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.