 12-hour shift.  I’m lucky if one of the calls is a good call.  By “good” I mean a call where I get to be a paramedic in a way more than routine.  Routine paramedic is asthma (duoneb), abd pain (maybe fentanyl), vomiting (zofran), chest pain with normal ECG (ASA), hip fracture (fentanyl), psych (versed only if violent or extremely anxious) type of call.  While these normal calls can all be rewarding in their own way, they are not memorable and are not worthy of a response when someone says, “Do anything good?”  A “good” call is one where when someone asks you that question, you can respond with “Yes, I did.” Sometimes a good call can be summed up in just a few words.  I did a code, used CPAP on a CHFer, gave 10 of Versed to take a duster down, did an open tib fib.  Good calls, but not worth elaborating on because the story is a known.  We have all done these calls.  The true good calls are ones that are more than a sentence fragment for a response.  True good calls are worth another paramedic’s listen.

Recently I had two calls that fell into the good category, and within that category, I would tag them with the surprise label.  Surprise is a special category of good call that I particularly enjoy doing and telling about.  By surprise I mean they turned out to be good when my expectations were for same old same old.  You can be dispatched to a shooting to the head or a CPR in progress and know you will likely have a call where you will have to earn your pay, but when you get dispatched to a city chest pain or a simple bee sting without initial symptoms of an allergic reaction, you are most likely going to end up with a routine call.

So I get dispatched to a chest pain a couple blocks from hospital.  The address is a rundown apartment building.  Our patient - a large fortyish woman wearing a do-rag -- comes out of the front door with her boy friend who is wearing a New York Knicks jacket and a Yankee baseball cap with a shiny round sticker on the bill.  (I do not mean to stereotype by this description, but in my mind at the time I am making judgments based on the stereotype which is based on experience). The woman says she has been having chest pain for about five days, and she answers my first question by saying yes she has been coughing up green phlegm.  Same old story, right?

I have a hard time getting a pulse -- she does have fat wrists,  I but think nothing of it.  When I put her on the monitor -- just part of the routine -- I do the classic double take.  Say what?  She is cranking at 220.  Holy Moly!

Later, I get dispatched for a 60 year old man stung by a bee.  He too walks over to the ambulance as we pull to the curb.  The first responders say the only reason he called is his wife got stung by a bee once and had an anaphylactic reaction.  He was stung by bees once ten years ago, and remembers some swelling at the time. He has no itching or hives.  No dyspnea.  His lungs are clear.  The first responder tells me his blood pressure is 140/90.  I feel his forehead and note it is clammy, but it is also humid out, and he was working in his garden  In the ambulance, I take his blood pressure.  100/60.  I ask him what his pressure normally runs and he says around 130.  I ask about meds and hear he is on beta blockers.  I tell him, I will be rechecking his pressure periodically on the way to the hospital.  I retake his pressure a few minutes later.  It is 82/40.  He is looking a little grey and he tells me he feels nauseous.  I check the monitor.  Heart rate is in the 60’s still.  He looks very grey now and says he is nauseous.  I take my the med bag out of my gear and set it next to me on the bench.  Interesting, I am thinking.  I take his pressure again.  I can’t hear anything.  He has delayed cap refill and is starting to look motley.  I’ll be...

What made these two calls “good” was for all the bullshit and boring repetition of many calls, sometimes someone actually turns out to be having a real problem.  We are supposed to put chest pains, even ones we think are muskuloskeletal,  on the monitor.  We are supposed to take repeat vitals signs.  9 out of 10 patients, maybe even 39 out of 40 show no change at all.  But you do your job, your routine and all of a sudden, there it is before you.  Paramedic time.

I wonder if this is how bird watchers feel when all of a sudden their binoculars focus on a rare speckled breasted winged creature or how antiquers feel when they discover a rare treasure at a neighborhood garage sale.  Or how a seven year soccer player feels when suddenly the ball is on her foot and the goal is open and she is unguarded and she kicks it straight and it goes in the goal and the team explodes with cheer.

Sometimes I love my job!

So instead of, the nurse saying hey did you know that BS chest pain patient you brought in was in a rapid afib at 200, or your BLS partner screaming up to you from the back that the bee sting dude just went into cardiac arrest, you actually get to be the one controlling the narrative.  Patient one gets 25 of Cardizem, which works like a charm.  The 190-220 rate comes down to the 70s, and she feels much better.  Patient 2 gets 0.3 epi IM, 50 Benadryl,  4 Zofran and 125 Solumedrol IV, along with a 300 cc fluid bolus.  And while he still feels a little nauseous, his pressure comes back and the mottling goes away.  His face is no longer grey.  His skin is warm and dry..

And I have two calls that are worth a listen, and a job that constantly reminds me it is never as boring as it can sometimes seem.

Assembly Line

 Many years ago, I worked on assembly lines in factories. I put together and or packaged everything from Christmas Tree stands and door knobs to fast food store deli sandwiches and grocery store beef ribs.

The key to the assembly line was to go a little bit faster than you were comfortable going.  You had to work hard and pay attention to keep up. If the line went too slow you were not as productive as you could be, or if it went too fast and people couldn't keep up the line fell apart and everybody had to stop and start all over at a loss of time and production.

At one of the hardware plants I worked at there were two competing inspectors. The time keeper studied your movements and taught you how to be move faster and more efficiently so more could be produced. At the other end was the quality guy and he got pissed if things were not put together right. The time keeper and the quality guy had different bosses and they hated each other. The foreman didn't care for either.  She just wanted to get the product out in as much volume and quality as possible. I was just a worker bee, paid by the hour, with the pay check coming every Friday as long as I decided to keep coming to work. I would listen to the time keeper and nod and do what he said, and then the quality guy would yell at me, and I would nod and do what he said, and then the time guy would yell at me, and then the time guy and quality guy would yell at each other and I would go back to working, trying to find my own balance between speed and quality.

The best example of this was packaging doorknobs.  They would lay a big thick cardboard sheet on the line.  On the sheet was the backing for thirty-two door knob packages. I had a big bin full of door knobs and I would try to lay them down as neatly as possible, while another guy laid down the package of screws that went with the knob.  There were several of us doing the same thing. The sheet would whip by and we would furiously lay the knobs and screws down. The sheet would go into a machine to get plastic wrapped, and then another machine -- the cutter-- cut and separated the sheet into 32 individual packages, which were then quickly hand packed into boxes of eight knobs each. If the knobs were not laid directly in the center of their package. the wrapper would wrap them and then they would get cut off-center and be unusable, provoking the quality guys anger.

What is the point of all this?  It reminds me of health care today. Whether EMS or hospital setting, there is the clash between time and quality and the two task masters aren't always working for the same person.  A friend of mine worked as a PA for a hospital walk-in clinic.  She was a great PA, a former paramedic with a great medical mind, but when her annual review came up, the only issue that mattered was coding and the number of patients she saw per hour.  On the ambulance, the conflict is often between dispatch who needs to get the calls off their board in the quickest amount of time and get cars to clear as fast as possible and the quality people who want to get the appropriate car to the appropriate call (i.e. paramedic to priority one, BLS to transfer or priority 2), and the documentation people who want to have the run forms fully documented, and all the billing collected and signatures obtained. The road people do their best to walk the line to please everyone, while not forgetting about the patients needs, not just the patient they have, but the holding 911s who don't yet have car assigned to respond to them.

I do not mean to point the finger at anyone here, just to say, not that everyone hasn't already noticed, but the health care dollar is getting stretched thin these days. ED staffs are overworked too. There is a huge turnover in our EDs due to burnout as nurses cat handle the loads they are being asked to shoulder.  And for EMS, while I love my job, I come home after 12 hours of nonstop calls and driving and want nothing more than to get in bed so I will at least be partially rested for the next days work. Even when I was a young man three 12-14 hour shifts on consecutive days wore me down and it is much busier now and I am much older.

I was listening to a medical podcast the other day, and I heard a doctor tell a group of younger doctors that while she recognized the need to face the computer and input everything the patient was saying, it was particularly important -- at least on the first patient visit -- to observe the person as they spoke to get a sense of their body language, and to better understand the meaning of their responses.  At least on the first visit!

I start writing my run forms on the way to the call.  I can fill in a lot, but  often when I am working with a new person (I have partner du jour these days as one of my regular partners has been out hurt), I can look up and see we have gone past our turn.  I screw up often in this manner, forgetting they do not all know the streets as I do.  I continue writing the form on the way to the hospital, hopefully finishing in triage so I can quickly print it, and be available for the next call. I find I chat less with the patients than I used to in the days when I could scrawl out a paper run form in a few minutes.  I am just like the doctor sometimes, looking at the computer and missing the body language.

Let me tell you a story.  I tech most every call because I cant stand to wait at the hospital while my new partners take an hour to write their run forms. But on this call, we are driving by a homeless shelter and notorious intersection for drunks. We are hailed down by a cop. She's been drinking, the cop says, and points to a twenty-five year old or so woman with dirty blonde hair, torn jeans and a scowl on her face who is motherfucking him and us both. Such a stream of cuss words. My poor ears. We finally talk her into getting on our stretcher on the enticement she can get something good to eat at the hospital.  The diced peaches are particularly good!

l do this one, my partner says.  I have already done seven calls, and it is after all just a drunk and we are a half mile from the hospital, so I let him tech.  I get in the front, and hand him back the computer, and then in the rear view mirror I see him open it up and start typing away.  I drive to the hospital and when we pull the patient out, she appears to not only be unconscious, but have agonal respirations.  I see the fresh needle marks on her arm now, and note the pinpoint pupils.  I look at my partner and am thinking “Dude, did you not noticethe change in her condition?

Hmm, he said.I bet shes on heroin.

I stimulate her with a light medium punch in the arm She opens her eyes, and motherfucks me again.  She is breathing well enough now that narcan is not indicated. I had for a moment thought of putting her and the stretcher back in the ambulance and giving her some of the intranasal stuff.  Instead we wheel her in, and oh, look, there is a line at triage. We do some vitals in there, and she is Sating at 95%. Every now and then, her respiratory rate drops and I have to nudge her again. he wait continues. More and harder nudging are required.  Eventually, not even the nudging works.  Her SAT is in the 80s now and her respiratory rate is less than 6 even with sternal runs.  She is no longer arousable.  I have to get the triage nurses attention, and borrow an ambu bag.  I should have just had my partner go back out to the truck and get my gear.

Anyway, bottom line -- no harm was done with this call, but it shows what can happen when you are looking at the keyboard and not the patient. I like to think I do a good job of typing, chatting and looking back and forth between the patient and my keyboard. I like to think I am a good employee and can find the proper balance between getting my forms done quickly and clearing the hospital and giving the patients what they need.  But I do lament that it is not like it was when I started, when I had long conversations with patients on each transport, when all my assessments were thorough, when I saw more than I do now.

I would like more of an acknowledgement from our health care leaders of the stresses the new systems place on individual practitioners who must balance the need for high volume, high-level care, full documentation and patient-provider rapport (the heart of the best health care,) while often reporting to different taskmasters for each.

I recognize if the assembly line of health care goes too slowly, it is costly and unproductive. I also recognize if it goes too fast, it all falls apart.  I will do my best to continue to try to keep pace, but the entire system bears watching. When in doubt, the only boss to listen to is yourself, doing what is right for that patient right in front of you. We can blame, often with good cause, the system, but an imperfect system does not relieve of us individual responsibility. If asked to choose between the timekeeper and the quality guy, go with the quality guy.

Paramedic Students

 I remember when I was an EMT student doing my hospital observation time and watching the paramedics come into the hospital with their patients.  How confident they seemed.  I marveled at the ease with which they moved through this strange new world.  I held them in awe as I did the paramedics I later rode with during my paramedic ride time.  They knew the secrets I wanted to know, they had succeeded in the world to which I aspired.  I wanted to see what they had seen, to be able to able to handle what they could handle, to stand ten feet tall in the midst of the shit, to have my own swager.  They were mythic characters to me, and I wanted to be worthy of them.

I write this now after rereading Lights and Sirens, Kevin Grange’s new memoir about going through UCLA’s paramedic school and doing his ride time on the streets of Los Angeles.  It has been so long that I was in EMT class, and then several years later paramedic school that I have forgotten the stress, and forgotten the perspective of the new man trying to be worthy.

Grange’s book, which should be essential reading not just for those new to the field and those going through the unique experience of paramedic school, but for people like me and those I have worked with for years to help us remember not only what it was like to be new, but to recognize the ability we have to shape and help those who will soon to be riding alongside us, and for some, riding the streets after we have done our time and faded away.

Some of the people I rode with were real dickheads.  I remember one guy gave me one try at an IV, and when I missed, condemned me to observing for the rest of the shift.  I watched him do IVs and then jam the needles in the bench seat.  I remember he chased a “seizure” patient right off a scene, yelling at him to never fucking call an ambulance again.  “You again?” were his first words to the guy.  Another young woman kept syncopizing, and when I insisted we do a 12-lead ECG, he told me not to speak if I couldn’t recognize bullshit for what it was.  Halfway though the shift, a supervisor came out and told him a hospital had complained about his attitude, to which he swore at the supervisor, who told him to just play nice.  I hadn’t yet understood that sometimes ambulance services needed paramedics in their ambulances more than they needed good ones.  I hadn’t yet heard the term “meat in the seat.”   At the end of the shift, he wrote a short (two words) negative comment on my evaluation sheet.  Rather than turn it in, I threw it away and lost credit for those 12 hours.

Other paramedics I rode with were great.  They coached me through intubations, explained the difference between asthma wheezes and cardiac wheezes, and showed me the value of holding a patient’s hand, and attending to loneliness with the same commitment as I should attend someone with a gunshot wound.  To this day, they shaped the way i view this job, and I am forever grateful to them.

More than twenty years later, I know now that paramedics aren’t special.  We are just people like anyone else.  We have good ones and bad ones, gifted ones and others who just never stop working hard to be better.  No matter what profession or line of work you enter, there are people who will be dickheads, others who will be kind, and others who will be a mixture of both.  Angels and psychopaths can be found on the paramedic streets.  There are more of the former than the later, but neither is an oddity.

I have had a lot of new partners lately.  Between my two jobs -- as a paramedic and a hospital coordinator, I work 70 hours a week, and it leaves me perpetually worn out when I add on top of that being a father to three girls and trying to keep in shape at the pool.  I like nothing more than to come into work and see my regular partner Jerry, so I can go through a day not having to worry about anything.  But two months ago when we had a precepting paramedic with us, we were short cars so they pulled Jerry to work with a new guy in another ambulance who didn’t have a partner and they let my preceptee and I work alone together.  Jerry and the new guy were doing a carry down and the new guy didn’t know what he was doing and Jerry, in compensating for his partner’s mishandle, ended up with an arm injury that has kept him on light duty.

I have found myself being very grumpy to some of the new folk.  I don’t say much, and don’t like being asked if I have any hobbies or what my plans are for after work if I have already answered the first fifty attempts at conversation with monosyllables.  I feel bad sometimes that I am not always gregarious.  Jerry gives my new partners for the day a talk about what to do to get along with me.  Don’t worry if he doesn’t talk to you,” he says.  “Only worry if he says ‘What are you doing?’” That is as close to a swear as I will come to.

I clearly have forgotten what it was like to not know the streets or where I was going, or not know how to get a stretcher in and out of a room, or how unimportant it is to ask someone who is having trouble breathing when they last ate as a lead-off to your questioning.

Once many years ago someone said to me when I was riding:  “Don’t bother to tell me your name because I have seen so many people come and go, I don’t have the energy anymore, you are just today’s rider. There will be someone else here tomorrow.“  I swore I would never be that guy.

Jerry told me some people are afraid to work with me.  I did not understand this.  I tell them you are just a regular guy, he says, but you intimidate them.  Do I really?  Have I become like the old bear in the zoo who the zookeeper has to give special treatment to, and who no longer has to perform for the visitors? I hope not.

I will say, while I may not always be overly sociable to my new partner for the day, who after all signed up to work with me and is getting paid, whenever I have a paramedic student, I do always go out of my way to be hospitable and show them the way.  Even if I am beat and tired to the bone.  I will never write “Clueless Fuck” on any one's evaluation.

All of this is an extended way of saying reading Grange’s book helped me remember what it was like to be new at this work that become my life, and the next time a student rides with me, I won’t forget that I should be a guide and a role model, and that being a good role model to an aspiring medic student is as important a part of the work as giving the patient the proper care.  I should probably also try to extend this to all new partners, even if they are only riding with me for a day.

Check out Grange’s book and remember what it was like in the beginning.

Mirrors

 In the late 1970s and 1980s, the G------Motor Lodge out on the Turnpike was the place to take your girl for a swinging good time.  Mirrored ceilings and heart shaped Love-Tubs.    The brochure featured a hairy-chested mustachioed man in a velvet bathroom holding a bottle of champagne in one hand and a filled glass of the same in the other.  Need I say more.

Whenever I returned to Connecticut with a new friend from a different part of the country, my New England tour for her included three stops -- Fenway Park to see the Red Sox,  Cape Cod to see the Atlantic Ocean and the G--  to see the Love Tub and mirrored ceilings.  All three were big hits.

Times change, years pass, we grow old, and so did the G---.  It’s still open, and while it looks the same form the outside, the clientele has changed.  It is a welfare hotel now.  We get called there periodically for several day old dead bodies, drunks, psychs, and assaults.  The last time I went there was for a lift assist.  A man of my age who life has treated much worse than it has me.  He was morbidly obese with a foley bag dangling from him and smelled like he hadn’t bathed in days.  The room was layered in dirt, an old style 24 inch TV sputtered on a cable-less channel.  Empty liquor and beer bottles were lined up on the dresser like a dusty trophy rack.  (Alas, none were champagne.)  A home health aide was there to check on him and was unable to lift him back into bed, which is all he wanted as he said he was not hurt.

We donned our gloves, and lifted him back to the edge of the large wooden canopied bed.  Not an easy task.  While my partner checked him out just to make certain he was not hurt and to again offer him transport, I saw still there, albeit with some cracks, was a large mirror lining the ceiling of the canopy.

I wondered then what the man saw there now when he lay alone in his bed at night.  Did he see what he had become?  Or did the mirror still hold some magic?  Did he see his old mustachioed self?  And perhaps in the mirror, he was no longer alone.

Intranasal Narcan for All

 I was on Park Street last week headed into El Mercado to get some pernil (roast pork), yucca and tostones for lunch when a gentleman came up to me and showed me his overdose kit.  He said he'd gotten it at the local needle exchange program.  He said he had already used it once when one of his buddies ODed and it worked great (though his friend was initially a little pissed at him, but later came to understand when the friend smacked him and said, "But you weren't breathing, bro!".  The kit contained two 2 mg prefilled Narcan syringes and one atomizer.

 

My EMT partner Jerry just stood there shaking his head.  He didn't understand how some dude on Park Street could give Narcan to his overdosed buddy, but as an EMT Jerry couldn't give it.  In Connecticut basic EMTs can give intranasal Narcan, but only if their service is approved for BLS Narcan by their sponsor hospital.  That hasn't happened yet for our service so no Narcan for Jerry.

And I stood there shaking my head because while as a paramedic I can clearly give Narcan, we are having a severe Narcan shortage at work.  Our supply shelves are bare.  I, at that time, had only 4 mgs of Narcan in my bag, and that was only because I was able to get the second 2 mg dose by raiding another car that had a spare Narcan on the shelves.  I had none on my shelves.

I have been working the streets for 20 years and other than a few brief periods when a particularly strong heroin hit the city, causing seasoned addicts to overdose, I have rarely seen as much heroin on the streets as there is today.  Rarely a week goes by that I don't do at least one overdose.

I am all for everyone being able to give Narcan (when appropriate).  I think it is great that the street dude was able to save his friend.  I would like to see the police be able to give Narcan instead of directing traffic around the car with the blue driver passed out at the wheel at the stoplight.  I would like to  see fire be able to give it instead of having to bag the patient until we show up or perhaps to stand around while the unresponsive patient's respirations decline to near zero  (I have seen both excellent airway management by the fire department and less excellent airway management). And I would like my partner Jerry to be able to give Narcan on the days when he works with a BLS partner and instead of giving Narcan has to bag the patient all the way to the hospital because there are no medics available.

But to be able to give it, we have to have it.  Which brings me back to the guy with the overdose kit.  The reason he stopped me in the first place was he was curious how much each vial of narcan was worth.  I told him I thought it was about sixty dollars a syringe.  "Yeah?" he said, "That's what somebody else told me.  That's a lot."

I wondered why he was so curious.  Was he pleased that the state not only was willing to trust him with life-saving medicine, but with valuable life-saving medicine?  Or was he maybe looking to sell it?

I had a vision then of ambulances lined up outside the needle exchange center where another type of exchange took place.  "I'll give you forty bucks for your kit."  "Throw in your roast pork and a pack of smokes and it's a deal."

The Jug

 There is a clear plastic jug -- actually it is an empty water cooler bottle -- that several times a year gets put on the table by the check-in window in operations. A handwritten note is attached asking for donations to help a fellow employee in need. A lot of money has gone into the jug over the years. Few professions know about hard times as much as ours. And we are not immune to them ourselves.

People in EMS don’t make a ton of money. That wasn’t why they went into this work or why they have stayed. Most need overtime or a second job to get by. And when hard times hit, few have the cushion to absorb them. That’s where the jug comes in. It is never enough, but at least it is something. A brother or sister in need. We see the jug and we reach for our pockets. A child with cancer. A bad accident that has laid someone up unable to work and with a long road to recovery. A sudden death. Over the years I have watched my fellow employees put their money in that jug. Maybe a $5, sometimes a crisp $20, others three or four loose crumpled bills and a handful of change, whatever they have on them.

I expect most EMS places have their own versions of the jug. It is Helping others is who were are.

Well, the jug is back up on the table by the window this week. One of our supervisors lost a son unexpectedly. The supervisor and his wife have eight kids. This was their oldest son (26), who leaves behind twin two-year-old daughters. It’s devastating. They are trying to get all the family home from far ranging places to bury him, including one daughter who is out of the country, as well as handle the bills. The money collected in the jug won’t come close to meeting what they need, but it will help. A friend of the family has also set up a gofund account.

You can contribute by going to this link:

http://www.gofundme.com/pjjjzo

I have only known Mark a year or two, but we all like and respect him here. He came up to our division from downstate. He is a 20-year street medic. He put his time in one the road, and that won’t ever come out of him. He deals with you straight. And he likes being on the road more than being in the office. When he shows up on a scene, we know he is there to help. He is one of us.

If you can contribute $5 or $20 or a number representing a few crumpled bills and a handful of change, that would great. Or if the jug is up in your place of work for one of your people this week, do what you always do. It’s why EMS is a family.

The Mentor (or What They Remember)

 I am working with a young man who I have mentored since his first day as a volunteer at my old suburban post. I have tried to teach him the right way to do the job – to be thorough, to be considerate, to be empathetic, to be professional. We have done many calls together over the years, and he has made great strides from his first tentative days. I work with him now occasionally in the city.

I come in to work this morning and am glad to see he is my partner. They post us in a location straddling two towns. We stop at a doughnut shop for breakfast. And then we are dispatched to a cardiac arrest at a nursing home in one of the towns. My partner fires up the lights and sirens. Depending on who your partner is a cardiac arrest call can cause a little bit of anxiety. I have no anxiety this morning. I can depend on my partner. He is the EMT is in the old saying. Paramedics Save Lives, EMTs save paramedics. I am very proud of him. I flatter myself that he will carry on in my fine tradition long after I have left the streets.

We are not three minutes into our response when we get shut down as a closer unit is now available. My partner shuts off the lights, and then turns suddenly into the Dunkin’ Doughnuts just ahead.

“What you didn’t get enough to eat?” I ask.

“No,” he says. “Isn’t that what you taught me?”

“What?”

“Whenever you get canceled from a lights and sirens response, pull into the next doughnut shop you see so people will think you were using lights and sirens just to get doughnuts.”

“I said that?”

“Yeah, you said it makes you laugh so hard you nearly pee yourself every time you do it.”

“You sure that was me?”

“Yes, you said the thought that someone thought you were using lights and sirens to get doughnuts cracked you up. You would innocently say to the person if they followed you into the doughnut shop, “Oh, no sir, we were on our way to a cardiac arrest and we just got canceled. I’m just trying to grab a quick bite to eat before the next call. We would never use lights and sirens to get doughnuts.”

I have to admit it does sound vaguely familiar. I suppose I might have taught him that.

“You said you need humor in this job to keep you sane. You’ve got to have your laughs, you said.”

“Okay, well," I say. "Well done then.”

What the young remember.

The Ideal Medic

I have been a full-time paramedic for over twenty years and a part-time hospital EMS coordinator for over six years. Over the years my ideas of who the best paramedic is have changed markedly. I used to think the best paramedic was the one with the swagger, the one without fear, who never hesitated to act, who never allowed doubt to enter the equation. And while I still admire many aspects of that paramedic archetype, from both my vantage of twenty plus years on the street and the newer position of someone who can actually match up what happens on the street (or at least as described in the prehospital run form) and what happens to the same patient in the hospital, I have learned that many paramedics I thought were never wrong, can actually be wrong quite often, and that some of the paramedics who I thought were rather dull, have actually pleasantly surprised me time and again.

So here is my new ideal medic(s):

A great medic will call a STEMI Alert even if he is not certain the patient is having a STEMI. He will never hesitate to call for backup on a call (he is not afraid of being seen as weak or unsure) if he thinks it might benefit the patient. A great medic doesn't always get the tube, sometimes she doesn't even try. She'll reach for the combi-tube if she thinks it will protect the airway sooner. While he tries to gauge the moment he enters a scene whether the patient is sick or not, he doesn't lock in his impression. She is not afraid of saying she is uncertain. He gives the benefit of the doubt to the patient. She would rather medicate a drug seeker than deny someone in pain. He considers before acting. Sometimes he is afraid, but he won't let his fear keep him from doing what needs to be done. But he always recognizes that sometimes, the best course is the conservative one. She understands the meaning of the phrase, 'It depends' And if he is criticized or if a nurse or a bystander says something offensive to him, he doesn't feel the need to put them in their place. She talks to her patients as people, explains what she is doing, what she thinks might be going on, she guides them through what is happening. Sometimes he just makes small talk. At the hospital, he seeks follow-up -- even and, in particular-- when he thinks he may have been wrong about a patient. She tries to learn from each call. She does her job. He puts the patient first.

So here's to you, my ideal medics out there. You know who you are. People notice. Carry on! 

The Butler Did it

There are any number of different ways to give a verbal handover report at the ED. All sorts of mnemonics. What form you use may depend on what your hospital expects. I try to tell a story. But I don’t tell a story in the same way I would write one. A written story takes you from point A to point Z with all the twists and turns, ending with the Da Dumm! The Butler Did it.

The other day I was listening to a new paramedic tell a triage nurse a great story of a very interesting call. Lots of the above mentioned twists and turns. It started with "We were called for..." It could just as well have started with "It was a dark and stormy night..." The problem was even though it was a great story the triage nurse was getting very impatient, not to mention she was interrupted by other nurses, doctors and her phone during the course of the medic's novella.

My suggestion to the paramedic was when giving an EMS report to a triage nurse, you have to start with the last line. Begin with “The butler did it,” and then you can explain why you think so. If you are uncertain, you can say, "Either the Butler did it or Miss Scarlet did it."

Here are some great opening lines:

Hip fracture. Asthma. Seizure. Epistaxis. Hypoglycemia. ETOH. You can fill in the blanks from there.

The bottom line is the nurse needs the bottom line first. 

Gifts

 I just hit my 20 year mark with the company. For this, I received my choice of anniversary gift. You go to a link and they have various gifts you can get depending on which anniversary it is. 10 years ago, I got a set of Henkels knives. 5 years ago, I got a GPS which I gave to my now wife because she was always calling me asking for directions. She lost the GPS so it was a bit of a wasted gift. This time around I got another set of knives. While I got 13 the last time, this time I only got 7, but these are larger and a higher quality of knife. Included was a steel to sharpen the knives with and a pair of kitchen shears. The same set sells on Amazon for $299.95. If I make it to 25, I get an even fancier and higher quality set.

In my younger years I worked as a line cook for a year when I lived in Iowa. The Chef taught me the value of a good Chef's knife. If there is only one knife you are going to get, it should be the Chef's knife. You can cut, chop, slice, dice, whatever you need. It is a tool of the trade, what makes a craftsman a craftsman. I bought an 8” chef’s knife back then that has lasted me until this day, although it is showing some serious wear just like its owner. I was hoping this set would have a replacement knife. It does have a 6” chef’s knife, but it is also not the same quality as the one I bought. My ten year gift set had an 8" chef's knife, but it wasn't the highest quality either, and thus has just sat in the drawer -- no threat to my best knife. This year's knives are better quality, but still not the absolute best. Not a bad quality, but still not as good as the one I bought. I am hoping the 25th anniversary set will have the 8” Chef's Knife and it will be of the absolute best quality.

I did not bother to look at what they offer for 30 years. I thought a few years ago, I could keep up at this until I am 72 when my daughter will graduate college, but I don’t think I will make it that far. To get to 30, I will have to work till 66. All I can do is hope for good health, and a very slow physical decline.

Today is a cold icy day, and coming into work, my one goal for the day was to make it through without slipping and falling. We did a third floor carry down and then outside down a set of icy steps, and onto an icy sidewalk. My partner and I took our time. Stopping on each landing, making certain one of the firefighters was watching my back as I went down backwards, carrying the foot end, using the tracks when we could, lifting when the turns were too narrow.

The next call was a young woman with abdominal pain. I don’t hear so well anymore, but I believe she said she had pain in her lower left abdomen going down into her “boom pie.” I have never heard that expression before and of course am not certain I didn’t mishear it. She may have said something else, but that is what I heard. Regardless, I got the general impression that she may have pelvic inflammatory disease. While my hearing is getting bad (my wife tells me I need to get it checked. What? I say.). My sense of smell was still going strong as this woman smelled like she had been smoking weed. I took in a deep breath just to confirm my impression. Yup, smells like weed, I thought, and found myself looking back on my own life and times. One of the hallmarks of getting old seems to be that you are always thinking about the past. People ask what it was like to be a medic in Hartford back in the day. I say, while for one, the expression "Back in the Day" hadn’t been invented then, or if it had it certainly wasn’t in common vocabulary. I'm not certain when I first started hearing people say that, but I know it wasn't being said around here 20 years ago.

All told, I have been in EMS 26 years, but you obviously don’t get credit for the gift awards for the years you weren’t with the company.

The sun is up now and the ice is melting. I take off my winter jacket. My partner is snoring next to me in the driver’s seat. My wife says I also snore, sometimes so bad she goes and sleeps on the couch. I don’t think I snored so much as a younger man, but maybe it is because I am more tired these days. Nevertheless, it is clearly warming up as melting ice falls on the windshield from the tree we are parked under outside a Dunkin’ Doughnuts. Instead of eating a frosted glazed doughnut like I used to, I have been snacking on my stash of organic food bars, including a tasty 100% Grass Fed Beef Habanero and Cherry Epic bar with 13 grams of protein and glutten-free. Trying to stay healthy. Trying to stay in the game.

I really do want to get that 25 year Knife Set.

***

Here’s what I wrote about my ten year gift. (Yes, I have been blogging that long!)

Steak Knives and Molecules

Back then, my blog was called Paramedic Journal: A Year on the Streets

I wrote almost every day. Not so anymore. But I still consider it a gift to be here, working as a paramedic, and writing when I have both the energy and the inspiration.

Practice

 A comment and discussion on my previous post sparked me to revisit a post I wrote 9 years ago about the issue of working a body for the practice.

Practice

Here's what I wrote back then:

My preceptee needs a code. He probably needs a couple. He hasn't done one as a medic yet. He's intubated Fred the Head, but mannequins just aren’t the real McCoy. While managing a cardiac arrest is about more than just intubating, a medic needs at least one intubation to get cut loose to practice on his own.

A week ago we were called for “a fall, not breathing,” then updated that it was a dead body with no one doing CPR. When we got there, we found a four hundred plus pound woman face down on the carpet in front of her motorized lark. She was just a big blob of flesh. You couldn't even see her face. It took a moment to make out where it was. We rolled her over, and quickly assessed her. She was in the gray area between being dead and workable by protocol and being dead and not workable by protocol. In either case, she was dead and not coming back. Asystole in three leads, unknown down time. Warm, but with a touch of rigor perhaps in the jaw, a touch of lividity.

Many things go through your head in the split seconds that you have to decide to start CPR or withhold it. If you are going to start, you have to start right this very instant, but if you aren't, you obviously have all the time in the world to do nothing but call the time.

Here’s what went through my head (as my preceptee looked to me for direction):

She's dead. I have a preceptee, my preceptee needs a code, but she's dead, plus she's huge. No neck, difficult tube. It might take us awhile to get the tube, much less find her sternum to start CPR. Damn, she's big. We do need a code. But she's not coming back. Getting a tube in her would be a feat. My preceptee might have a hard time. I would have a hard time, but getting a tube in her, that'd be a feat. I'd be the man but who would I show it too other than my preceptee and my partner? Look at me, I got a tube in her. She surely isn't going anywhere. We'll work her for twenty minutes and call her. We'll probably break her sternum, and who knows what may come out of her stomach, and maybe we'll chew up her throat and break some teeth trying to get a tube into that jaw and mouth. All for what? Valiant effort. She's dead. Let her be. There's enough stiffness in the jaw to call it. Give her her peace. Her dignity. No, we should code her. No, no, she's dead.

"No, no," I said to my preceptee. "She's dead."

***

That call and a comment I received on this blog set me to thinking about the subject of practice. Practice on bodies.

Another medic told me about a medic he knew who told him when she was precepting after she brought in a code, which was declared dead at the hospital, the doctor pulled the curtain and let her practice intubating the deceased patient. Perhaps the doctor said, "He's all yours, Go nuts!" He said she got an hour practice before they came and took the body away.

This is not the first time I have heard of this happening. It may not be common, but it is not unheard of. The theory is practice on a dead person may save a live one someday. Along with that goes the belief that the dead are dead.

I was on a call where a paramedic worked a code for twenty minutes, and then presumed the still asystolic patient. Then with no bystanders in the room, he extubated the patient, and then let the partner, who was a paramedic student, intubate the dead man.

Matters are grey for some, black and white for others. While I might not cross the line in the cases above, I wouldn't feel comfortable reporting it to authorities, either.

I have been considering taking an airway class down in Baltimore where you get your own fresh cadaver to practice on for the day. There is a disclaimer, something about you may have to share a cadaver in the event of a shortfall in supply. They don't know in April, how many cadavers will be available on a certain date in November.

I suppose they get them at the city morgue -- people who have checked organ donor on their license plates.

Maybe its okay then, if after checking the patient's wallets for organ donor status, for medics to practice on them to do extra intubations after the code has been called or to work them even though they are pretty much dead. People could have a DNR that says, they can be coded, but you have to stop after twenty minutes no matter what the outcome and let them go back to the shadows, the dying light.

***

It all leaves me…uneasy.

***

Eight year older and thus eight years closer to the end myself, and with eight more years of these types of calls, I can say, I do not work cardiac arrests that are a shade over the line. Maybe it is because I don't need the practice any more, but I think it is more a feeling of respect for the dead than maybe I had before. My heart says just leave them be. A couple weeks ago, I had three dead bodies in one day. Three souls who had passed on and who were beyond our grasp. On one call, the first responders were working the patient -- a special needs patient who had passed in the night. It was a bit of an emotional scene, but she was dead, you could barely open her mouth because of the setting in rigor. Stop, I said, she'd dead. After running my asystole strip, we put her back in bed and then we all sat there with her foster mother who had nursed her from a baby when they all told her she wouldn't live three months. Here twenty some odd years later she had finally come to her end. Her foster mother told us about how she had gotten her eat when they said she wouldn't, the concoction she'd made for her with juices, tinctures and nectars and all the love in heart. She wondered now what her house would sound like without her daughter's laughter that used to fill it up. We all told her of the respect we had for her and of our sorrow for her loss, and we stayed and helped her contact the funeral home and her pastor.

We could have tried to pry her mouth open enough to get a tube in, beat on her chest, and drilled her tibia -- all just to work her for our sake and for the family's sake. But I was more comfortable with the way it went down. We all were. It was the right way.

***

I guess some of it depends on how you feel about a body. When the person dies, is their soul released? And does all that made them who they were fly off? And is the remaining body then just inanimate? Like a stone. Or is it a memorial to the life they lived? To the lives we all lead?

If they are dead, I say, and they are not coming back, leave them in peace.

Vision

 

When I was 12 years old, I was a good baseball player. I loved the game and had great hand-eye coordination. I was a contact hitter and a slick fielder. In the regional Little League tournament, I made a diving backhanded catch of a line drive at 3rd base that people talked about for years. But while I was good at baseball, there were many good baseball players of my age, and quite a few very good and even great ones. I was also good at tennis, and there weren’t many other good tennis players of my age so, at my father’s suggestion, I stopped playing baseball to concentrate on becoming great at tennis. I played in tournaments all over New England and went to tennis camps as far away as Nevada. The problem was while I became quite good at tennis, I didn’t like tennis as much as baseball, and burned out at it. When I was 18 I took a year off before going to college to work in Washington DC . I got mono the following Spring, and after recovering at home, decided I would stay at home and play in a new baseball league that was just starting up. I was one of the first draft picks based on reputation. But when I showed up for the first practice, it was another thing altogether. I could not hit. I could barely make contact. I was even afraid to catch the ball. Right before the ball got to me I’d find myself flinching. I was on the bench for the first game. Not into humiliation, (An old man watching the game, said to me, “Say, didn’t you used to be Peter Canning?”) I quit after just a few games and spent the rest of the summer driving around America with my best friend from high school, logging 14,000 miles onto our old Olds Cutlass, which we lived out, often sleeping in with our feet sticking out the windows.

A year or so later, I had my eyes tested and lo and behold, I needed glasses. I put my new glasses on and suddenly I could see the leaves on the trees. So that was the reason I couldn't hit! If only I had known! But it was just as well, I wouldn’t have traded the summer adventure for anything.

Fast forward a couple centuries to one night where I am now an aging paramedic, having trouble reading the fine print on map. I know most of the streets, but the call destination is in a suburban town and in the map book, the streets are listed in a very small font to fit it all on one page. I can’t read it for the life of me. Fortunately, I compensate by using “MAPS” on my iphone.

Anyway, a couple months ago, I did a code and when I went to tube, the chords were very blurry. I couldn’t really make out what I was looking at. I pulled the larengyscope out and dropped a Combitube instead. Got great ETCo2, and even got the patient back, although it was more like epi got the patient back, and then in the ED the family made the patient comfort measures.

A year ago I had my eyes checked and got two prescriptions -- one for long vision and one for up close. I had actually lost my only pair of glasses over 10 years ago on a code, and never bothered to replace them. I finally went back to the vision place and with my daughter’s help picked out two pairs of stylish glasses -- one for driving and one for reading. I decided I would carry both, curious to put my reading glasses on for my next intubation attempt.

Last week, I got the chance. The patient was already in the back of a BLS ambulance. I jumped in the side door, attached my monitor -- asystole, popped in an EJ, pushed an epi, then got out my intubation roll. I assembled my gear. ET tube with ETCO2 filter attached, stylet placed and shaped, and 10 cc syringe attached. I took out a commercial tube holder and my trusty Mac 3 blade snapped into place. Last, I reached into my side pants legs pocket and took out my eye glasses case and opened it up, taking out my new reading glasses, and putting them on.

I tell you. Not only could I see the chords, it was like looking at the chords under an electron microscope. What clarity! What definition! Amazing! Needless to say, I got the tube on the first pass.

Moral of the story: Get your eyes checks regularly. If you need a prescription and you need to see well to do your job properly, get it filled.