Dementia

We're sent for hallucinations -- a third party caller -- a man's daughter says her father is hallucinating and needs to go to the hospital. She says her mother is concerned.

**

“We’ve been married 70 years,” the wife says in a deep cigarette voice. “Last night he says there’s a man in the shower. There’s no man in the shower. He ain’t right in the head. I can’t take care of him. I ain’t well myself. I only got one valve."

The two of them, husband and wife, ninety years old each, are sitting there in matching arm chairs in the living room that needs to be vacuumed.

“Now, honey, you don’t understand, what you’re going and doing now. You don’t understand the trouble you’re causing.” He raises his voice and looks at the police officer who is the first responder. “Seventy years, seventy years, I never raised a hand to this woman. 65 years in this house, I never once said God dam under this roof. And now look at what she’s gone and done.”

His wife shakes her head. “He said there was a man in the shower. There was no man. Never anything like this happen before. He needs to get his head checked out.”

“I never laid a hand on her,” he says again to the officer.

“You’re not in trouble,” I say. “The officer is only here as a health responder. You’d have fallen and cut your head, he’d be here. You are in no trouble.”

“Never so much as said goddamed under this roof."

“Tell me about the man in the shower," I say.

“Left the bathroom a mess,” he says. “Water everywhere. She wouldn’t let me get out of bed to chase him out.”

“One valve I have,” the woman says, shaking her head sadly.

“What you’ve gone and done,” the man says.

He agrees to go to the hospital to get checked out. He is very lucid on the ride in. He knows his phone number, but not his social security number. “I only remember the important stuff,” he says. “The hell with the rest of it.”

He tells me his son died two weeks ago. “67 years old. Sugar problems. Ate too much. Couldn't breath when he tried to walk. Water in his lungs, they said. Drowned in his own fluids. February 12. Died on his birthday. I’ll remember that day thirty years from now, you ask me.”

I offer my condolences, and then try to steer the subject to something happier. I ask how many grandchildren he has.

“We don’t count,” he says. “You ask my wife, she’ll say the same, 'We don’t count.' There’s just grandchildren and great children. Can’t count them. They just are. Quite a many." He smiles, but it fades as he focuses back on what is happening.

"What's my wife going to do now? I do all the cooking and cleaning. I do the laundry. She just sits and watches TV.

“You want to know what kind of a man I am?” he says suddenly. “I bought 57 new cars. One every year. I was a salesman. I could deduct it. Put 40,000 miles on the car each year, then traded it in. You keep it two years, that’s 80,000; no dealer would want that car. Trade them in before they get run down.”

He tells me the Oldsmobile was his favorite car, but he stopped buying them when he heard they might stop making them. "People wouldn’t want to buy a car you couldn’t get parts for. It'd have no trade-in value.”

Later when we are back at the hospital after bringing another patient in, I see him in his room, and he beckons to me. He is in a hospital gown with an ID tag on his wrist. His clothes are in a plastic bag. They are getting ready to admit him for the night. “You know I was thinking," he says. “I made a tactical error back at the house. I should have sent you upstairs to check out the bathroom for yourselves. The floor is wet, the boards are soaked. Water seeps out of the ground when you step on it. You would have had your proof, if only I'd had you go up there, I wouldn't be in this predicament.”

***

I read a book recently called Jimi Hendrix Turns Eighty. It takes place in the year 2022 when the baby boomers are in the nursing homes. One of the main characters, Guy Fontaine, (who has recently moved to California to live with his daughter after the death of his wife in Oklahoma) is playing golf, and then the next thing he knows he is riding his golf cart down the freeway thinking he is cruising in his old Bell Air. When the cop pulls him over he realizes what he has done. He is back to reality. The episode leads to his getting placed in the nursing home. On his first day there on his way back from the dining room, he can’t find his room. It’s not that he is lost; it’s that no one had told him his room number. The nursing administrator accuses him of being disoriented. She asks him where he is.

Guy said, “the third ring of hell.”

“Sarcasm is a defense mechanism we do not appreciate, Mr. Fontaine. Tell us where you are and what month it is, or I shall be forced to call Dr. Beaver."

He answers specifically and exactly, and then recites the names of the books of the Bible and more. “If I recite the Gettysburg address, will you tell me my goddam room number?"

She then accuses him of being aggressive and disoriented.

“I am not aggressive, Miss Truman. I just want to go to my room and lie down.”

“Then you are dizzy.”

They argue back and forth.

“And what would your daughter think if I let you wander the grounds alone and disoriented?"

“I wandered for seventy two years without my daughter’s permission. I can wander now.”

**

As a result he is forced to visit with the nursing home doctor, who tells him his new adventure – wandering the halls disoriented – just confirms he has multi-infarct dementia. Guy argues against that, telling the doctor he’s been researching on the internet. “Absent mindedness to the point of hallucination is completely normal after a major trauma, such as losing your wife. It’s a natural defense against grief and almost always temporary.”

The doctor then says, “Let’s pretend I’m not a highly trained physician and twenty minutes on the internet has made you a medical expert. What is it you want, Mr. Fontaine?”

Guy says he just wants to go back to Oklahoma where he can take care of himself and not be an embarrassment to his daughter. The doctor says fat chance – he’s been declared legally incompetent, his daughter controls his money now and he is just in denial. “Here is the hard truth. You are in deep, deep denial if you think there’s a chance in hell of you ever going back to Oklahoma. You are in continuing care now. My care. Adjust your attitude, Mr. Fontaine. You aren’t going anywhere.”

It was a funny novel (the old hippies revolt and take over the home) but it is also very sad. I had hoped it would help me see people in nursing homes in a different light, but I admit it is hard to see them as unique people. I try, but its hard to see through the skin. I think the fact of being institutionalized strips people's uniqueness and personality away after awhile. I guess I need to try harder.

I wonder if maybe the 90 year old man’s hallucination of a man in the shower wasn’t just his body dealing with his grief over the loss of his son.

Acknowledge, but Don't Accept

A reader asked me to comment on the following article.

Public Safety Personnel Work Through Danger

Here is the most relevant passage:

A few years ago, in a discussion among several of us who do critical incident stress debriefings, we talked about the difference between acknowledging and meekly accepting danger as part of one's career. It wasn't long before we were in total agreement that the majority of us were willing to quickly acknowledge danger, but none of us would buy into the old myth that merely accepting injury or death was part of our professions and that was what we were paid to do.

One member of our group summed it up best when he said that we were paid to serve and survive, not serve and die.

As medics and EMTs we generally don’t go into burning buildings or face down badmen with guns. If we come close to gunfire, we get the f—out of the way. Now, every year or so, a medic is shot or stabbed in the line of duty, it is much rarer obviously than a policeman being shot.

The danger for us comes in three main areas.

1. Ambulance crashes
2. Pathogens and communicable diseases
3. Psychological

I have been impressed with ambulance safety efforts in recent years. The company I work for has installed black boxes in the vehicles, which have led to mandatory use of seat belts, much slower and safer driving and turning. They have also installed safety nets, which I have written about before. I also believe as each new generation of ambulances come out they will have more and more safety features. The state is also in the process of adopting a new lights and siren policy that will reduce the use of lights and sirens – particularly their use to the hospital from the scene. The area I would like to see improved is the use of lights and sirens to the scene. I think the current EMD is way too permissive in its lights and sirens use, and I feel police and fire too frequently request our arrival hot for non-life-threatening reasons – standbys, vehicles in the road, psychs.

The pathogens and communicable diseases are a little harder to control. We get our training, which is sort of a waste of time. It can be summed up with the following words: there is nasty shit out there, wear your gloves, put on a mask if you have to, eye shield when intubating and be cautious. I don’t use gloves as much as I should, and have never gotten in the habit of putting the face shield on intubate. I use to wear glasses, and then when I lost them, well, I just never got another pair. (I’ve done mouth to mouth on patients only twice, but they were both babies, handed to me limp and inbreathing, and I did what I had to do until I could get them in a position where I could use an ambu-bag.) They have gone to safety needles, which I think are great and probably have reduced needle sticks. Still -- ambulances are teeming with germs and disease, and when the avian flu or anything new and bad gets here, we are going to get whacked with it, no matter what we do.

The third danger area is more insidious. I think over time the damage that EMS does to people’s relationships, to their mental health and view of the world is a silent epidemic. The divorce rate is EMS has to be off the charts. I heard about a soon to be published study of sleep deprivation done on EMS workers that showed EMS again is off the charts. Most people in EMS work unbelievable hours to support their families. There is little advancement, and then the time comes when the job has beaten them down so bad they can’t physically or mentally work any more. Unless you have a job with a city pension, it doesn’t leave you much in the end.

So to go back to the article, I think EMS people and society need to acknowledge that EMS is dangerous, but we should not accept it. We all need to continue to work to make it less so. I applaud the efforts people have made so far, but there is more to be done.

While I see ambulance safety continuing to improve (partially for liability reasons), and I see the disease training being continued to the extent mandated by OSHA, I don’t see any efforts being undertaken for the psychological aspects. I think here is where we need to protect ourselves. If it is a job that we love and if we love our families, we need to fine the balance that enables us to do both. But the problem comes from wanting more for the family, we work harder to pay for the house, the family vacation, the better school, the Christmas gifts, the health care bills, and then some people get behind and can never get ahead. The problem with unlimited overtime is you start doing it to pay for something better, and then you get in a position where you have to work it to survive.

And then when your body starts breaking down, you just can’t keep it up. You can’t keep carrying people down from the third floor out into the icy night and not expect it to wear on you, particularly if you are not staying fit. And sometimes, it’s the mind that breaks down under the stress and you lose perspective. When patients who you entered this profession to help become the enemy, it’s time to reassess. Go do something else if you can. I know many good medics who have walked off the job for this very reason. And you have to applaud them for having the courage to recognize the job was killing them. We all know there is no pot of gold at the end of this rainbow. No million dollar reward for twenty or more years of grinding the runs out. If we are not getting the reward each day, or even once a month, something to keep us going, we need to save ourselves if we can.

Finances are hard all around – it is not in the interest of towns and cities already burdening their citizens with high taxes to take on more costs either by upping benefits for exiting city EMS personnel or by replacing commercial EMS service with a new tax-payer funded city service. I just don’t see that trend happening.

We can’t let the job become a lives – it shouldn’t define us – because it will betray many of us in the end. I see it in some people and I fear it one day happening to me. I don’t want to be old and bitter and betrayed by this job I love.

Be safe out there people – in body and mind. Don’t let this job take your life or your happiness. Acknowledge it can happen, but don’t accept it.

Not a Bad Thing

Not a Bad Thing

The state was here inspecting our ambulances. Everything was in order except all the pedi ET tubes in the airway kit were expired as were all the replacement pedi-tubes in the supply room. 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5 – all expired. I didn’t even know tubes had expiration dates, but they do. We had to throw out nearly fifty tubes. Better they ended up in the trash than down some poor children’s throats.

We had to have someone from the commercial service drive us up two new sets of pedi-tubes.

Finally

I had a bad GI bug last week – the worst I had ever had. Not bad enough to keep me home, but bad enough for me to be chugging pedi-lite to stave off dehydration. I called my doctor after the fifth day and his nurse said, try some immodium. So I did. Never had it before. It will save you on the toilet paper bills.

Today after five days of the other extreme, we got a call for vomiting and diarrhea. There’s a lot of the GI flu going around, I told the woman who thought maybe she had eaten some bad ribs. I tell you, this woman had had a lot of ribs in her time and most of them must have been pretty tasty. She was one of those large women, whose weight you can mistake for being 325 looking at her, but then when it comes to lifting, you realize she is more like 450 plus. I went to lift up and she wasn’t going up. She was about to start going down when I gave a good grunt and almost threw her toward my also struggling partner, as if I was dropping from a dead lift to a power snatch. She must have shaken something up because as soon as we left her in the room, I finally got the call to nature, and I’m happy to report, things are back to normal.

My Bad

Yesterday trudging through the snow drift now caked with road dirt, we pushed our stretcher to an apartment door, where we were told the patient would be walking out. I walked in, first brushing my boots on the mat, to see what was going on, if the patient could indeed walk out. It would have been a bit of a tight fit getting the stretcher in so I was pleased to see a man in his sixties, standing up, putting a jacket on. “I just need to use the bathroom,” he said.

I grabbed the monitor and house bag and brought them back outside and trudged back through the snow to put them in the ambulance. Then I walked back and had to step somewhat awkwardly around the stretcher. As I went through the door, I felt something was wrong, something off in just the slightlest way, but I could quite decided what it was. The man was sitting down now and was saying he didn’t feel he needed to go by ambulance – his wife could take him, and he started to explain how he just had a brief episode where he had seemed confused in his thoughts, but was normal now. That’s when I looked down at the white carpet, at my boots and saw the dirty ice snow melting around my boots, I looked back toward the door – giant black footsteps leading to me. I looked at my partner and the two first responders. No footprints leading to them.

“Oh, no,” the man’s wife said, seeing what I was seeing for the first time. “My carpet, I just had it cleaned.”

“Sorry,” I said.

I really did feel bad about it. I knew she was mad at me, but she also at least probably thought it would be rude to yell at someone wearing a uniform that said Volunteer ambulance – I’m sure she probably didn’t even consider I might be making a living at this – and who was here to help her and her husband in their time of need.

I apologized again at the hospital. She still had that pained look on her face. What a day. Her husband sick. And that one little thing to push her over the edge – those unsightly footprints on her freshly cleaned carpet that would be there greeting her when she returned home.

I’m going to try to not let that happen again. We all wipe our feet so much that it becomes second nature. But then I went and suffered my own moment of confusion.

They Cat-Scanned her husband. If they Cat-scanned me they probably would have found a burned out bulb behind the “Please wipe your feet” flashing sign.

Pain Relief

Last week I had a call for a patient who fell and hurt her hip. Typical shortened and rotated. 8 on the 1-10 scale. But then she said she was allergic to codeine and sulfa drugs. I thought about calling the doctor to see if it was okay if I could give her morphine. I seemed to remember having a patient who was allergic to codeine, but who said she had had morphine before and could take it -- and I then gave it to her with no problem -- but also in the back of my mind was a strong voice saying you couldn't give morphine to someone with a codeine allergy. Conflicting signals. Unfortunately she had some dementia so I couldn't get out of her what happened when she took codeine. So we rode in and every bump hurt her. About half way there, I thought about calling medical control again, but I didn't. At the hospital, the nurse gave me a hard time saying she hadn't heard you couldn't give morphine to someone allergic to codeine. I don't think so, she said, shaking her head. I talked to a doctor later who told me next time just call and ask medical control. They might say yes, they might say no. I looked in my protocol book later and saw a codeine allergy is listed as a contraindication to morphine. I will call next time because she was in a lot of pain and was suffering, and I felt like her torturer. I need to learn more about this.

Today I had an 80 year old lady who fell and same deal, leg shortened and rotated, pain 10 of 10. I gave her 4 mg IM, and then 2 IV. Didn't seem to touch her much. She was still laying on the rug. I like to medicate before I move a patient. I weighed just getting her on the stretcher and having her suck it up for a minute, but then I decided to call for orders for more morphine. I asked for 5, the doctor told me 3. That helped some, but she was still in pain. I think she was a bit of a drama queen. Still she was 80 and there was pain, even if it wasn't still the 9 out of 10 she was saying. At the hospital the doctor asked if I was okay with just getting the 3. I said that was fine. I said there was a line between medicating enough to comfort them during the move and bumpy ride and overmedicating them for the ED. He said next time, I should ask for it in increments, 2mg every 5-10 minutes titrated to pain. That way you won't overmedicate. It's easier to add than subtract, he said. Good point.

When I stopped to see the patient on the way out, she clasped my hand to her chest, called me by my first name, and thanked me. I had a hard time getting my hand loose.

A Two-Year-Old's Pain

Thirty percent of the calls in my town are patients over 80 years old. Lots of pneumonias, CVAs, COPD, hip fractures, etc. We rarely get kids.

Started off the day with a 95-year-old who “went into a trance” and “fell out.” When we got there, there were people running toward the house in panic and a woman standing in the doorway, crying and holding her throat. Code, I said, has to be.

But it wasn’t. Granddad just went into a trance and fell out. He was lying there on the kitchen floor with jelly on his shirt, talking to us. He threw up some orange juice on the way out the door – got it all over the stair chair-- but other than that he was okay. He had eight family members standing around giving him attention.

Then we did a three-year-old who choked on some candy, but was okay. We transported anyway, just to be safe. I never want to leave a kid with a refusal, who turns out to have a problem.

Then, amazingly, we were sent for another toddler – a two-year-old with some kind of leg injury, no lights or sirens. We got there and found a crying baby and mom saying he was running and he fell and his leg went under him at an odd angle. I looked at both legs -- they looked symmetrical. He had full range of motion. I didn’t feel any point tenderness or crepitis, but he kept grabbing at the right femur and he couldn’t stand on it. We should go get it checked out, I said. So we bundled up the boy and with mom sitting in the back, we started to the hospital.

“Is there a reason we’re not going lights and sirens?” she asked.

I explained how we only go lights and sirens when someone’s life is at stake. We only go lights and sirens if there is something the hospital can do that we can’t that will make a difference in his condition is the amount of time that is saved by going lights and sirens. She wasn’t happy with my explanation.

Whenever we hit a bump, he grabbed at his leg, which I now had on top of a pillow wrapped in ice. He would cry and then breathe hard, and cry and breathe hard. Without a deformity, I was hard pressed to give morphine, but he impressed me that he was in some serious pain. I didn’t have a grimace meter, but I would put it at very unhappy, crying face or whatever is a ten. I explained to mother that I think he needed some morphine and I would call the hospital to ask for it.

“Morphine? Do you think he needs that? Is that something you can give him? What if he has a reaction? Are you qualified to give it?”

I had to keep from smiling. I felt like saying no, but I have some leftover from my last score and I don’t mind sharing just to shut the boy up. Yes, I am qualified, I say. We are licensed to carry and give the drug, which is very safe, but I will first consult an emergency physician before giving it.

I called and got orders for 2 milligrams, which I have to say didn’t really touch the kid. Mom was going “When is it going to work? How come it hasn’t worked yet?” And when briefly he closed his eyes, she said, “He’s going to sleep, he’s going to sleep, is that okay?”

She’s a mother and she loves her kid. Nothing wrong with that. My hair is getting pretty long and at my age, I may look like I’ve walked down some roads. Maybe I need a trim.

At the ER, the first thing mom asked them was if it was okay that I gave him morphine. Yes, that’s fine, they said. The head doctor came up and thanked me for giving it, saying it was the best thing I could do for him, but mom wasn’t listening, she was looking around waiting for some TV moment where they push the kid into the trauma room, and needles and oxygen comes out and there is George Clooney to tell her everything will be all right, as he puts his arm around her and walks her toward a quiet spot in the ED.

They sent us down to a room and I heard them put in an order for an X-ray and more morphine, but no one followed us to the room. We moved him over to the ED bed, and his femur was starting to look swollen now.

“Are you leaving?” She asked, again almost frantically. There was no hospital staff there yet.

“I just have to write my report, and then I’ll be back.”

“Isn’t anything going to happen?” She asked.

“They’ve already ordered an X-ray and more pain medicine,” I told her. “They’ll be down shortly. Everything is in the works.”

When I came back, the ED staff was putting in an IV. Mom looked at me and smiled, somewhat apologetically, and said thank you. I felt it was sincere. I felt like she was saying sorry, I’m just a flustered mom.

It is hard with kids to figure out there pain. They are always screaming at first. I don’t often get them with a real injury.

If I had to do it over again, I would have asked for 2 milligrams with permission to give an additional 2 in 10 minutes dependent on pain, mental status and vital signs.

The last call of the day was for a 92-year-old who fell and broke his hip. I think his son was a doctor based on the report he gave us. He had no objection to my giving his dad morphine. I gave it to him where he lay, and then waited for it to take effect before we moved him. 5 milligrams of morphine did the job.

Sick

Working sick. It happens all the time in EMS. Why? In EMS you get exposed to so much, its hard to make it through a winter without getting whacked by at least one bout that would put a salaried worker in bed with a thermometer in their mouth and a water bottle on their chest. Not anything against salaried workers, only that when I was one, and I didn’t feel well and no one was really counting on me, I stayed home when I was sick. “Uh, sorry, I won’t be in today, I’m feeling a little under the weather.”

In EMS, most people can’t afford the time off. Sure you get a certain amount of sick time every year. I try not to use mine if I can help it, so I can cash it out at the end of the year as needed pay. Other EMS people, well, aren’t as fortunate. Thinngs happen -- family issues, sickness, child care issues -- and suddenly they are just plain out of personal time, and can’t take another day.

I don’t think any EMS worker beyond a few months experience hasn’t had one time or another, or many, many times, when they had patients who weren’t as sick as the responding EMT. “You’ve got a fever?” they say to the patient. “A bad chest cold? You vomitted a few times? Diarrhea? Poor dear.” If they were playing Can You Top This? they’d be rich. “You want to see some phlegm? I can show you some phlegm,” they feel like saying to the patient.

On a cold night like tonight, I wonder how many EMS workers are getting breathing treatments in the back of their ambulances or who’s partners are sticking them with an IV in between calls and hanging a bag of saline running wide open to fight back dehydration? Does all the phenergan go to the patients?

It’s a good thing morphine is controlled and locked up because if it was as common as the baby aspirin (and there wasn’t the certainty of losing your job much less the fear of becoming a skanked out drug addict), maybe people would use it for their back pains.

In my days, I’ve had partners puke and stay on the clock and I’ve had strong partners who uncharacteristically stuck first responders with the carry-down because their stools were so loose they didn’t dare attempt a dead lift. I’ve seen asthmatics work through treatments, diabetics work through unresponsive hypoglycemic episodes after getting their D50. I’ve heard people on the radio who’s voices were so shot you’d think they were on their death beds. Without complaining, their partners, who hate to tech, will tech every call to protect their coughing, wheezing, puking other EMS half.

Most lines of work, you get injured on the job and miss work, its comp. But that really doesn’t account for all the microbes and cooties we deal with. Prove, you didn’t get that home. I guess the excuse is we have gloves and masks and gowns and hepa-filters and hand washing supplies.

I don’t know if I was a patient I would want a sick medic taking care of me. At least most of us cough onto our shoulders instead of our hands. Plus we all wear gloves. Especially when we're sick.

It won’t be a problem for me for the next couple days. I made it through another working week. The monthly mortgage is paid. I’ve got food on the table. I’ve got a few days off to regain my strength.

Pass the hot water bottle.

Arms

Nearly every day a stranger’s arm rests on my knee. I roll their sleeve up and strap a tourniquet around their arm just above the elbow. I usually have already eyeballed their hands for veins. Is this going to be an easy stick? Or am I going to work for it?

While their arms rest on my knee, I draw up a saline lock and unwrap a Ven-A-Guard. If I see my vein, I take out the appropriate size catheter; usually an 18 or a 20 along with an alcohol wipe to clean the site. If I don’t see the vein, I will then use my finger tips to hunt for a vein beneath the surface. Today I had a rather large thirty-five year old female with a lot of fat on her arms. I couldn’t see a vein, but I felt the sponginess in the crook of the elbow. I wiped the site down with the prep, and then plunged in a 20. Flashback. All right. It made me think if I was oil driller I would be a rich man – the times I have stuck red gold. You can get on a streak where you can’t miss. You just plunge in and blood fills the chamber. Send me to Texas or Oklahoma. Pay me more – a lot more if you want me to the Middle East. Or maybe I could be a water finder. Send me to the Sudan or Ethiopia. With my water stick, fountains will sprout from the earth where I have plunged it in. Of course there are times when you can’t get anything. You go in and you miss. That’s life.

When I am done with the IV, the lock attached and flushed and taped down, I usually take the person’s arm and move it to their side. But sometimes, particularly for older people, I leave it there if isn’t in my way or doesn’t seem awkward or uncomfortable for them.

Sometimes the IV is never used for drugs or fluid. It is just put in because it is protocol. You have chest pain or shortness of breath or syncope or had a seizure, you get an IV. The IV is there in case you need it, and so you are ready, prepared for if the patient takes a sudden turn for the worst.

I try to talk to my patients. Lately, as I have written, I have been doing it more so. It breaks the tedium, and patients like it, for the most part. They are wondering what lays ahead and maybe sharing that time with another person helps ease that worry.

Yesterday I had a patient who had a syncopal episode when she walked in the door from visiting her sister in Florida. Passed out and smacked her head hard. There was blood all over the foyer and kitchen and bathroom as she wandered in circles, saying “Oh my, oh my, what have I done?”

She was covered in blood – She looked like a Hollywood poster for a horror film. I inspected the wound, a deep lac on her left forehead that was still bleeding. The first responder had wrapped it, but not tight enough to hold pressure. I rewrapped it and then helped get her out of her bloody coat, and get her cleaned up as well as we could. Then we helped her onto the stretcher. She was alert and oriented with no neck or back pain. She just couldn’t remember if she fell because she got dizzy – she had been feeling lightheaded all day -- or whether she tripped over her suitcase.

In the ambulance her arm rested on my knee as I put an IV in her forearm. She commented on how nice my knee was. I’ve actually heard that a number of times. Better than the stretcher side rail isn’t saying much. Her vitals were all good and her 12 lead normal. I told her this as we talked. She thanked me for explaining and said she remembered me from the times I had come to help her husband, who passed away during the winter. I gave her my condolences. She said she had no family in the area anymore.

The hospital we were going to was a fair distance away so we talked quite a bit. I checked on her lac, and it was still bleeding underneath the bandages so I got some more 4X4s and pressed them against her forehead, pressed them hard and held them there. She looked up at me her eyes blinking, and thanked me for taking her to the hospital.

“It’s what we do,” I say.

We rode on through the night, her arm on my knee, my hand pressed to her forehead, talking quietly.

When I checked the head after five minutes, the bleeding had stopped. She seemed pleased when I told her.

“You’ll need some stitches,” I said.

“Its not too bad, is it?”

“You’ll have a scar.”

“It could have been worse, I guess,” she said. “At least I’m alive.”

“You most certainly are.”

When we parked at the ambulance, I moved her arm off my knee, and I bundled her up against the night wind. “It’s cold out there,” I said.

“Thank you,” she said, looking right at me.

When we wheeled her into the crowded ER, a triage nurse, her hands on hers hips, saw her, and exclaimed, “Why who hit you with an ax? Look at that gash!” But then she touched our patient’s arm warmly and looking her in the eyes said, “Don’t worry; we’ll take good care of you.”

Eagles Coalition

The Conference I wish I was going to.

As I’ve mentioned I am going to JEMS - EMS Today in March. Great conference, great speakers, great chance to find out what’s going on in EMS.

But if I could go to only one conference this year – and I am kicking myself that this is not the one I am going to (because I didn’t think to check into it), it would be the Conference of the Eagles Coalition held in Dallas, Texas from February 16-17.

The Eagles are the EMS medical directors of the nation’s largest EMS systems, including doctors like Paul Pepe who are on the leading edge of EMS care.

Check this out for an Agenda.

Fortunately many of the Eagles will be at JEMS giving presentations of their findings.

I'll try to go to as many as I can and report back.

Tired

I taught my first ACLS class today. Well, actually, I was monitored for a class. This is necessary in order to get your instructor’s card. I choose to teach the VT/VFIB class, which I felt was the most challenging.

It is a lot harder in person that I imagined it. I know the subject matter well, but I think part of my problem was I knew too much and tried to spill it all out, instead of sticking to the basics of the algorithm. And of course I went off on a lengthy capnography tangent. I think my monitor probably wished he had a cattle prod to zap me every time I went off track.

The class was doctors and nurses all recerting so they knew a good deal of it anyway. I taught the same station to two groups. Only one person nodded off, but maybe he was just really tired.

I believe I will do much better the next time now that I have had a run through. I’ll stick to the core material, and then have handouts on capnography and some of the new cardiac studies I wanted to share – something they can read on their own time.

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I have avoided teaching groups for years, preferring individual teaching, but believe I am ready now. I am passionate about the subject matter, and feel my years doing calls have given my some credibility.

Next week I will be giving my capnography lecture to a group of paramedics as part of their service’s training and then later in the week I’ll be doing a skill session on capnography for some ED nurses and staff. Next month I’ll be giving it at the state EMS convention. I am going to try to really hone it so I can say everything I want to say in a simple understandable way. But it never quite comes out the way I plan.

Like I said, maybe in time my group teaching will get better.

**

I am excited that I will soon be getting a new preceptee. I’m not certain who it will be yet, but a couple of the candidates seem to be very sharp. I hope I get someone who really wants to learn, and who will put up with the tangents and not just want to know only want they think they need to know -- someone who will ask a lot of questions -- including ones where I don't know the answer. I want to learn too.

Thank Yous

A number of months back I had a discussion about thanks or lack of thanks in EMS, after which I decided to keep a record of how many times I had a thank you said to me in a single day. My list only lasted a few days, but it was actually quite lengthy. It is not at all unusual to receive the following thanks routinely on a call:

1. Nurse at SNF or family at home on departure from scene.
2. Medical Staff (triage nurse, room nurse, MD) following verbal report.
3. Patient and or family on saying goodbye at the hospital

We probably remember the rude episodes more than the daily gratefulness. Sometimes I think why are they thanking me. I'm just doing a job for which I get paid. I didn't do anything beyond the job basics.

But there are times I do go beyond the basics and I have to say, I feel appreciated for it, particuarly by the patients.

The last week I have worked hard at being thorough and pleasant, everything from making certain the patient was well bundled up against the cold to explaining everything I was doing to the patient, as well as telling them to the best of my ability what they could expect at each stage of their trip. I wanted them to feel like they were in good hands, under the protection of an experienced guide.

I have to tell you, I have been doing this a long time now (since 1989 as an EMT, 1993 as a medic, 1995 as a full-time medic). For all the good feelings I get from performing well on the big bad cal(when I do) – the cardiac arrest, the shooting, the ST elevation MI, the ongoing stroke, the status seizure -- it doesn’t compare for me with how I feel when a patient looks at me when I say goodbye to them in their room or cubicle and they thank me for helping them understand what is happening to them and what they are going through, with being their pathfinder through the unknown.

Sometimes I sit here and think I have nothing exciting to write about, but when I think about what I actually do sometimes it is all very exciting to me. I had a patient this week with a persistent cough for a month (I think he had a pneumonia brewing). He went to the doctor where he was discovered to be in a new onset a-fib so suddenly he goes from expecting a prescription for some strong cough medicine to being whisked away to the hospital in an ambulance for a “heart problem.” We talked all the way in. As we got to the hospital, he asked me how long I had been doing my job, and then said, I must really love it. I told him I did.

I brought in two people this week who had unexplained syncope, an alcoholic with a new abdominal pain, a man who had severely burned his hand with cooking oil. They were all very nervous, and while I could not take away what had happened or was happening to them, I feel like I took away some of their anxiety, made them a little less afraid. I took good care of them.

I wish I could make my love for the work and life of a paramedic come through on every call. I wish my heart would always be open and kind.

It isn’t, of course. I have crabby days where I do little more than grunt as I assess my patients, ask only what I need to know, and then write my report while the patients sit there alone and afraid on the stretcher.

I don’t deserve a thank you from them.