Listening.
It seems like such a simple thing, but we're all so busy.
I had a patient the other day -- an old man who has been losing weight and growing weak. He had his esophagus removed 10 years ago and has had problems ever since -- diarrhea, loss of appetite. Now almost ninety, he is frail and spiritless.
He meets us at the door of his room in the assited living retirement community, all dressed up with his buttoned and pressed shirt and pants, a cowboy hat in his hand. He is annoyed when I tell him I have to take off his shirt and undershirt and put him in a hospital johnny. He says the nurse shouldn't have told him to get all dressed up if he was just going to have to get undressed again. Then he sees the scrape on his elbow that he got when he banged it against the dresser, and he is annoyed that the nurse didn't put a band-aid on it. I tell him not to worry, I will dress it for him.
He slowly takes off his shirt, refusing my help and then we put the johnny on him. He stands there for a minute, just a few feet from the stretcher that is in the low position with a clean sheet spread out on it. Finally he stakes a few small steps over and with my help now, sits down.
I put a 4 X 4 on his elbow and wrap a little kling around it. I read the W-10 and see the words, malnutrition, depression. His skin is very dry, but his vitals are all normal and the only pain he has is in his abdomen -- pain he says he has had every day for ten years. All the way to the hospital, he looks uncomfortable, a sour look on his face. The hospitals have stopped taking our bloods so I am less inclined to put in an IV as a matter of course. The man, who needs to be hydrated, can wait for it at the hospital. I sense he will be bothered if I tell him I need to put in an IV. I think I have taken him in before -- he seems familiar to me. We don't make much conversation. Its a long trip to the hospital -- not the closest one, but the closest one to where his daughter lives. He's not happy about it, but that's where she wanted him to go.
I call the hospital and give the basic story -- elderly man losing weight in recent weeks, no appetite, stable vitals.
I spend the rest of the time writing up my form. I could be conversing with the man, but he seems rather miserable, and I want to get my form written, front and back, because its the last day of my shift and I want my paperwork done by my shift's end so I can get out on time.
When we come through the door, the nurse gives us a room number, and then comes in after we've moved him over to the bed. I start to give my report, but she is already interrupting me, asking the patient and me questions. I try to tell her that he had his esophagus out twelve years ago, but she starts asking him about esophagitis. She sees the bandage on his elbow and says, "You fell? Did he fall? Were you dizzy or did you trip?" She says "We need an EKG in here." She is going 100 miles a hour -- this is not the first time I have dealt with her. I just say, "I'll finish writing up my report and you can read it when I'm done." I leave the room. She'll get the story eventually. I'm tired of dealing with her. The only time I ever interrupt her and tell her to stop and listen is when I feel the patient needs immediate intervention in which case I usually just go find the doctor. Its like she has attention deficit disorder compounded by ten cups of coffee.
A couple weeks ago I brought an elderly patient with an open ankle fracture to a hospital only to find no triage nurse. At the same time two critical patients came in. The triage nurse came running to the front then and was trying to triage all three patients at once. She asked me what I had. I said a severe ankle fracture, but the patient was stable and medicated. I probably should have said an open fracture instead of a severe fracture. She triaged the other two patients -- a stroke and a semi-responsive OD, and then went back to me. She was looking at her computer screen and typing as I started my report, and she cut me off almost right away. I told her it was a severe fracture with an open laceration and that I had given 7 mg of morphine. We took the patient down to the room and I waited there for about ten minutes until the PA came in and I gave the report, telling him how badly fractured the ankle was, but that the patient was now pain-free. I later heard the triage nurse was pissed at me because the patient met their internal guidelines for a trauma room activation and she hadn't triaged it to the trauma room.
Hey, she was busy, looking at her screen, not listening to me, and for my part, I could have been more demonstrative about the injury, could have used different buzz words. We both could have used a do-over.
EMS is a hectic world -- both prehospital and in the ED. Listening is a rare skill. It's hard to block everything out. We make decisions based on "pattern recognition." Its easy to make a mistake or go down a wrong track. Most of the times it doesn't affect a patient's treatment. The old man will get hydrated in the end and hopefully also have his depression addressed, and the old woman will get her ankle fixed.
I read an article in the New York Times :
Study Says Chatty Doctors Forget Patients
It set me thinking. We are with patients longer than their doctors are. Now I know at times I am mostly interested in getting the info I need: an assessment, history, do the skills I have to -- IV, ECG, maybe 02, occasionally give meds, and get the demographics and patient signature to make my reports written and verbal, but that still leaves a good amount of time to talk to the patient -- more time it seems than the doctor or nurses can afford at the busy ERs.
I want to try to make the most use of that time I can -- I want to try to use that time to really find out what is going on with the patient -- and not just use the extra time as silence -- a time to wander in my own thoughts. A famous medical saying is that "if you listen, the patient will tell you what is wrong."
I should master my own listening skills before I get too upset at others for the lack of their own listening skills.
I'm going to try to do better.
***
Here's a post I wrote a few weeks ago that talks about listening and pattern recognition.
How Doctors Think
Wednesday, June 27, 2007
Sunday, June 24, 2007
"Street Cred" for EMS Physicians
I read an interesting article on Jems.com this week called "Street Cred" for EMS Physicians written by Sabina Braithwaite, an emergency physician (and paramedic) from Charlottesville, Virginia. She asks an interesting question about whether the relationship between paramedics and their medical directors is affected by the medical director's experience or lack of experience with the prehospital environment.
She asks:
What gives an EMS physician “street cred”?
Is it being on the street now, or is it having been on the street then (or both)?
Is it such resume items as an EMT card from 1984 and stories of being paid $3.35/hr (back in the dark ages) to get shot at?
Is it knowing how to “play” the siren?
Is it knowing when something just doesn’t sound right on the radio?
Is it owning not just one, but two pairs of steel-toed boots?
Is it doing practical and didactic teaching for the providers?
Do you think “street cred” is a plus or a minus for an EMS physician? How and why? What do you see as the added value? Does it really have a positive impact on the practice of an EMS physician and the agency they provide guidance to? Does it help them interface with administration/county government, or does it just help them with the providers?
Here are my thoughts on it:
I have great respect for a group of doctors called the Street Medicine Society who have taken their paramedic pasts, gone onto medical school and then becoming physicians, have dedicated themselves to improving and advocating for prehospital care and care-givers.
But I don't necessarily feel that being a paramedic is essential to being a better (or more respected) EMS medical director or even ED physician. In recent years as more and more hospitals are offering emergency medicine residencies and medical school students and residents are being required to ride with paramedics (however briefly) as part of their training, as a group, newer doctors are more in tuned with the prehospital environment and more understanding of what we encounter than some of their predecessors -- many of whom did not like us doing "doctor" jobs such as intubating and pushing drugs on standing orders.
I have met many non-paramedic EMS physicians who are very pro-EMS. The key is not about their street experience, but their willingness to listen to us, try to understand what we face, to advocate for us, and to share their medical knowledge with us so we can better apply it to the work we do.
Time riding with us is a bonus, but not essential.
The best thing that can be said about an EMS medical director around here is that he or she is pro-EMS (meaning they respect and value the work we do and fight to see our work is recognized). A pro-EMS physician would be more supportive of standing orders than a mother-may I approach and would work to increase our education and scope of practice rather than reduce it. At the same time a pro-EMS physician would set high standards for us and help us try to reach them as opposed to a you guys are great whatever you want goes attitude.
A good EMS physician doesn't have to try to be one of the boys to be respected.
I should point out that EMS medical directors around here are full-time employees of their hospitals and often carry a large clinical load. They are really not at liberty to spend much if any time on the road with us. I know other cities have their own dedicated medical director who works 100% of the time for the EMS system, and thus is out riding on a fairly regular basis.
What do you think gives an EMS physician "street cred?"
Post a comment here and/or send an email to Dr. Braithwaite at the email address listed in the article above.
She asks:
What gives an EMS physician “street cred”?
Is it being on the street now, or is it having been on the street then (or both)?
Is it such resume items as an EMT card from 1984 and stories of being paid $3.35/hr (back in the dark ages) to get shot at?
Is it knowing how to “play” the siren?
Is it knowing when something just doesn’t sound right on the radio?
Is it owning not just one, but two pairs of steel-toed boots?
Is it doing practical and didactic teaching for the providers?
Do you think “street cred” is a plus or a minus for an EMS physician? How and why? What do you see as the added value? Does it really have a positive impact on the practice of an EMS physician and the agency they provide guidance to? Does it help them interface with administration/county government, or does it just help them with the providers?
Here are my thoughts on it:
I have great respect for a group of doctors called the Street Medicine Society who have taken their paramedic pasts, gone onto medical school and then becoming physicians, have dedicated themselves to improving and advocating for prehospital care and care-givers.
But I don't necessarily feel that being a paramedic is essential to being a better (or more respected) EMS medical director or even ED physician. In recent years as more and more hospitals are offering emergency medicine residencies and medical school students and residents are being required to ride with paramedics (however briefly) as part of their training, as a group, newer doctors are more in tuned with the prehospital environment and more understanding of what we encounter than some of their predecessors -- many of whom did not like us doing "doctor" jobs such as intubating and pushing drugs on standing orders.
I have met many non-paramedic EMS physicians who are very pro-EMS. The key is not about their street experience, but their willingness to listen to us, try to understand what we face, to advocate for us, and to share their medical knowledge with us so we can better apply it to the work we do.
Time riding with us is a bonus, but not essential.
The best thing that can be said about an EMS medical director around here is that he or she is pro-EMS (meaning they respect and value the work we do and fight to see our work is recognized). A pro-EMS physician would be more supportive of standing orders than a mother-may I approach and would work to increase our education and scope of practice rather than reduce it. At the same time a pro-EMS physician would set high standards for us and help us try to reach them as opposed to a you guys are great whatever you want goes attitude.
A good EMS physician doesn't have to try to be one of the boys to be respected.
I should point out that EMS medical directors around here are full-time employees of their hospitals and often carry a large clinical load. They are really not at liberty to spend much if any time on the road with us. I know other cities have their own dedicated medical director who works 100% of the time for the EMS system, and thus is out riding on a fairly regular basis.
What do you think gives an EMS physician "street cred?"
Post a comment here and/or send an email to Dr. Braithwaite at the email address listed in the article above.
Wednesday, June 20, 2007
New Regional Guidelines On-Line
Our new regional guidelines are now on-line at:
North Central Regional EMS Guidelines
I've been using the new morphine pain dosing with great success.
0.1 mg/kg slowly over at least 4-5 minutes up to a total of 10 mg.
If after 10 minutes, patient still reports moderate to severe pain, another 0.05 mg/kg slowly over at least 4-5 minutes up to a maximum total dose of 0.15 mg/kg
I've done a couple of hip fractures and one severe ankle fracture -- all recieved a good measure of relief.
***
Speaking of pain relief there is a fascinating article in the New York Times Sunday magazine about a doctor who is in jail for "over" prescribing pain meds. It raises some interesting issues between a doctor's right to practice and to heal versus society's fear of drug addiction.
When is a Pain Doctor a Drug Pusher?
An excerpt:
Proper pain management will always take time, but the D.E.A. can at least ensure that honest doctors need not fear prison. It should use the standard it claims to follow: for a criminal prosecution to occur, a doctor must have broken the link between the opioid and the medical condition. If the evidence is of recklessness alone, then it should be a case for a state medical board, the D.E.A.’s registration examiners or a civil malpractice jury.
Undoubtedly, such a limit will allow a small group of pill-mill doctors to escape prison. But America lives with freeing suspects whose possible crimes are discovered through warrantless searches or torture — and unlike other suspects, doctors who lose their licenses are as incapacitated as those behind bars. For cases without the broken connection, prosecution is too blunt an instrument. It runs too high a risk of condemning innocent physicians to prison and discourages the practice of a medical specialty desperately needed by millions of Americans.
Pain patients are the collateral victims here...
Opioids have immense power — both to harm and to heal. They can be life-destroying, but high doses allowed Ben to work, to be with his family, to be who he is. In its prosecutions of pain doctors, the government fails to recognize the duality of these drugs. Ben’s wife told me: “When Ben first went to Dr. McIver and filled out the form on what he used to be able to do and what he could do now, he cried. McIver said to him, ‘I’m going to get you back to doing what you used to do.’ And he did.”
I found the following progressive policy statement on the Connecticut Medical Examining Board (the disciplinary body for MDs in out state) web site:
Use of Controlled Substances for the Treatment of Pain
It includes the following passage:
"the board may not judge the validity of treatment solely on the quantity and duration of medical administration...may take into account the outcome of pain treatment including patient functioning/and or quality of life; and will not assume that all types of pain can be completely relieved."
North Central Regional EMS Guidelines
I've been using the new morphine pain dosing with great success.
0.1 mg/kg slowly over at least 4-5 minutes up to a total of 10 mg.
If after 10 minutes, patient still reports moderate to severe pain, another 0.05 mg/kg slowly over at least 4-5 minutes up to a maximum total dose of 0.15 mg/kg
I've done a couple of hip fractures and one severe ankle fracture -- all recieved a good measure of relief.
***
Speaking of pain relief there is a fascinating article in the New York Times Sunday magazine about a doctor who is in jail for "over" prescribing pain meds. It raises some interesting issues between a doctor's right to practice and to heal versus society's fear of drug addiction.
When is a Pain Doctor a Drug Pusher?
An excerpt:
Proper pain management will always take time, but the D.E.A. can at least ensure that honest doctors need not fear prison. It should use the standard it claims to follow: for a criminal prosecution to occur, a doctor must have broken the link between the opioid and the medical condition. If the evidence is of recklessness alone, then it should be a case for a state medical board, the D.E.A.’s registration examiners or a civil malpractice jury.
Undoubtedly, such a limit will allow a small group of pill-mill doctors to escape prison. But America lives with freeing suspects whose possible crimes are discovered through warrantless searches or torture — and unlike other suspects, doctors who lose their licenses are as incapacitated as those behind bars. For cases without the broken connection, prosecution is too blunt an instrument. It runs too high a risk of condemning innocent physicians to prison and discourages the practice of a medical specialty desperately needed by millions of Americans.
Pain patients are the collateral victims here...
Opioids have immense power — both to harm and to heal. They can be life-destroying, but high doses allowed Ben to work, to be with his family, to be who he is. In its prosecutions of pain doctors, the government fails to recognize the duality of these drugs. Ben’s wife told me: “When Ben first went to Dr. McIver and filled out the form on what he used to be able to do and what he could do now, he cried. McIver said to him, ‘I’m going to get you back to doing what you used to do.’ And he did.”
I found the following progressive policy statement on the Connecticut Medical Examining Board (the disciplinary body for MDs in out state) web site:
Use of Controlled Substances for the Treatment of Pain
It includes the following passage:
"the board may not judge the validity of treatment solely on the quantity and duration of medical administration...may take into account the outcome of pain treatment including patient functioning/and or quality of life; and will not assume that all types of pain can be completely relieved."
Sunday, June 17, 2007
Compelling Reasons
At our regional medical advisory committee's meeting last week I listed a number of issues I wanted us to address when we reconvened in the fall, including changing our state's DNR regulations to enable paramedics to accept a family's verbal wishes not to initiate resuscitation in a patient with a terminal condition in cardiac arrest. I will be giving a presentation on the proposal in September.
This proposal is the "Compelling Reasons" protocol initiated in King Country, Washington.
I have written about this in previous entries:
DNR Study Results
Here is a direct link to the King County study:
Futile Resuscitations
Withholding Prehospital Resuscitation: A New Approach to Prehospital End of Life Decisions (Full Study Text)
Withholding Prehospital Resuscitation (Editorial)
***
Today I had a ninety-seven year old man found in his bed by his daughter not breathing. She had previously seen him alive an hour before. It was hot in the room and the patient was still warm with no rigor or lividity. As I put the pads on(which showed asystole), I asked the daughter if her father had any DNR orders. She replied he did in the nursing home, but they had expired. I asked what her wishes for resuscitation were? She said his wishes were that he not be resuscitated. I had my crew start basic CPR and then I called the hospital and spoke with a doctor who gave me permission to presume the patient dead without having to initiate ACLS. The daughter was already on the phone calling her brothers and sisters to tell them their father had died.
This scene could have played out any number of ways. The family member could have said she wanted the father to be resuscitated, I could have simply chosen to work the patient on my own lacking a current DNR, intubated him, and put in an IV and done 20 minutes of ACLS before presuming him dead, or when I did call for permission to presume, the doctor could have told me to work the patient doing full ACLS and transport.
All in all I thought it worked out all right. A 97 year old dead, curled on his side in his own bed, in the house (I found out) he had lived most of his life and raised his family in.
***
My preceptee was cut loose last week. We never did get a cardiac arrest. I wonder how I would have handled the call if she were still with me. Finally, getting the code, the warm body to prove her skills on.
I wrote about a similar situation last summer in Practice.
This proposal is the "Compelling Reasons" protocol initiated in King Country, Washington.
I have written about this in previous entries:
DNR Study Results
Here is a direct link to the King County study:
Futile Resuscitations
Withholding Prehospital Resuscitation: A New Approach to Prehospital End of Life Decisions (Full Study Text)
Withholding Prehospital Resuscitation (Editorial)
***
Today I had a ninety-seven year old man found in his bed by his daughter not breathing. She had previously seen him alive an hour before. It was hot in the room and the patient was still warm with no rigor or lividity. As I put the pads on(which showed asystole), I asked the daughter if her father had any DNR orders. She replied he did in the nursing home, but they had expired. I asked what her wishes for resuscitation were? She said his wishes were that he not be resuscitated. I had my crew start basic CPR and then I called the hospital and spoke with a doctor who gave me permission to presume the patient dead without having to initiate ACLS. The daughter was already on the phone calling her brothers and sisters to tell them their father had died.
This scene could have played out any number of ways. The family member could have said she wanted the father to be resuscitated, I could have simply chosen to work the patient on my own lacking a current DNR, intubated him, and put in an IV and done 20 minutes of ACLS before presuming him dead, or when I did call for permission to presume, the doctor could have told me to work the patient doing full ACLS and transport.
All in all I thought it worked out all right. A 97 year old dead, curled on his side in his own bed, in the house (I found out) he had lived most of his life and raised his family in.
***
My preceptee was cut loose last week. We never did get a cardiac arrest. I wonder how I would have handled the call if she were still with me. Finally, getting the code, the warm body to prove her skills on.
I wrote about a similar situation last summer in Practice.
Saturday, June 16, 2007
Triathlon
Last October I got the crazy idea* in my head that I could be a triathlete, meaning I could enter and finish one of those swim, bike and run distance races.
I read an article in Men's Health called: Anyone Can Be a Triathlete.
And I met a nurse on one of my Dominican trips who despite, being in her sixties, often entered triathlons.
I learned that not all triathlons were the 2.4 mile swim, 112 mile bike, and then run a full length marathon that the classic Hawaiian Ironman Triathlon they used to show on ABC's Wide World of Sports was when I was a kid.
Now you can enter a sprint triathlon that is only a 1/4 to 1/2 mile swim, 12 mile bike, and a 5k or 3.1 mile run.
Triathlete -- I liked the sound of that.
Not impossible, but still a challenge given I couldn't run 1/4 mile at the time without hacking and spitting and having to stop and bend over with my hands on my knees, and that I hadn't been on a bike for almost forty years when I over the handlebars, knocked myself out and was transported to the hospital in the back of an old Cadillac ambulance. I do swim pretty well.
Anyway, I've been training since October, although I didn't start riding a bike until April because I first wanted to prove I could finish a 5K road race, which I did, before I invested the money in a bike.
Last week I entered my first triathlon. The good news was I finished. The bad -- I was pretty far back.
Race Report
* Past crazy ideas include wanting to become a paramedic, a poker player, a writer, a Spanish speaker. Not all my crazy ideas have come to fuition, including wanting to become a black belt Kung-Fu Tae Kwando Ninja Master.
I read an article in Men's Health called: Anyone Can Be a Triathlete.
And I met a nurse on one of my Dominican trips who despite, being in her sixties, often entered triathlons.
I learned that not all triathlons were the 2.4 mile swim, 112 mile bike, and then run a full length marathon that the classic Hawaiian Ironman Triathlon they used to show on ABC's Wide World of Sports was when I was a kid.
Now you can enter a sprint triathlon that is only a 1/4 to 1/2 mile swim, 12 mile bike, and a 5k or 3.1 mile run.
Triathlete -- I liked the sound of that.
Not impossible, but still a challenge given I couldn't run 1/4 mile at the time without hacking and spitting and having to stop and bend over with my hands on my knees, and that I hadn't been on a bike for almost forty years when I over the handlebars, knocked myself out and was transported to the hospital in the back of an old Cadillac ambulance. I do swim pretty well.
Anyway, I've been training since October, although I didn't start riding a bike until April because I first wanted to prove I could finish a 5K road race, which I did, before I invested the money in a bike.
Last week I entered my first triathlon. The good news was I finished. The bad -- I was pretty far back.
Race Report
* Past crazy ideas include wanting to become a paramedic, a poker player, a writer, a Spanish speaker. Not all my crazy ideas have come to fuition, including wanting to become a black belt Kung-Fu Tae Kwando Ninja Master.
Friday, June 15, 2007
First Responder Pandemic Survey
I recieved an email from Jamie Davis, the pod medic, asking that I pass the following allow to readers of this blog:
Rick Russotti and I are conducting a survey of first responders and
pandemic
response. It is a follow up survey to a survey conducted in a rather
small
sample size in Massachusetts. Rick wanted to try it via Blogs and
Podcasts
in an effort to show the power of our reach into the community and to
see if
the original study's findings could be validated on a larger scale.
A number of studies have been done asking if first-responders
(EMS/firefighters/hospital workers) will come to work or remain on duty
during a pandemic. Distribution of this survey will be a collaborative
effort among several bloggers and podcasters. You may find links to
this
survey on numerous sites. In order to maintain accuracy, we ask that
the
survey be completed once per person.
I'd like to invite you to express yourself in our version of this
study:
Effects of Pandemic Situation on First Responder Staffing
Find it here:
http://www.opinionpower.com/Surveys/815048727.html
***
I urge all EMS responders to participate. Any Bloggers out there, please feel free (you are encouraged) to cut and past the survey into your blogs.
***
Rick and Jamie are leaders of the podcast wave, and put in an enormous amount of time and effort to help educate EMS providers. Check out their information-packed sites at:
The Mitigation Journal Podcast
The MedicCast
Rick Russotti and I are conducting a survey of first responders and
pandemic
response. It is a follow up survey to a survey conducted in a rather
small
sample size in Massachusetts. Rick wanted to try it via Blogs and
Podcasts
in an effort to show the power of our reach into the community and to
see if
the original study's findings could be validated on a larger scale.
A number of studies have been done asking if first-responders
(EMS/firefighters/hospital workers) will come to work or remain on duty
during a pandemic. Distribution of this survey will be a collaborative
effort among several bloggers and podcasters. You may find links to
this
survey on numerous sites. In order to maintain accuracy, we ask that
the
survey be completed once per person.
I'd like to invite you to express yourself in our version of this
study:
Effects of Pandemic Situation on First Responder Staffing
Find it here:
http://www.opinionpower.com/Surveys/815048727.html
***
I urge all EMS responders to participate. Any Bloggers out there, please feel free (you are encouraged) to cut and past the survey into your blogs.
***
Rick and Jamie are leaders of the podcast wave, and put in an enormous amount of time and effort to help educate EMS providers. Check out their information-packed sites at:
The Mitigation Journal Podcast
The MedicCast
Thursday, June 14, 2007
No IV
Yesterday was my last day riding with my preceptee. She rides with the chief paramedic on Friday to get cut loose. She will do great. She was a pleasure to precept.
We were still checking out our equipment when we were sent for a difficulty breathing. It was an area of one of the towns we respond to where it almost always turns out to be a major call -- either a heavy duty overdose or a big MI or serious trauma. It is a lower middle class working area with a big drinking/substance abuse problem. Anyway, when we arrived two cops were standing on the front lawn, not looking very excited. They explained the man in his forties was having trouble breathing, but the visiting nurse was in there with him. He had a host of medical problems, including ascites and pulmonary hypertension and was on home 02. The nurse said his pressure was 70 and she couldn't feel a pulse. The man was breathing about thirty times a minute with clear lungs and warm, dry skin. I tried for a pressure, but couldn't hear anything. We popped him on the monitor and he was cranking away at 200, which certainly explained it. While I felt bad for the gentleman to be in this condition, I was glad for my preceptee that she was getting a PSVT. I suggested we put him on the stretcher, do a 12 lead and then treat his rhythm right there in the living room. But when I mentioned doing an IV, the man said, "No, no IV. No IV. Uh-uh. NO!"
I hate that when that happens. We preceded to then have a battle royal about the need for an IV. He was not only adamant, but knew the right lingo. "You can't treat me. I have the right to refuse. I will not let you put an IV in me. Let the IV nurse at the hospital do it. It took them 4 tries on me Friday. Wait until the hospital. You do not have my permission."
We kept at it all the way out to the ambulance. When his wife showed up, I tried to enlist her, and she gave her best persuasive case, but to no avail. The patient was just yelling at us to get moving to the hospital if he was so seriously ill. We kept up our arguments. Your heart, particularly with your medical conditions isn't strong enough to last long beating at 200 times a minute, its just a small prick in your arm versus possible lifelong disability. We are IV professionals. We teach the IV team how to do IVs(so we fibbed on that one). He finally, surprisingly relented and agreed to let us do one IV, but only in the hand. My preceptee later said she thought I was going to push her out of the way and do the IV myself, but I told her I had faith in her and she got the IV in the hand -- a #20. The patient was very impressed. "You got it? It's in? On the 1st try? I'm sorry I gave you such a hard time, its just that they never get it."
But a problem was the IV was in the hand and adenosine is better given in a vein closer to the heart. Still you get what you can get and I have had adenosine work many times with hand veins.
The first dose of adenosine did nothing. We did it again -- this time it temporarily broke the rhythm, but caused him much distress as adenosine does when it briefly disrupts the electrical charges in the heart in an attempt to reset them. He was clutching at his chest in terror and we were shouting it will pass, it will pass, which it did (as it does) in about ten seconds, but then the heart rate went right back up to 200.
After that he didn't want anymore medicine. Our option was electricity by shocking him or try to convince him to let us try another medicine. I didn't think he was going to be happy with us placing pads on his chest and jolting him -- not at all, plus I am from past experience uncomfortable with shocking people who are talking to me(admittedly those were patients with VTack, diaphoretic and no pressure who needed immediate shocks and who did not have good prognoses). We managed to talk him into letting us try Cardizem, which we said he wouldn't feel. We were just about at the hospital now, and my preceptee finished slowly pushing the drug into the IV line while our driver partner stood at the back door waiting to pull the stretcher out.
In the ED, while the nurses tried to argue with the patient that he needed another IV, and he was shouting, "No, no, no more! No IVs! It took you 4 times last week, I'll get up and leave," the doctor came in, introduced herself to the patient and asked "What brought you to the hospital?", and he smiled, looked at us and said, "the ambulance." "No, no," the amused doctor said, "Why are you here?"
Just then we looked up at the monitor and the rate was down to 120, showing an afib as the Cardizem finally kicked in. The patient said he felt much better. The rate stayed down and he and his wife were very thankful to us, and shook our hands when we said goodbye.
I'm glad my preceptee got the IV. Grace under pressure.
I wish her great luck in the future. She will be a credit to the profession.
We were still checking out our equipment when we were sent for a difficulty breathing. It was an area of one of the towns we respond to where it almost always turns out to be a major call -- either a heavy duty overdose or a big MI or serious trauma. It is a lower middle class working area with a big drinking/substance abuse problem. Anyway, when we arrived two cops were standing on the front lawn, not looking very excited. They explained the man in his forties was having trouble breathing, but the visiting nurse was in there with him. He had a host of medical problems, including ascites and pulmonary hypertension and was on home 02. The nurse said his pressure was 70 and she couldn't feel a pulse. The man was breathing about thirty times a minute with clear lungs and warm, dry skin. I tried for a pressure, but couldn't hear anything. We popped him on the monitor and he was cranking away at 200, which certainly explained it. While I felt bad for the gentleman to be in this condition, I was glad for my preceptee that she was getting a PSVT. I suggested we put him on the stretcher, do a 12 lead and then treat his rhythm right there in the living room. But when I mentioned doing an IV, the man said, "No, no IV. No IV. Uh-uh. NO!"
I hate that when that happens. We preceded to then have a battle royal about the need for an IV. He was not only adamant, but knew the right lingo. "You can't treat me. I have the right to refuse. I will not let you put an IV in me. Let the IV nurse at the hospital do it. It took them 4 tries on me Friday. Wait until the hospital. You do not have my permission."
We kept at it all the way out to the ambulance. When his wife showed up, I tried to enlist her, and she gave her best persuasive case, but to no avail. The patient was just yelling at us to get moving to the hospital if he was so seriously ill. We kept up our arguments. Your heart, particularly with your medical conditions isn't strong enough to last long beating at 200 times a minute, its just a small prick in your arm versus possible lifelong disability. We are IV professionals. We teach the IV team how to do IVs(so we fibbed on that one). He finally, surprisingly relented and agreed to let us do one IV, but only in the hand. My preceptee later said she thought I was going to push her out of the way and do the IV myself, but I told her I had faith in her and she got the IV in the hand -- a #20. The patient was very impressed. "You got it? It's in? On the 1st try? I'm sorry I gave you such a hard time, its just that they never get it."
But a problem was the IV was in the hand and adenosine is better given in a vein closer to the heart. Still you get what you can get and I have had adenosine work many times with hand veins.
The first dose of adenosine did nothing. We did it again -- this time it temporarily broke the rhythm, but caused him much distress as adenosine does when it briefly disrupts the electrical charges in the heart in an attempt to reset them. He was clutching at his chest in terror and we were shouting it will pass, it will pass, which it did (as it does) in about ten seconds, but then the heart rate went right back up to 200.
After that he didn't want anymore medicine. Our option was electricity by shocking him or try to convince him to let us try another medicine. I didn't think he was going to be happy with us placing pads on his chest and jolting him -- not at all, plus I am from past experience uncomfortable with shocking people who are talking to me(admittedly those were patients with VTack, diaphoretic and no pressure who needed immediate shocks and who did not have good prognoses). We managed to talk him into letting us try Cardizem, which we said he wouldn't feel. We were just about at the hospital now, and my preceptee finished slowly pushing the drug into the IV line while our driver partner stood at the back door waiting to pull the stretcher out.
In the ED, while the nurses tried to argue with the patient that he needed another IV, and he was shouting, "No, no, no more! No IVs! It took you 4 times last week, I'll get up and leave," the doctor came in, introduced herself to the patient and asked "What brought you to the hospital?", and he smiled, looked at us and said, "the ambulance." "No, no," the amused doctor said, "Why are you here?"
Just then we looked up at the monitor and the rate was down to 120, showing an afib as the Cardizem finally kicked in. The patient said he felt much better. The rate stayed down and he and his wife were very thankful to us, and shook our hands when we said goodbye.
I'm glad my preceptee got the IV. Grace under pressure.
I wish her great luck in the future. She will be a credit to the profession.
Monday, June 11, 2007
The MacMedic
The MacMedic, a pioneering EMS blogger, is back on the net after nearly a year absence.
Welcome back. We wish you well.
Welcome back. We wish you well.
Mediccast Live!
Tommorow night (Tuesday, June 12, 2007) at 10:00 P.M. I am going to be on the MedicCast Live call-in show discussing Precepting, Preceptors and Preceptees with Jamie Davis, the pod Medic.
MedicCast
Visit Talkshoe.com to register for free and get a pin number to login.
Talkshoe.com
The show runs for an hour.
If you miss it, you can download the show later.
MedicCast
Visit Talkshoe.com to register for free and get a pin number to login.
Talkshoe.com
The show runs for an hour.
If you miss it, you can download the show later.
Sunday, June 10, 2007
How Doctors Think
Giving a verbal report at the hospital is an art form. You want to be able to tell a story clearly and with brevity and nuance so you can accurately convey the issues the patient presents. You want to encapsulate the entirety of your physical exam, history, treatment and thirty minutes spent with the patient so the patient can be properly placed in the appropriate hospital area and treated with the appropriate concern.
I have found it frustrating lately to discover a number of hospitals have introduced computers to their triage areas. Where before, the triage nurse looked you in the eye and listened to your thirty to sixty second report, they now stare at their computer screen and have you slowly dictate the patient's name and then date of birth, and then list the complaint, as they manipulate the computer mouse or hunt and peck at the keyboard. The report still gets done, but it is more disjointed. I feel like saying to them, you ask me the questions you want to know, and I'll tell you, rather than me attempting to give any kind of narrative. I get frustrated because "the chest pain" may not be just a chest pain.
I was mentioning this to a fellow EMT when she took out a book she was reading and read me the following passage:
"Electronic technology can help organize vast clinical information and make it more accessible, but it can also drive a wedge between doctor and patient when used in this way to increase "efficiency." It also risks more cognitive errors, because the doctor's mind is set on filling in the blanks on the template. He is less likely to engage in open-ended questioning, and may be deterred from focusing on data that do not fit the template."
The passage is from a new book, How Doctors Think? by Jerome Groopman, M.D. that is a fascinating read. I recommend it to EMS providers to help understand how the modern health care system, its finance practices and time constraints can affect patient care.
(In EMS, I have never felt subject to financial constraints, but I do feel time constraints -- I need to get through this call and be available for the next one.)
The author talks about how health care providers diagnose through pattern recognition, but how this sometimes can keep us from considering a broader picture. He also talks about the dangers of the "monotony of the mundane." The flu is not always the flu.
I know I too often write my run form as I question a patient, that in "typical" calls where I have already decided what the problem is, I often ask only the questions that I need to get the answers I need to complete my report and I get impatient when the patient wanders. I often jump to conclusions on what is wrong based on pattern recognition and can tend to ignore a different story that the patient may be trying to tell.
As I wish that the nurse would listen to me instead of looking at her computer screen and trying to pigeon hole the patient into a defined category, I need to listen more to the patient instead of writing my run form, and that instead of going always with my first impression, I need to listen more to the story the patient is trying to tell. They may not be practiced in giving a perfect thirty to sixty second short story, but it will be my job to condense their story once I have gotten it out of them. I need to ask more, "What do you think is wrong?"
Early in the book, the author mentions the famous doctor William Osler who believed that if only you listen, the patient will tell you the diagnosis.
In the final chapter, the author writes:
"A doctor's office is not an assembly line. Turning it into one is a sure way to blunt communication, foster mistakes, and rupture the partnership between patient and physician. A doctor can't think with one eye on the clock and another on the computer screen...(I have) a vital partner who helps improve my thinking, a partner who may, with a few pertinent and focused questions, protect me from the cascade of cognitive pitfalls that cause misguided care. That partner is present in the moment when flesh-and-blood decision-making occurs. That partner is my patient or her family member or friend..."
I have found it frustrating lately to discover a number of hospitals have introduced computers to their triage areas. Where before, the triage nurse looked you in the eye and listened to your thirty to sixty second report, they now stare at their computer screen and have you slowly dictate the patient's name and then date of birth, and then list the complaint, as they manipulate the computer mouse or hunt and peck at the keyboard. The report still gets done, but it is more disjointed. I feel like saying to them, you ask me the questions you want to know, and I'll tell you, rather than me attempting to give any kind of narrative. I get frustrated because "the chest pain" may not be just a chest pain.
I was mentioning this to a fellow EMT when she took out a book she was reading and read me the following passage:
"Electronic technology can help organize vast clinical information and make it more accessible, but it can also drive a wedge between doctor and patient when used in this way to increase "efficiency." It also risks more cognitive errors, because the doctor's mind is set on filling in the blanks on the template. He is less likely to engage in open-ended questioning, and may be deterred from focusing on data that do not fit the template."
The passage is from a new book, How Doctors Think? by Jerome Groopman, M.D. that is a fascinating read. I recommend it to EMS providers to help understand how the modern health care system, its finance practices and time constraints can affect patient care.
(In EMS, I have never felt subject to financial constraints, but I do feel time constraints -- I need to get through this call and be available for the next one.)
The author talks about how health care providers diagnose through pattern recognition, but how this sometimes can keep us from considering a broader picture. He also talks about the dangers of the "monotony of the mundane." The flu is not always the flu.
I know I too often write my run form as I question a patient, that in "typical" calls where I have already decided what the problem is, I often ask only the questions that I need to get the answers I need to complete my report and I get impatient when the patient wanders. I often jump to conclusions on what is wrong based on pattern recognition and can tend to ignore a different story that the patient may be trying to tell.
As I wish that the nurse would listen to me instead of looking at her computer screen and trying to pigeon hole the patient into a defined category, I need to listen more to the patient instead of writing my run form, and that instead of going always with my first impression, I need to listen more to the story the patient is trying to tell. They may not be practiced in giving a perfect thirty to sixty second short story, but it will be my job to condense their story once I have gotten it out of them. I need to ask more, "What do you think is wrong?"
Early in the book, the author mentions the famous doctor William Osler who believed that if only you listen, the patient will tell you the diagnosis.
In the final chapter, the author writes:
"A doctor's office is not an assembly line. Turning it into one is a sure way to blunt communication, foster mistakes, and rupture the partnership between patient and physician. A doctor can't think with one eye on the clock and another on the computer screen...(I have) a vital partner who helps improve my thinking, a partner who may, with a few pertinent and focused questions, protect me from the cascade of cognitive pitfalls that cause misguided care. That partner is present in the moment when flesh-and-blood decision-making occurs. That partner is my patient or her family member or friend..."
Monday, June 04, 2007
Nut Allergy - Sneezing
There are certain calls you get that usually turn out to be nothing -- baby choking, person slumped over wheel of car, fall with severe bleeding. In fact, just about every call you get, usually turns out to be nothing much. That's good. Over time it is a great calmer. I usually say to myself, it's probably nothing.
We get dispatched to a seven year old having an allergic reaction to some medicine he got at church. We are being dispatched to a local supermarket where the patient will be found in a green SUV. I'm sitting in the back of the ambulance as we have a three person crew today, and my EMT partners have been working for the ambulance each for over twenty-five years so they get the front seats. I think about getting the epi out just in case, but I don't. Whenever I preprepare, it ends up as a wasted effort. I can't tell you how many packages of defib pads I opened up on the way to "cardiac arrests" when I first started -- "cardiac arrests" where we found the patients alert and talking when we arrived.
We pull up and a cop comes over and asks if I have an epi-pen. I have the house bag over my shoulder as I step out -- the med bag is in one of the main pouches. He says the boy ate some nuts or something in a brownie or cookie at a church party and he's allergic to nuts and he started throwing up, and he got hives and his eyes started swelling, so his parents got him in the car, and drove to the supermarket and got him some liquid benadryl. But they don't have his epi-pen with them.
The mother is holding the boy and I can see the eyes, still open, but swollen, and I can see some hives on his arms. He looks very pale. The mother says the boy was wheezing so they also gave him some puffs from his inhaler. I sit the med bag down on the hood of the car and take out the epi after asking the boy's age and weight, I draw up .15 mg of epi 1:1000 in a 1cc syringe. The child starts screaming when he sees the needle. The mother has to give the child to the father to hold so I can hit him with the shot. IM, instead of SQ, as our new protocols dictate. I stick the needle in and dodge a fiercesome kick. One of my partners then says to the child, its okay, no more shots. In the back of my mind, I am thinking, don't make promises you can't keep. I hope no more shots. I think they did give him some benadryl syrup so I can at least hold off on the benadryl, which would have meant another needle.
I ask the parents which hospital they want to go to, and they ask which one is closest and then they ask for directions, and then I say, no, he needs to go to the hospital in the ambulance, with us, one parent can ride along. He needs to be monitored, I say, just in case. When you ingest an allergen, the reaction can come back.
***
Many years ago I did a call for a large man who had eaten several brownies with peanuts to which he was allergic, but he said that he had been hungry and they were so good, he went ahead and had them, and hoped he wouldn't have a reaction. He was dripping with sweat and vomiting. I hit him with the epi and he was doing a whole lot better until we got to triage when I turned around to talk to the nurse and then turned back and he was out -- his BP went down to 60 and he was pale diaphoretic and mottled, and they had to hit him with more epi. He crashed again on them later in the shift. I never forgot that.
***
We get in the ambulance and the boy stops crying and the swelling around his eyes subsides, although he is still very pale. I put him on the monitor. He is afraid that the stickers will hurt, but I say no, and he lets me put them on. His heart rate of 144 slowly goes down to 116. His lungs are clear. His SAT on ambient air is 100%. We take off to the hospital, non-priority, and mom and I have a nice chat about the dangers of nut allergies, etc, while I write my report up, but still keeping an eye on the child.
I call the hospital and tell them we are just a couple minutes away with a child allergic to nuts, who had a reaction, didn't have his epi-pen, I gave epi, and the child is better. They like it short and sweet.
I'm looking at the monitor and I see the heart rate start to rise, which I find very odd. It goes to 140, and then 150, and then 160, and then 170. The SAT starts to drop as well, 96, 92, 90, 85, 80. The child looks the same. Equipment failure? I check the sensor. It is on solidly. The boy isn't shaking his finger. He sneezes. "Bless you," his mom and I say together. He sneezes again. "Bless you."
"Are you okay?" I ask.
He doesn't say anything. I stimulate him and he at least looks at me, then he sneezes again and again. I look at the SAT -- it still reads 80. As I reach for an oxygen mask and try to think how I will explain this to the parent, I notice, he is rubbing his legs. I look at where he is rubbing -- I don't see any hives, but the skin almost in front of me starts to turn red. His face is flushed now as well.
"He's having another reaction," I say.
Just like that multiplying hives appear like in some sci-fi movie of a human turning into a creature. I touch his red bumpy skin and when I move my hand off I see my finger prints. He's mottling. We're in the ER driveway now.
I have the epi out, draw it up quickly and hit him again. No resistance from him this time. For good measure, I give him some benadryl IM also. No messing around worrying about another needle. He doesn't even flinch.
Wheeling him down the hall, we navigate through a maze of stretchers, patients, staff and other EMS people and visitors. I tell the triage nurse the patient has had another reaction. The boy is crying and scratching himself. The nurse directs us to a treatment room.
The boy is doing better now, the hives have retreated almost magically, but his skin is still somewhat mottled. His Sat is up to 98%, but that's with the 02. We get him over onto the bed, and I give my report to the nurse.
They put in an IV and give him Solumedrol, and tell the mother they will have to keep him at least 24 hours for observation.
After I've written my run form I go back to the room, where the child, a non-rebreather on, the swelling much subsided around the eyes, no hives visible, sleeps under the watchful eyes of his mom, who signs the back of our run form agreeing to let us bill the insurance company, and she smiles, and thanks us for helping them, for all we did, for helping her son.
We get dispatched to a seven year old having an allergic reaction to some medicine he got at church. We are being dispatched to a local supermarket where the patient will be found in a green SUV. I'm sitting in the back of the ambulance as we have a three person crew today, and my EMT partners have been working for the ambulance each for over twenty-five years so they get the front seats. I think about getting the epi out just in case, but I don't. Whenever I preprepare, it ends up as a wasted effort. I can't tell you how many packages of defib pads I opened up on the way to "cardiac arrests" when I first started -- "cardiac arrests" where we found the patients alert and talking when we arrived.
We pull up and a cop comes over and asks if I have an epi-pen. I have the house bag over my shoulder as I step out -- the med bag is in one of the main pouches. He says the boy ate some nuts or something in a brownie or cookie at a church party and he's allergic to nuts and he started throwing up, and he got hives and his eyes started swelling, so his parents got him in the car, and drove to the supermarket and got him some liquid benadryl. But they don't have his epi-pen with them.
The mother is holding the boy and I can see the eyes, still open, but swollen, and I can see some hives on his arms. He looks very pale. The mother says the boy was wheezing so they also gave him some puffs from his inhaler. I sit the med bag down on the hood of the car and take out the epi after asking the boy's age and weight, I draw up .15 mg of epi 1:1000 in a 1cc syringe. The child starts screaming when he sees the needle. The mother has to give the child to the father to hold so I can hit him with the shot. IM, instead of SQ, as our new protocols dictate. I stick the needle in and dodge a fiercesome kick. One of my partners then says to the child, its okay, no more shots. In the back of my mind, I am thinking, don't make promises you can't keep. I hope no more shots. I think they did give him some benadryl syrup so I can at least hold off on the benadryl, which would have meant another needle.
I ask the parents which hospital they want to go to, and they ask which one is closest and then they ask for directions, and then I say, no, he needs to go to the hospital in the ambulance, with us, one parent can ride along. He needs to be monitored, I say, just in case. When you ingest an allergen, the reaction can come back.
***
Many years ago I did a call for a large man who had eaten several brownies with peanuts to which he was allergic, but he said that he had been hungry and they were so good, he went ahead and had them, and hoped he wouldn't have a reaction. He was dripping with sweat and vomiting. I hit him with the epi and he was doing a whole lot better until we got to triage when I turned around to talk to the nurse and then turned back and he was out -- his BP went down to 60 and he was pale diaphoretic and mottled, and they had to hit him with more epi. He crashed again on them later in the shift. I never forgot that.
***
We get in the ambulance and the boy stops crying and the swelling around his eyes subsides, although he is still very pale. I put him on the monitor. He is afraid that the stickers will hurt, but I say no, and he lets me put them on. His heart rate of 144 slowly goes down to 116. His lungs are clear. His SAT on ambient air is 100%. We take off to the hospital, non-priority, and mom and I have a nice chat about the dangers of nut allergies, etc, while I write my report up, but still keeping an eye on the child.
I call the hospital and tell them we are just a couple minutes away with a child allergic to nuts, who had a reaction, didn't have his epi-pen, I gave epi, and the child is better. They like it short and sweet.
I'm looking at the monitor and I see the heart rate start to rise, which I find very odd. It goes to 140, and then 150, and then 160, and then 170. The SAT starts to drop as well, 96, 92, 90, 85, 80. The child looks the same. Equipment failure? I check the sensor. It is on solidly. The boy isn't shaking his finger. He sneezes. "Bless you," his mom and I say together. He sneezes again. "Bless you."
"Are you okay?" I ask.
He doesn't say anything. I stimulate him and he at least looks at me, then he sneezes again and again. I look at the SAT -- it still reads 80. As I reach for an oxygen mask and try to think how I will explain this to the parent, I notice, he is rubbing his legs. I look at where he is rubbing -- I don't see any hives, but the skin almost in front of me starts to turn red. His face is flushed now as well.
"He's having another reaction," I say.
Just like that multiplying hives appear like in some sci-fi movie of a human turning into a creature. I touch his red bumpy skin and when I move my hand off I see my finger prints. He's mottling. We're in the ER driveway now.
I have the epi out, draw it up quickly and hit him again. No resistance from him this time. For good measure, I give him some benadryl IM also. No messing around worrying about another needle. He doesn't even flinch.
Wheeling him down the hall, we navigate through a maze of stretchers, patients, staff and other EMS people and visitors. I tell the triage nurse the patient has had another reaction. The boy is crying and scratching himself. The nurse directs us to a treatment room.
The boy is doing better now, the hives have retreated almost magically, but his skin is still somewhat mottled. His Sat is up to 98%, but that's with the 02. We get him over onto the bed, and I give my report to the nurse.
They put in an IV and give him Solumedrol, and tell the mother they will have to keep him at least 24 hours for observation.
After I've written my run form I go back to the room, where the child, a non-rebreather on, the swelling much subsided around the eyes, no hives visible, sleeps under the watchful eyes of his mom, who signs the back of our run form agreeing to let us bill the insurance company, and she smiles, and thanks us for helping them, for all we did, for helping her son.
Sunday, June 03, 2007
Katherine Howell - Frantic
I just finished reading* a great EMS-police crime/thriller written by Katherine Howell, a former Australian "ambulance officer." One of the main characters is a woman paramedic, the other is a female detective. The paramedic's husband, a police officer, gets shot and their baby is kidnapped. From that point on it is a nonstop rush to the conclusion. There are many EMS scenes -- as authentic as you will find in any book. While this is Howell's first novel, this is an incredibly accomplished thriller, filled with unexpected and shocking twists.
At the end of the book there is an excerpt from her next novel, Panic, that will be out in 2008. Like Frantic, it features a paramedic as a main character. While the book has not yet been published in the United States, it is being published in the UK, Germany, France, Italy and Russia, in addition to Australia. Hopefully, we can look forward not only to a US edition sometime soon, but many more EMS-related crime thrillers from Howell in the future.
Here's a link to an Australian on-line bookstore.
Angus & Robertson Books
Australian Crime Fiction Review of Frantic
***
* I started the book at work yesterday, got 120 pages into it, and then was slammed with four back-to back calls to end my shift at 10:00 P.M. Fortunately this morning, I was able to finish it in a sitting.
At the end of the book there is an excerpt from her next novel, Panic, that will be out in 2008. Like Frantic, it features a paramedic as a main character. While the book has not yet been published in the United States, it is being published in the UK, Germany, France, Italy and Russia, in addition to Australia. Hopefully, we can look forward not only to a US edition sometime soon, but many more EMS-related crime thrillers from Howell in the future.
Here's a link to an Australian on-line bookstore.
Angus & Robertson Books
Australian Crime Fiction Review of Frantic
***
* I started the book at work yesterday, got 120 pages into it, and then was slammed with four back-to back calls to end my shift at 10:00 P.M. Fortunately this morning, I was able to finish it in a sitting.
Saturday, June 02, 2007
Yankees Fan
Circus atmosphere:
Yankees come up big, top Red Sox in series opener
Connecticut is divided in a diagonal line between Red Sox and Yankees territory. The Red Sox rule the North Eastern section, the Yankees the South Western. There is much intermixing, however, and the center of the state (where I live) is up for grabs.
We get called for the lift assist. Man slipped getting out of his easy chair and needs help getting up. Not hurt, just needs a lift. We lift him back up and get him set comfortable in his chair in front of the TV. "You guys are great!" he says. "I hated to bother you."
"No bother at all. It's our job. It's what we do. Happy to help."
"Thanks a million."
"Call us anytime you need us."
"Will do. Next time I'll have the wife have breakfast ready for you."
"Sounds good. My partner likes her coffee black. I prefer a Diet Coke."
"Okay, I'll remember that."
"You take care now."
"Hey, how about those Yankees last night," he says.
Silence.
Then...
"Hey, how about we put you back on the floor?"
Boston Dirt Dogs
GO SAWX!
***
Note: I added this comment:
The patient was a good sport about our ribbing. I did feel bad for him, having to watch the Red Sox whup his team that afternoon.
I know someday when I am on the floor and need to be picked up, if I am still in these parts, I will be careful about saying, "Hey, how about those Red Sox?", to avoid the retribution I surely have coming to me (unless both medics are wearing Red Sox hats.)
PC
Yankees come up big, top Red Sox in series opener
Connecticut is divided in a diagonal line between Red Sox and Yankees territory. The Red Sox rule the North Eastern section, the Yankees the South Western. There is much intermixing, however, and the center of the state (where I live) is up for grabs.
We get called for the lift assist. Man slipped getting out of his easy chair and needs help getting up. Not hurt, just needs a lift. We lift him back up and get him set comfortable in his chair in front of the TV. "You guys are great!" he says. "I hated to bother you."
"No bother at all. It's our job. It's what we do. Happy to help."
"Thanks a million."
"Call us anytime you need us."
"Will do. Next time I'll have the wife have breakfast ready for you."
"Sounds good. My partner likes her coffee black. I prefer a Diet Coke."
"Okay, I'll remember that."
"You take care now."
"Hey, how about those Yankees last night," he says.
Silence.
Then...
"Hey, how about we put you back on the floor?"
Boston Dirt Dogs
GO SAWX!
***
Note: I added this comment:
The patient was a good sport about our ribbing. I did feel bad for him, having to watch the Red Sox whup his team that afternoon.
I know someday when I am on the floor and need to be picked up, if I am still in these parts, I will be careful about saying, "Hey, how about those Red Sox?", to avoid the retribution I surely have coming to me (unless both medics are wearing Red Sox hats.)
PC
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