Pediatric Cardiac Arrest

 

I just watched a fantastic and very thoughtful lecture of pediatric cardiac arrest given by Dr. Peter Antevy as part of the Refresh2021 free national registry program, which I encourage everyone in EMS to sign up for.

Register for Refresh 2021

 When I precepted as a paramedic in 1995, my preceptor told me when we had a baby code that we should “OJ Simpson” it.  This was in reference to the old OJ Simpson Hertz commercials where the former football star and future killer ran through the airport, leaping benches and cutting through the crowds like he was on a 100 yard touchdown run.  The point was, waste no time, get moving-- that way we don’t have to deal with everyone freaking out at the scene, and we can get the baby to the hospital and do what we can on the way. 

My first baby code I intercepted with a basic ambulance crew.  No sooner did I climb into the back of the ambulance, then the driver hit the gas and I went flying.  When I recovered myself, I saw his partner and a police officer doing CPR on an infant.  I managed to get the pedi pads on the infant and stop CPR long enough to see the baby was flatline on the monitor.  By the time I got my intubation kit out we were already at the hospital.   I had done nothing to help.  I hadn’t even had time to get much of the story other than the baby  was found not breathing in his crib.  The BLS crew took off so fast, they even left the family at the scene.  They didn’t even have the kid’s name.  Later I was congratulated for not delaying the transport.  You had a one minute intercept time.  That’s awesome.  It didn’t make me feel any better.  If time was what mattered, they shouldn’t have even stopped for me.  I hadn’t done anything to save the baby and that was true.  I hadn’t.

Still I held to the OJ Simpson mantra even sharing it with new paramedics I precepted.  We get a dead baby, I told them, snatch it and make feet to the ambulance.  Intubate or try to in the back of the ambulance hurtling through traffic with lights and sirens blazing.  In the old days before EZ-IOs we had the Jamshidi bone needle which he had to twist into the baby’s legs while holding it down.  Not the easiest thing to do when you are airborne.

Now it is true in many of these cases, the patients were already dead.  Many times I have run down stairwells holding a dead baby stiff as a doll in my hands and giving mouth to mouth to its cold lips, running from the screams in the apartment.  In other cases they were still warm, and I moved my fingers up and down on the chest in between breaths as I walked carefully down to the ambulance, and then the race was on again.

It is important to understand the chaos on many of those baby code scenes.  People are screaming and out of their minds.  I remember vividly one of the first ones I did.  A mother had rolled over her baby while they slept together and suffocated her.  The baby was dead, but everyone was screaming at me.  The firefighters were screaming at me.  What the hell took me so long to get there!  Do something! Get moving!  And the crowds -- it seemed nearly everyone who lived in the housing complex was screaming at me.  “Move, W-Boy!  That baby’s dead!  Do something!  Move!  I OJed it to the ambulance.  Even after we shut the doors, they banged on the ambulance until we peeled out.

Recently I had a baby in arrest, but this time I elected to stay on scene.  It just seemed like the right thing to do.  We cleared off space on the top of a dresser and laid the baby down.  We managed the airway, and epi through an IO.  We worked the child for at least twenty minutes with no luck --still asystole-- before we finally decided to make our way to the hospital.  I felt terrible leaving like we had given up, even though I knew the baby was dead.

I have had very poor luck with pediatric resuscitations.  I don’t know anyone who has.  There are many reasons for this.  Many of the children were already gone, others had died from congenital defects.  I guess also, I was always taught that pedis once they arrest, they are nearly impossible to bring back.

I have been complimented on my calm at many pedi-codes but that calm came largely from knowing the baby had either died or had little hope of recovery.  We were just going through the motions.  I never thought for a moment the babies would come back.  I had never seen it happen.

Dr. Antevy, in his lecture, advocates that we treat pedis in arrest, not like pedis, but like little adults. (The dogma for years has been pedis are not little adults and need to be treated differently).  Not in this case, Antevy says. They deserve the same stay and play attention.  Work them on sight until you get ROSC or until you have exhausted every hope.  Explain to the family why you are not running off to the hospital, that you are making your stand there.  Use pit crew CPR.  Know your pediatric dosing in advance, so you don’t have to lay them on a Braslow tape and do your calculations.  Get epi in early.  

A number of years ago when we adopted the stay and play for adult resuscitation, I started having people come back who I had never expected to make it.  Good CPR, defibrillation.  Early epi at least if you want pulses back.  Kids deserve the same chances, not just in the ED, but in the field.  Stay on scene.  Defend your ground.  Take a stand.

Antevy also advocates improving local dispatching to help them be quicker in giving CPR instructions to 911 callers.  His lecture concludes with an excellent section on bereavement, making certain you talk to the family at the hospital, explain what you did and why, let them know you care.   Administrators should follow up with the family, even in unsuccessful cases, offering to attend the funeral and send memory cards on birthdays.  

I am great at explanations on adult scenes.  I let the family watch the codes.  I narrate what we are doing and explain everything.  If we get pulses back, I let them kiss the patient before we go.  And in those cases where we finally decide to stop if we are unsuccessful, I let the family members hold the patient’s hand and say their goodbyes before we stop. Afterwards I stay on scene awhile and make certain they are okay.  But with pedi codes, I leave the grief counseling to the hospital and make myself a ghost.  Never again. 

Thank you, Dr. Antevy, for the fine lecture.  I can’t say I look forward to practicing the lessons, but if my number is called to respond, I will do my best to demonstrate what I have learned.  I only wish I had learned those lessons thirty years and too many resuscitations ago.

COVID Transfers

 

If you work in commercial EMS, you are also likely to do what we call transfers.  These are non-emergency calls where you take a patient to a destination that is not the emergency department.  This can be a trip to dialysis, from a hospital or nursing home to a home or from a home to a direct admit at a hospital or a trip to a doctor’s office.  If the patient is going to a doctor’s office or to a hospital for a procedure that doesn’t take too long, you often wait with the patient and then return them to where they started.  These trips are called wait and returns.  Dispatch tries to give them to the basic ambulance crews  in order to leave the paramedic ambulances available to take 911 calls, but on days when the paramedic rooster is full, medics can be asked to help out with the transfer load.

In the age of COVID, there are now COVID transfers.  I have been involved in a few of them.  Back shortly after the epidemic began in the spring the state started opening skilled nursing facilities (SNFs) solely for recovering COVID patients.  Several times I have transferred a patient from Hartford to a SNF over a hour’s drive away.  I drive while my BLS partner sits in the back with the coughing COVID patients, unless of course the patient needs ALS monitoring, in which case I am in the back.  This happened once.  You can’t maintain six feet of distance from a patient in the back of an ambulance.  You just gown up, turn on the exhaust vents and hope for the best.  Our PPE (personal protective equipment) are not self-contained biohazard suits, and even though the patient is wearing a surgical mask, they often have dementia or sometimes a simple unwillingness to keep their mask on properly, and even if they do have their mask on, COVID can still get around it.  The crew member is basically trapped in a COVID soup for the length of the trip.  Sixty minutes is too long.

I don’t think the system has had time to properly process what a COVID transfer means.  This one didn’t happen to me, but I have heard of it happening to two other crews.  In the hospital patients are often kept on COVID wards where each room is biocontained.  That means, the medical staff dons PPE in a foyer, enters the room, treats the patient and then doffs their  PPE in the foyer before returning to the hallway and medical worker’s stations.  You can’t wear PPE in the hallway.  Now enter the EMS crew.  EMS dons their PPE in the foyer, enters the room, puts the patient on their stretcher, and then exits.  They are asked to remove their PPE.  No.  But you can’t be in the hallway with PPE on.  Well, how the hell do you get the patient down to the ambulance?  You can’t wear PPE in the hallway.  You will contaminate the rest of the building.  Do you have a chute we can put the patient in that will automatically deliver the patient into the back of our ambulance?  Because otherwise we need to walk through the hallways to get back to the ED and our ambulance.  Put a clean sheet on the patient.  And what about us?  You can’t wear PPE in the hallway of this ward.  We are not taking our PPE off.  See you later.  (I heard that a compromise was later reached on one floor where EMS doffs the PPE they wore in the room, then immediately puts on a new set of PPE and are permitted to leave enter the hallway with the patient who is covered in a clean sheet, except of course for their face covered with a surgical mask.)

In the meantime in the ER, EMS crews donned in full PPE with their COVID patients, wait in the same triage line snaking out the door as do crews with only surgical masks on with COVID negative (based on screening questions), and once assigned a space, the PPE covered EMS crews and their patients maneuver their stretchers down ED hallways with regular overflow patients sitting in chairs or lying on beds.  This is opposed to the early days of the epidemic where all possible COVID patients entered the ED through a separate decontamination room.

Then there are the COVID wait and returns—calls in which you can be with the same patient for several hours.  I did one of these recently.  The patient needed to go to the hospital for a procedure.  Taking a patient to a hospital for a procedure can involve many stops as you are directed from one floor to the next.  No, this is the wrong floor, you need to be in radiology, that’s down a floor, take a left when you get off the elevator, go down a hallway, turn right, go through the double door, and then it’s your next left. Those types of directions are common.

So imagine this.  An ambulance crew fully gowned in decontamination gear with a coughing COVID positive patient on oxygen on their stretcher wandering the halls of a hospital.  I wish I had a camera to record the terror on people’s faces.  We went to admissions where we had been told they would send someone down with a bed to take our patient, instead we were sent to another floor.  After several stops we finally ended up where we were supposed to be, which was a hospital office waiting room.  I waited with the patient in the hallway, while my partner checked the patient in.  Recognizing that the COVID patient was a potential hazard to the others in the hallway as well as the waiting room per their policy, we were escorted into a small room off the waiting room.  The appointment was not for another hour and a half so they wished us to wait there until with the patient until they were ready.  This is another common issue with wait and returns.  The nursing homes often schedule the pickups early compensating for the times the ambulance is late due to 911 call volumes, so we often end up arriving at the destination only to find we are an hour or two hours earl for their true appointment.  Our dispatchers don’t like us to wait more than twenty minutes.  Often we can unload the patient onto a hospital bed to wait for their appointment and send another crew to pick them up when ready, but the hospitals and the doctor’s offices  can’t always accommodate this.  They try to keep us there by saying they are almost ready and it shouldn’t be long, but the time keeps ticking away and we are stuck there.  On this call, the staff came back moments later and said not only did they not have a bed we could move the patient too, but they asked us to close the door to the room where we had the patient as keeping it open was in violation of their policy.  The room was not a patient room, but a closet sized consult room with barely enough room to fit the stretcher.  I told them if I closed the door if would be hazardous for my partner and I.  We discussed it and I asked them to call a member of their safety team.  The team member who was very pleasant explained the reasons the door had to be kept shut.  I understand those, I said, but do you believe it is safe for my partner and me to be in this confined space with this patient for an hour?  What about the ambulance? the safety person said.  Aren’t you confined there?  Well, we have exhaust vents and we are usually not in with the patient for an hour.  Point taken.  They moved us to another room which was larger.  By this time we were close to running out of oxygen, and then the room that they had moved us to, the staff who normally used the room were uncomfortable with us being in there with a COVID patient, so we were moved again to the hallway (waiting a further solution) where we stood and watched other visitors scurry past us.  In the end the hospital cancelled the procedure and we returned the patient to his facility with instructions to reschedule and to have the nursing facility send someone with the patient next time who could wait with him in whatever space they would try to figure out that they could safely border a COVID patient while waiting for his procedure.

When we returned to the SNF where our journey began, the guard at the door took all our temperatures per the facility policy before allowing us entry.  Fortunately none of us had fevers so we were allowed to go down a hallway, up an elevator, down two more hallways and through a set of double doors where we at last came to the patient's hallway, found his room, and returned the patient to his bed.

How likely were we to get COVID from this patient?  Well, I was just vaccinated, but only with the first shot and my partner had already been out for a few weeks with COVID pneumonia several months back, but they say it is possible to be reinfected.  We kept our PPE on the full time.  (I doffed mine each time I drove, and then had to put on a new set to reengage the patient).  I was glad the hospital safety officer was understanding and recognized the danger to us and responded to it.  No way was I going to close that door.  Scene safety at all times.

I am glad Connecticut has recognized EMS as a priority 1A group at risk for COVID exposure. 

COVID has been hard on everyone, and people are doing their best, adapting to the challenges.

 

Christmas - Winter's Fuel

 

These are two old Christmas posts I wrote years ago, reposted now.

***

Fifteen on the Scale

It's Christmas eve. We get called to one of the local nursing homes for rib pain. The room number sounds familiar. As we wheel our stretcher through the lobby, "Good King Wencelous" plays through the speakers.

Gently shone the moon that night, thou the frost was cruel.
When a poor man came in sight, gathering winter's fuel.

In the East Wing, the nurse hands me the paperwork. "Mr. Ryder says he needs more Percocets. He's requesting transport."

Mr. Ryder is a tattooed biker, an emaciated COPDer with a long white beard. Almost sixty, he can't weigh more than a hundred pounds. He sits in his wheel chair, in his Rebels motorcycle jacket, wearing an oxygen cannula.

"I'm in real bad pain," he tells me in his whisper of a voice. "Fifteen on the scale." He nods as if to say it is the truth.

"Well, we'll check you out when we get you out in the ambulance," I say.

It seems he fell a couple weeks ago and cracked a rib.

I have taken him to the hospital at least ten times over the years. The night medics have taken him more. Nearly every time it is self-dispatched. He agitates the nurses until they call his doctor who after several calls relents and tells the nurses to go ahead and call an ambulance just to get him to stop pestering them. He gets pneumonia a lot and complains of the chest pain. It is always "real bad," he says. He goes to the hospital and gets sent back a couple hours later. He is rarely admitted, and in those cases it is usually for a COPD exacerbation.

While I don't like to categorize patients in this way, he does fall into the "pain in the ass" category. But a patient is a patient, and none of my paychecks has ever bounced, so I'm not really complaining. They'll be turkey with all its fixings on my feast table tomorrow. And besides, there is always something to be said for the familiar.

I see Jimmy nearly everytime we go into the nursing home. He is usually sitting out in his wheelchair in the main TV area. I say "Hey Jimmy! How'ya doing?" as I push the stretcher past going for someone else on the wing.

He lights up and says, "Not too bad, hanging in there."

That's the jist of our relationship.

Today in the ambulance, I have an EMT student do vitals as we start toward the hospital.

She chit chats with him.

"You've got all your Christmas shopping done?"

"Yeah, I just bought stuff for myself," he says. He tells her Dial-a-Ride took him to the Mall. His favorite store is Spensers where he gets a lot of novelty gag items.

"I buy presents for myself sometimes," she says. "How about you?" she asks me.

"I'm pretty much done."

"Well, unless you're going to the drug store when you get off, you're out of luck. Time's run out."

"I'm in good shape," I say. I think to myself if I get out in time, I'll probably make a quick stop at the liquor store where I'll buy myself some Christmas beer -- a case of Red Stripe. I always ask for a case of a specialty beer for Christmas. Last year it was Presidente from the Domminican. This year I want Red Stripe from Jamaica. My girlfriend was going to buy it for me, but she is still hung up at the hospital. I told her not to worry about it. I'd get it myself. There is a liquor store that doesn't close till eight on my way home. I'll drink the beer slowly over the course of the year, taking one out every now and then and drinking it slow. I'll buy other beer during the year, but this case -- my Christmas beer -- I'll stretch out.

The patient looks up at the EMT student and says, "This guy over here, me and him go back a long way."

"He's taken care of you before?" she says.

"Yeah." He nods at me and then says, "He's probably one of my best friends in the world."

I melt a little inside at his words. It also makes me terribly sad. I think of all his biker buddies -- Hoss and Snake and Big Steve -- and wonder if they are enjoying their winter's fuel at the Iron Hog without him tonight or if maybe they are all either in the cold ground or solitary in nursing homes themselves.

Jimmy looks up at me now, his eyes locking on mine. "I'm in real bad pain," he whispers urgently. "Fifteen on the scale."

-Christmas 2006-

***
Christmas

Last night I watched Scrooged, the Bill Murray version of "A Christmas Carrol," where Murray is the bah humbug head of a big TV network. Bill Murray is a very funny actor, and Scrooged always chokes me up at the end, when the little mute kid speaks for the first time and says "God Bless us Everyone." Then they all start singing "Put a Little Love in Your Heart" with Murray singing like his old Saturday Night Live lounge singer character.

Sometimes I feel like I am a Scrooge. I am always working on Christmas. My brother invited me to go to New Jersey and have Christmas with him and his family this year. Of course I couldn't go -- I had to work.

What kind of a bah humbug am I? Working on Christmas all the time. But working in EMS on Christmas is different than working a regular job on Christmas. I have always been proud that when my name is written in the book, I can be counted on to be there. It is not like we can just close up shop on Christmas. Christmas falls on my day to work, I work it. I like being reliable.

I read an interesting article -- "Will Words Fail Her?" -- about a young Chinese fiction writer, Yiyun Li, who wrote a great collection of short stories called A Thousand Years of Good Prayers. One of her teachers, James Alan McPherson, who was also a teacher of mine many years ago, was quoted in the article as saying in American fiction, we have lost the community voice. It is all about the self, but that community voice still exists in writers in Japan and China, writers like Li.

In this job over time you can lose yourself. You become a part of the community, the blanket of watchfulless over the cities and towns that you cover, and that becomes more important than who you are as an individual. People say it is bad to lose yourself in your job, and I don't disagree -- you need balance in your own life. But at the same time, I don't think it is neccessarily all bad.

In Scrooged, Murray's ex-boss, who comes back as the dead Jacob Marley, says his work, his life should have been that of mankind, not TV ratings. While I am not knocking the fact that today I am getting paid double time and a half holiday pay, I think you can make the arguement that our work in EMS is not the work of material advancement, but the work of mankind. There is a certain privledge in looking out over the community, in being its protector, particularly on Christmas Day.

There are some sacrifices in this job, and I am not advocating putting it before everything else in your life, but if you find meaning, even redemption in your work, that is no small thing.

-Christmas 2005

***

This year 2009, Christmas falls on Friday so I am off work. I will spend it gratefully with my family.

Connecticut Opioid Forum

 

On December 18, 2020, I participated in a panel hosted by United States Senator Richard Blumenthal and Connecticut Attorney General William Tong to discuss the opioid epidemic. 

I want to thank both of these fine public leaders for their consistent and longstanding involvement in the fight against opioid deaths.  We were joined by several other leaders in the state, including my friends, Mark Jenkins of the Greater Hartford Harm reduction Coalition and Bobby Lawler, of the New England HIDTA (High Intensity Drug Trafficking Area).  I also want to thank Brandon Bartell, the operations manager at American Medical Response Hartford, who let me adjust my paramedic shift at the last moment so I could participate.

It was a great discussion that can be viewed in its entirety at this link.  

Forum with Attorney General Tong and U.S. Sen. Blumenthal on the Opioid Crisis During the COVID-19 Pandemic

 

I start speaking at the 42 minute mark.  I was told I could speak for five minutes, and I managed to keep within my time.

The Hartford Courant wrote a nice article summarizing the meeting.

Connecticut projected to exceed last year’s number of fatal overdoses, as COVID-19 results in isolation and fentanyl drives deaths; over 1,300 fatalities expected in 2020

When thinking about what I was going to say, I focused on the question of why people die from opioid overdoses.  Most people involved know the larger causes of the opioid epidemic: over prescription, corporate greed, poor public policy, etc., but I wanted to focus on the causes, from my experiences as a paramedic, that are actually leading to people's deaths.

The two main reasons people overdose are low tolerance and excess potency.

Low tolerance occurs when someone who has just gotten out of prison or rehab, or someone who relapses from a period of abstinence, uses the same amount they used to use, and consequently they overdose because they have lost their former tolerance.  

Excess potency comes from buying a product that is stronger than you anticipated.  The best example of this would be (a few years back) buying a bag of heroin that is unexpectedly laced with fentanyl (hardly unexpected these days) or a bag of fentanyl that has a larger than normal percent of active ingredient compared to cut.  This can happen easily with fentanyl because the active amount of fentanyl is small and widely variable (you could easily have 0-10% or more in different $4 bags from the same batch).  Because fentanyl tends to clump, you don't get dilution like when you put food coloring in water and stir, instead you get the chocolate chip cookie effect, and your bag may have a deadly fentanyl chip of death in it.  

The major way to address tolerance is education.  Warn people to be careful if they haven’t used for awhile.  Just do a little at a time.

Excess potency can be addressed through quality control. The problem with street drugs is there is no quality control.  In addition to not knowing the strength, the drugs often contain other potent chemicals.  Xylazine is a horse tranquilizer increasingly implicated in opioid deaths in Connecticut.  We’ve seen PCP and other drugs added to the mix.  No one really knows what they are putting in their veins.  It’s Russian Roulette.  How about we try some medicinal fentanyl or heroin pilot projects where a trial group of users are allowed to receive medical quality heroin or fentanyl in a clinical setting under a physician's care?  They do this in England and other countries.  It may be considered outrageous by many, but it would reduce the problem of people dying from “hot spots” in batches mixed by street dealers.

New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond

Another method would be helping harm reduction clinics purchase lab equipment so users can test what's in the latest bags on the street.  This could less drugs for sale adulterated with other harmful additives.

Drug checking as a potential strategic overdose response in the fentanyl era

While addressing low tolerance and excess potency will help limit deaths, the number one reason people die is because they use alone.  If they use alone and their tolerance is down or they have a batch with excess potency, and they overdose, if no one discovers them in time, no amount of naloxone will bring them back.

Why do people use alone?  They use out of sight because stigma and law drive them into the shadows.  I have found people dead behind dumpsters, in porta-potties, down wooded ravines, in cars in secluded back parking lots, and behind locked bathroom and bedroom doors, as well as in solitary hotel rooms. Had any one of these people used with someone else or used in a public location where they could have been spotted, they would have survived to live among their loved ones another day.

Think of all the parents who find their children cold and dead behind their locked bedroom doors.  What if it was normalized for users to dose in the kitchen (as part of their care plan or a simple stay alive pact) under their parent’s eyes with an injector of narcan on the table?  Think of the tragedies avoided.

People hide their drug use because addiction is thought of as a character flaw, not a disease.  People hide because they don’t want others to see their struggle.  They hide because they have to break the laws of our country to get what they need to fight off the sickness of withdrawal.  We recognize them as victims of a larger societal, medical and governmental failure to keep its citizens safe, yet we treat those with addiction as outcasts.

How do we stop our loved ones, our neighbors, and our nation’s citizens from using alone?  End the stigma with education campaigns.  Decriminalize drug use and possession of drug paraphernalia.  Reverse the justice department’s position on the federal crack house statutes and their opposition to overdose prevention sites. Fund harm reduction including money to establish these same overdose prevention sites where they can dose themselves under the eyes of trained professionals who can not only administer naloxone, but who are there to talk with them and perhaps help guide them to treatment if they are ready.

Hear the drums beat.  Twelve hundred (1200) dead in Connecticut in 2019 with 1300 or more expected in 2021.  It’s time to do what’s necessary to save lives.  If we don’t want people to die we have to find ways to help them use under supervision.  Let’s end the stigma, and bring our people in from the cold.  Let’s welcome them back to our communities.  Let's welcome them home.

***

How Biden’s win could help S.F. address skyrocketing drug overdoses and other issues

Safe Injection Sites

Judge Rules for Safe Injection Site

 

Vaccinated!

The American Hospital Association, the American Medical Association, and the American Nurses Association issued a joint release today urging health care professionals to “to get the COVID-19 vaccine and share your experience with others.”

They wrote:

“While the arrival of vaccines is good news in the fight to defeat COVID-19, it does not signal an immediate end to our nation’s suffering. Just as we have been pushing for adoption of the precautions we all know work – masking, hand hygiene and physical distancing – we must also push for high rates of vaccination within the U.S. population if we hope to overcome this virus.  This will require trust in the COVID vaccination process, from the development, distribution and administration of a safe and effective vaccine as well as a willing public to get vaccinated….As frontline caregivers, our essential role in protecting the health and wellbeing of our communities goes beyond the care we provide. As a valued and trusted voice, our example is perhaps the strongest health resource we have.”

Here is my story.

I was extremely fortunate to be among the first group of providers at our hospital to get vaccinated on Wednesday.  (The top dogs got the vaccine on Tuesday!}  I had no qualms about getting it.  I read about it, talked to experts and was sold.  A few key points:

1. You can’t get COVID from the shot. It contains no dead virus or attenuated (weakened virus.)  Corona virus consists of 25 proteins; the vaccine tells the body to make one protein.
2. The mRNA cannot mess with your DNA. It enters the cell, but not the nucleus.  MRNA viruses have been given safely to cancer patients for years without major issues.
3. While vaccines typically take much longer to approve, thanks to advances in technology, including the mapping of the human genome, great strides were possible. Red tape was removed, funding was plentiful, the best minds worked on it, and most importantly, no shortcuts were taken in the final clinical portion of the trial.  Over 70,000 doses of the vaccines were given to people before approval and independent safety boards found no major concerns.
4. The vaccine is 95% efficacious.
5. My man Dr. Fauci says it’s good enough for him, so it’s good enough for me.

For those looking for more facts, here’s an excellent link from Rebel-EM on the Pfizer Vaccine, which is the one I received:

COVID-19 Update: The COVID-19 Pfizer Vaccine

I received the shot at noon on Wednesdays and as I write now over thirty hours later, I have had no fever, no aches and no fatigue.  I didn’t feel the needle go in and I did not bleed.  Once in the night when I lay on my left shoulder, I could feel I had a shot there.  Once, I had a five second shiver, but that was  due to an unpleasant thought.  I was going to take it easy today, but we had a Nor’easter last night that dumped more than a foot of snow on us, and with the wind drifts, almost buried my car in the driveway.  For my 25^th work anniversary gift (we get to pick it from a catalog), I chose my first ever snow blower, which I assembled last night.  Unfortunately, The storm was too much for it.  It wasn’t very powerful, and crapped out before my driveway was a third done.  I grabbed the manual shovel and like John Henry, I showed the machine who was the man.

 

I did have some help from my youngest daughter.

Still feeling good, I’m ready to hit the streets tomorrow.  COVID is still out there, and I don’t think the vaccine kicks in fully for a week or so (I will have to get a booster in 21 days) but I will be armed with my mask and PPE and be ready to do my job.

I hope everyone gets a chance to get the vaccine soon and that they will act on it.  Protect yourself.  Protect your family and protect your community.  That’s what we do in EMS.  It’s our job.

Peace to all and a middle finger to COVID.

Also, many grateful props to the scientists who developed the vaccine and all who helped make it a reality.  Thank you.

Refresh2021-Free EMT/Paramedic Refresher

 How would you like to have a FREE on-line NREMT-Paramedic and EMT refresher (good for 30 hours), available to you ON DEMAND?  CAPCE Approved.

Thanks to Tom Bouthillet (of EMS 12-Lead fame) and his assembled crew of top educators in the country, it is becoming a reality starting on December 15.

The course is presented in honor of EMS professionals everywhere.

 

Sign up here: http://link.prodigyems.com/refresh2021 

I signed up today.

COVID and Harm Reduction

 Just Say No didn’t work for the War on Drugs and it doesn’t seem to be working for COVID messaging.  Maybe it is time for a harm reduction approach.  This according to a thought-provoking article in the LA Times today.

Many aren’t buying public officials’ ‘stay-at-home’ message. Experts say there’s a better way

“Harm reduction aims to mitigate the risks of dangerous behaviors instead of trying to get people to cease altogether.”

Harm reduction is about straight talk and giving people the tools to make good decisions.

There is a growing clash even in a largely obedient state like Connecticut between wanting to “do the right thing” and “live our lives.”  We were all pretty good during the first wave, but the prospect of bunkering in again for our second wave (this one in the winter) is bleak.

A group of Doctors recently met with Governor Lamont calling on him to shut down gyms and indoor dinning.  While recognizing their concerns, he has held off for the most part on draconian shutdowns.  Even the Hartford Courant has questioned why he is slow to act.

Dozens of Connecticut doctors ask Gov. Lamont to close gyms and indoor dining as COVID-19 hospitalizations continue to spike

Editorial: More Connecticut residents have died from coronavirus than in World War II, Korea and Vietnam combined. It’s time for Gov. Lamont -- once again -- to take decisive action.

There are people who happily embrace the shutdowns, others are outraged by them, and still others who are confused and distrustful.

While I support the public health needs of taking precautions, the shutdowns do seem arbitrary.  Why is my daughter’s basketball team prohibited from practicing in empty gyms while wearing masks while pros and college teams can play without masks?  Why are people told to stay home when indoor dining is still allowed and stores are open?  The state recently issued an edit that only four people could swim in our town’s 11 lane Olympic pool at the same time while allowing four people to sit in a hot tub provided they kept six feet apart.  Fortunately, this was overturned by outcry and now 11 people can swim again one to a lane.

I guess for me, I hope that we can all wear masks and keep some sort of distance from each and avoid places of high risk.  We don’t have to close down everything or close down everything that doesn’t have money and power tied to it.  If you are going to have basketball, allow it with no fans or a small number of fans only in large arenas, and have safety measures in place.  Treat a large cavernous gym differently from a small gym with no ventilation.  Teach people where the risks are and allow them to choose.  Issue edicts in only the most serious of instances. 

I can see people accepting mandatory masks if it enables you to keep other aspects of life open. 

I think Connecticut did an okay job with much of their reopening after the first wave.  You don’t have to close schools, with imagination; we can find safe ways to keep them open.

People will not follow rules that are seen as arbitrary or political.  Work with people.  Find common ground.  Speak the truth, warn of dangers, and take steps to mitigate the risks.

If we can regain people’s trust (hard given all the truth warfare/alternate reality of the last four years), we may have more success than the free for all we have now.

Honest talk, harm reduction, mitigating danger will always work better than forced abstinence and government fiat.

Self-Service

 

I had my third COVID test of this pandemic today.  It was part of the hospital survey of asymptomatic clinical employees to gauge the prevalence of COVID.  Last time I did this they went medieval on my nose and brain, shoving that swab all the way down and scrapping.  Ohh, it was unpleasant. Today, was much different.  We self-swabbed, and only went into the nares, ten swirls on each side.  Very tolerable.  You put the swab in the test tube, sealed it, put it in a bag and then stuck it in another bag being held by the testing assistant.  I got the result eight hours later.

I'm hoping to keep COVID-Free until I get the vaccine, which could be later this month.  I hope so.

 

Stress in EMS

 Based on my twenty-five years as a full-time street paramedic, here are the five most stressful situations in EMS (for me, at least).

5. Pedi Codes. There are two kinds of pedi (pediatric) codes. Those were the patient is dead and is not coming back and those where you have a chance. The second are obviously more stressful than the first, but even the obviously dead kid is a highly stressful situation. The family is largely hysterical. You new partner may be freezing because she has never seen a dead baby before, and you have to manage it all. I usually always pick up the baby and do CPR all the way out to the ambulance. I have had quite a number of calls where the pedi was already cold and as stiff as mannequin baby. While we presume many of our cardiac arrests dead on scene and do not transport, it is uncommon to do so with a child. We usually show our best efforts and get everyone to the hospital where there are grief counselors and more staff to handle the collateral issues. If the baby is workable, that is hard too, because despite all the PALS classes, it is not as usual for us as when we do adult arrests. The tendency is also to just get the baby out to the ambulance, but I still believe in working them right there – or at least until you can get them stabilized. I can’t do as good CPR walking with the baby as I can when I lay them on a table or counter. The sad fact is most of the time a baby is in arrest it is for a reason that you cannot reverse. I have done too many of these calls and they are always sad, although with time I have learned how to disassociate myself from the chaos both of the scene and of my emotions. These are the calls that remind you of what you asked to do as an EMT or paramedic.

4. COVID patients. This is a cumulative stress of having to gown up and then trying to take care of a sick person who is vomiting or gasping for air with PPE that doesn’t fit. It’s hard to see through a fogged up face shield, hear through masks, maneuver with gowns, deal with the roaring sound of the exhaust fan, and all the while worrying that the germ is going to somehow slip through your defenses and find purchase in your lungs, and every time you get a sniffle or an ache or irregular bowels, you worry its COVID and then in two weeks you’re going to be in an ICU, and listening to a nervous doctor tell you need to be intubated. It’s the unrelenting nature of these calls that frays and exhausts the nerves. I knew I would have to do pedi codes, but I never imagined having to deal with a pandemic like this one.  A quarter million dead and rising.

3. Legitimate obstructed airway calls. We get called for choking all the time and usually by the time we have arrived, the person is breathing fine. The object has been removed or it was a false alarm in the first place or the person says they ate some fish and feel like they have a fish bone stuck in their throat when most likely it is just a scratch there. I am talking about the turning blue, losing consciousness. If you can’t get the airway cleared with the Heimlich or with your McGill forceps, the person is going to die. You only choice is to cut the neck, and you know there will be blood, and you know it may not work, and if it doesn’t, you will be questioned why. Others will question you and you will question your fitness.  These are the calls that end medic’s careers.

2. Vent transfers and vent transfers with IV pumps. Most of the calls I do are emergency 911 with a few transfers thrown in. Every couple months, I get called for a vent run taking a patient out of an ER or ICU going to another ICU. We have a vent that I have been trained on multiple times (I got to every vent training they offer), but every time I use the vent, I feel like I have never used it before. I nervously review the manual on the way to the patient's room. The problem is the patient who may be very stable on the hospital vent has difficulty adapting to our vent. I always try to transfer them to our vent while they are still in their bed. I wait at least ten minutes before leaving with them. Despite that I have had numerous episodes where they suddenly desaturate, and I end up having to play with the vents dials (and our vent has a ton of them and lots of flashing lights and alarms –not like the simple three dial one we had when I first started). My adjustments don’t always work and I  end up having to manually ventilate the patient the patient with a bag-valve mask. Add to this meds pumps that also malfunction and beep for air in the lines or other problems (I once had an old med pump that malfunctioned and the messages it flashed were all in French), and some of these meds need to be run constantly at a steady rate or the patient will crash. Their pressure could tank; if they are sedated, they could suddenly wake up in a rage and pull their ET tube. I am sometimes all alone in the back and quite far from the destination hospital or you are in a driving rain storm or both. I don’t do enough critical care transports to be at ease.  I have finally learned to refuse transfers that I consider unsafe.  Sometimes the ERs or floors just want the patient gone and they will pressure you to take them, but I will no longer do it, and our training backs us up.  Never take a critical patient you are uncomfortable with.  When I was newer, I took everything for fear of being judged.  I took patients I had no business transferring.  I took them and prayed nothing went wrong.  No longer.  Give me another medic, another set of hands in the back or call us back when the patient is stable.  I’d rather being doing a cardiac arrest in the field than doing vent runs. Maybe that’s just me.  I can't take the stress of it.  If all I did was critical care transports, I would more comfortable.

1. And the number one stressor. .. If you are not in EMS, you may find this hard to believe, but if you are in EMS,  you likely understand. It’s waiting out the last fifteen minutes of your shift. You’re in the bone zone, and you’re just hoping, please no late call, don’t call my number, please tones don’t go off. After twelve plus hours at work, you’re already half home. You have plans, things you need to do. Dinner’s on the table, your daughter’s softball game is starting, the gym or the liquor store (your preference) are closing, you want to go for a run before the sun sets, whatever it is you do after work, you’re not going to be able to do if they give you a late call. Please no. Don't get me wrong.  I like doing calls.  I bust it all day long, but when its time to go, it's time to go.  I hate being held late and I hate late calls.  The dispatcher calls your number with urgency. F---! Is he toying with you? Is he going to say, “Never mind, head on in.” Or is he going to say, “471-Priority one. Main Street for the unconscious.” Even if dispatch does send you in, those fifteen minutes of waiting it out, the constant stress of not knowing if you’re going to be able to make your plans, get your few moments of nonEMS time to yourself before having to come back to work the next day and do it all again takes years off our lives. Years. That’s the street truth.