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.

Thoughts on Ebola

 Working at the hospital and on the ambulance, it has been heavy duty Ebola lately. Memos, flyers, posters, policies, and lots of questions. I have written power points, given talks and had many conversations on Ebola. Every day I read the CDC site for updates, which are numerous. I have even, along with two of my daughters, played an Ebola patient in a hospital drill.

Ebola hasn’t been with us long, but already I am hearing a lot of people have Ebola fatigue. While the actual number of cases in the US is likely to remain small – at least in the near term -- I don't think we have heard anywhere near the last of Ebola.

Ebola is like a serial killer assassin who we believe is coming here to do some killing. We are not certain his target, but we believe, based on his rap sheet, he will most likely come after health care workers. We have set up roadblocks at airports, the most likely place Ebola is going to enter the country. We are quarantining people who are coming in from West Africa. In some states like Connecticut, we are quarantining people even if they are symptom-free, just to make certain Ebola is not hiding out in them. And, thankfully, we are hopefully training all of our responders in the proper use of PPE, and letting them practice in case Ebola shows up in our town and we show up on his scene.

Ebola is a tricky microbe. While he has us all busy up here in the US of A battening down the hatches to keep us all safe, he is doing his really nasty work down in West Africa. We can take all the safeguards we want up here, but unless we can stop Ebola in West Africa, we are going to be dealing with Ebola for a long time. Sure we can limit his damage and contain him in each isolated case that comes to America, but there will be more and more cases here unless we kick his ass in Africa and drive him back into the bats in the jungle from which he likely came.

Think about this. With, at the time only 2,000 cases of Ebola in West Africa, Ebola sent two exports out -— one to Spain and one to Texas. (Imagine if the guy in Texas went to a bar instead of a hospital, and there he got drunk, vomited, stumbled, hit his head, died and then someone lifted his wallet before calling EMS). The cases are increasing exponentially in Africa. People are dying in the streets and in crowded apartments. There are not nearly enough isolation centers to contain all the patients. The CDC has predicted there could be 1.4 million cases by January. 1.4 million. Wow. That's some heavy duty suffering. And for those who care only about this country, how many of those cases will be exported here? Imagine even if they don't get to the US right away, what if they get to India or China, countries that may not be able to contain Ebola like we can? More cases, more exports here. More chance we are in his reach. Millions dead and Worldwide Ebola's red laser on our foreheads the next time we walk into an unknown.

Those of you who have seen the movie World War Z may recall a scene where Brad Pitt and his family are eating breakfast in their home while on the small TV Zombies are eating everyone in sight. Think Ebola. I say load up the transport planes with building materials, IV fluids and PPE gear. Recruit doctors and nurses and paramedics and EMTs and send them in with combat pay. Here's a real chance to be a hero, to make a difference. You can go from being Meat in the Seat up here to Ebola Killer. You think you're an inner-city bad ass with a bullet-proof vest and an ET tube? Imagine yourself with a blue hood and cape on the continent where we all came from. Fighting for the future of civilization. Beat Ebola down in his own hood.

Isolate those with symptoms, give them the best care and most compassion we can, and trace their contacts. Isolate, treat, and trace on and on until there are no new cases – at least until the next time Ebola spills over from the jungle to people. Just as Ebola did last December to a 2 year old village boy. One two year old boy in December. 10,000 Ebola cases today. 10,000 is no easy task, but if we don’t act now, there will be 100,000, then a million. The math won't be working in our favor.

Tired of asking patients if they have traveled to West Africa? What question will be asking a year from now? It depends on how and where we respond today.

STEMI Call

 Years ago my favorite calls were the traumas-- the shootings, stabbings, high-speed MVAs. You were on the clock and there was a task list. You had to c-spine immobilize the patient, get their vitals, put in two large bore IVs, open up the fluids wide, and do it all on the go, as well as getting name, date of birth and social security number on your race to the trauma room.

After the initial rush, they were unsatisfying because the calls were over almost before they even started, and there wasn’t a real sense that what you did for them made any real difference. Their injuries were their injuries. It is hard to fix a bullet to the head, a broken spine or a torn aorta. And eventually we learned that the fluids wide open and even the c-spine were bad for the patient.

Today, my favorite call is the STEMI. It is also a clock and task call, but there are so many more tasks. Plus your recognition abilities are tested and the outcomes are much better. Do your job well and can make a huge difference. Screw up, either missing the recognition or not calling soon enough and the patient will suffer harm.

Here’s my vision of the perfect STEMI:

I get called for an unusual complaint, toe pain or vomiting or something not quite so obvious as “Man clutching chest, says he’s having the big one!”

My sixth sense tells me to do a quick ECG. Within two minutes of arrival, I have the patient’s chest exposed, and am running my 12-lead. It is not a huge honking STEMI with tombstone T-waves. No, it is subtle. Let’s say an isolated posterior, where I spot the inverted T waves in V1-V3. No hesitating a moment, I am on my cellphone simultaneous with tossing four baby aspirin in the patient’s mouth (after of course asking is he has any allergies.) On the phone, I call CMED, and request a phone patch with medical control for the STEMI Alert to my favorite cath lab hospital. As they connect me, I orchestrate getting the patient on the stretcher, after first having him stripped naked and have applied the defib patches, and then of course recovered him with the sheet. We are already moving down the hall when the doctor picks up. “This is Ace paramedic with a STEMI Alert requesting cath lab activation, " I tell him. "I have a 55 year old male with toe pain and a diagnostic 12-lead that shows a posterior STEMI with isolated T wave inversion in V1-V3. He says his father and seven uncles all died of MIs at the same age after experiencing the same symptoms. We’re twenty minutes from your door. I’ll transmit when I get down to the ambulance, but trust me on this one…”

En route, I bang in two large bore IVs, give the patient Zofran and Fentanyl (He’s vomiting now and in 10 of 10 pain that has now moved from his toe to his chest). His ECG has now popped an inferior with elevation in II, III, and aVF. I withhold the nitro to not risk knocking his pressure down. I get all his demographics while explaining to him what will happen at the hospital, how we will go right up to the cath lab and they will put him on the table and run a wire into his heart to clear the blockage. I stop the explanation only long enough to defibrillate him as he goes into sudden v-fib, but because I have the pads on already, I just shock him back to our conversation, missing only the slightest beat.

At the hospital, I hand the demos to the registrar and she chases after us with the bracelet. The ED staff bows as they signal for us to go right up to the cath lab. We are upstairs in a flash, and on to the table, where after the patient signs the consent with the pen I have already strategically put in his hand, cap off, ready to sign. Before we even have our stretcher out of the room, the interventionist (using the radial artery approach) has the wire across the lesion and the patient sighs and says, “Wow, I feel so much better,” and the cath lab doc says, you owe your life to these wonderful public servants. Door to Balloon 9 minutes, beating your old record of 10 minutes. Hats off gentleman!”

That’s how its supposed to go.

Here’s how my last one went.

Dispatched to MD’s office for “Confirmed STEMI.”

Now, keep in mind, I have been to many doctor’s offices for ECG changes that the doctor thought was a STEMI, but clearly were not. “Interesting, doc," I say looking at the ECG he has handed me. "How long has the patient had a pacemaker?” But in this case, the doctor’s office is actually a cardiologists’s office so "Confirmed STEMI" sounds much more likely.

Mentally, I psych myself up for the call. Got to make this qood and quick.

The Fire Department first responders are already there. There are in fact so many of them, I can barely make it the room. Someone hands me a 12-lead ECG and sure enough it looks like an inferior STEMI. ST elevation in II, III, and aVF, slightly less than 1 mm, but with a distinct cove shape as well as slight reciprocal depression in I and aVL.

I look for the patient now, and after clearing the room somewhat I find a fairly athletic looking man in his 50’s sitting comfortably in his chair. I introduce myself and ask how he is doing. “Fine,” he says. "I feel great."

He does not look like a man having a STEMI. I ask him if he is having any pain, nausea, shortness of breath? Nothing. How did you come to be here today? He says he saw his own doctor earlier in the day, and the doctor was concerned with his ECG so he set up the appointment this afternoon with the cardiologist. I ask why he saw his own doctor this morning. He says he wasn’t feeling well yesterday. He says he felt like he had the flu.

I have him strip down and get him in a gown, then attach him to my monitor and start taking him down to the ambulance. I did not get a chance to speak to the doctor directly, but the staff tells us to take him to the cath lab at their affiliated hospital. They will be expecting him.

In the ambulance, I do my own 12-lead so I can transmit it to the hospital. Not certain that I have to, since the patient is apparently already scheduled to go there, but it is protocol, and you never know. I do my 12-lead and it looks like this:

I look in the lower left at my inferior leads and I only see elevation in one lead, and the corresponding lateral depression is gone. I re-check my placement. It is pristine. I ask the man again about how he feels and he says he is fine. No symptoms. I ask about family history. None. I start to wonder if maybe the 12-lead placement in the doctor’s office was screwed up. I transmit the 12-lead calling in a STEMI alert, telling them we are en route to the cath lab. I mention that the patient is asymptomatic and my 12-lead is no longer showing the clear STEMI the doctor’s office ECG was. They tell me they are familiar with the patient and I should continue to the cath lab.

Meanwhile, I am trying to get an IV, and having difficulty. The first blows. On the second, the catheter bends on the patient's tough skin. On my third shot I have dropped from an 18 to a 20 to a 22 which is all I can fit in the one vein I can find in the wrist. At least this one is good.

I ask the patient again how he feels and he assures me he has never felt better. I open my mouth then and say, well, maybe his arteries will come out clean and this all just a better safe than sorry deal. I feel great, he said again, putting conviction into it.

When we arrive at the ED, their first question is did we patch? Most certainly. I have the name and social security and DOB all set for the registrar, but they are training a new registrar and tell us to wait. When I tell them we are supposed to be going right up the cath lab, I am able to leave my piece of paper with them so they can enter it.

Up in the cath lab, the team is waiting for us. They ask if we have registered the patient and we say yes, we left the information with the registrar. They demand to know why the patient doesn’t have a bracelet on. We repeat that we registered them. More argument until someone announces the patient's name is in fact in their system now so they can begin their procedure. The doctor comes over and I hand him the ECG and tell him the patient is asymptomatic. He stares at the ECG as well, then begins the questioning. At first the patient denies the symptoms, then under grilling he confesses that it feels like someone is sitting on his chest, and that he was sweaty earlier and also felt nauseous. My partner and I just shake our heads and remain silent. It never ends. The man has a hairy chest and the leads are coming off. One of the nurses plucks at them so my partner goes ahead and takes the man off the monitor as we prepare to move him to the table. Another nurse looks at me and demands to know why I took him off the monitor before they hooked him up to theirs. Again, I just shake my head, thinking why are you yelling at us?

We get him over then sure enough, as they look for what kind of access I obtained, they see the 22 and the harassment starts anew. "A 22! That's all? A 22!" We don’t bother to stay to watch the procedure. We just pack up our stretcher. On the way down in the elevator, I say to my partner, "10 times I asked him if he felt anything but fine." "What are you going to do?" my partner says.

The call is completely unsatisfying. Last time we went up that lab we were heroes, treated like honored guests. Today we are just bumbling delivery workers. I sit in the ambulance and stare at the ECG. I still can’t figure it out. There is elevation where there should be depression and no elevation where there once was. It takes me 10 minutes of starring at it to figure it out.

The first six leads are completely scrambled.

Lead I is where Lead II should be, lead II is where aVR should be, lead aVR is where III should be, lead aVR is where III should be, aVL is where I should be, and aVF is where aVL should be.

F-me, I say. Can you believe this?

I think what would have happened is I had this guy on the street, presenting like he was, denying any problem and this was his ECG. I would never have called it a STEMI. Good thing he was already booked for the cath lab.

Back at the base, I report my monitor malfunction and have the monitor reprogrammed. I go into archives and I am able to retrieve the 12-lead now in the proper order.

In 20 years, I have never seen anything like this. I find an ECG from earlier in the day and see it too was scrambled. I find one from two weeks before with the same monitor and it was proper.

I can only think of 2 explanations. 1. There was a computer glitch or 2. Someone went in and reprogrammed it.

You get so used to seeing things a certain way, you don't notice the lead labels anymore.