I rise early in the morning. I shower and shave. I put on my working clothes and lace up my black boots.
It is dark outside. I drive through deserted streets to the ambulance base, where I punch in -- always fifteen minutes early (even though I don't get paid until the top of the hour).
I get the keys to the narcotics box from the duty medic, and then walk out to my ambulance. I put my backpack in the front between the seats, set my Diet Coke in the drink holder, and lay my stethoscope on the dashboard.
In the back of the ambulance, I methodically go through my gear.
Cardiac monitor -- Electrodes, defib pads, 12-lead cable, spare roll of ECG paper, ETCO2 filters both intubated and cannula. Both batteries at full power. Spare batteries on the bench. I run the user test. Everything okay.
House bag:
Intubation roll first. All the blades in working order. I leave the Mac 3 blade on the handle. One of each side tubes. Two stylets, one adult, one pedi. 2 ten cc syringes. Mouth holders, one pedi, one adult. Spare ETCO2 filter. Nasal trumpets and oral pharyngeal airways in assorted sizes. Petroleum jelly. Check.
Med Kit. 8 Epis and 3 Atropines. Bristo-jets. 4 Lidocaines and one smaller bristo jet. Two 20 unit vials of Vasopressin. Amiodarone. 2 D50s, 1 Sodium Bicarb. I check off each of the drugs in my head. Calcium, Magnesium, high dose Epi. Solumedrol. Adenosine, Toradol, ASA, NTG, Lasix, Zofran, Phenergan, Glucagon, NTG paste, Benadryl, Cardizem, Narcan, Haldol. Assorted syringes and needles. Everything in order.
IV kit - 2 catheters each size - 14s, 16s, 18s, 20s, 22s, 24s. Two saline locks, 2 saline vials, 2 10 cc syringes, 5 cc, 3 cc, 1 cc. A tourniquet, alcohol wipes, 4x4s, Venoguards. Io needle. Check. Glucometer.
Oxygen supplies. Nonrebreather, cannulas, nebulizer, albuterol, atrovent, cpap mask, ambu-bag, LMA and syringe.
1000 cc bag of Saline, Buretrol, premixed dopamine and lidocaine, 500 cc bag. Blood pressure cuffs in three sizes, pedi, adult and obese. Assorted bandages trauma dressing, burn sheet, tape and kling. Spare run form. Sharps box.
I take the keys out and open up the narc box. Two sets of drugs. 20 mg of morphine, 4 mg of Ativan and 10 mg of Versed in each. Lock them back up.
Everything on the shelves in good. More bandages, IV supplies, 02 gear. Combi-tube, emergency tracheotomy kit, EZ-IO, OB kit, mass casualty bag.
Two boards, scoop stretcher, board and collar supplies. Stair chair, Ked, traction splint. Urinal and bed pan.
Portable 02 has a 1000. On board 02 at 2000.
Suction works, house and portable.
Tourniquet hanging from the top rail. BP cuff on bench.
Lots of linen -- sheets, towells, pillow cases, bath blankets, and one heavey blanket.
Ambulance is gassed and the lights are in working order.
Only thing to do is reload the metal clipboard with run forms.
What's written on them over the next twelve hours will tell the story of the shift.
Sunday, March 30, 2008
Saturday, March 29, 2008
Removed
We get called for a medic alarm. "Eighty-year-old man having a problem with his aneurysm."
Odd.
Just before we get there we hear the first responder call for backup saying "There is a lot of blood here."
I make certain to grab a pair of gloves before I enter the house. The door is ajar. I step in and call out hello. I see an elderly woman standing in the living room. "What's going on?" I ask.
"He's in here," she says nonchalantly. "We were at the doctor yesterday."
I'm looking about for blood but I don't see any. When I get to the kitchen, I see the first responder standing holding a man up in a chair. The man's head is leaning forward. He is quite pale.
"What's going on?" I say again.
"He's out."
"He passed out?"
"No, no, he's out." I notice the responder has a finger on the man's neck. "He doesn't have a pulse."
"Well, let's get him on the ground." I grab the legs and the first responder holds under the shoulders and we lay the man down. It's then I see the blood. It is coming out of his nose and the corners of his mouth.
"We were at the doctor just yesterday," the woman says. "He has an aneurysm. The doctor had a hard time getting a pressure yesterday at the office."
"We're having a hard time too," I say. "He isn't breathing and his heart doesn't seem to be working." We already have his shirt off and are starting CPR. I put the monitor on and there is a PEA at 60.
"He uses an inhaler," the woman says. "Do you want me to look for it?"
"If you could write his name and date of birth on a piece of paper for us, that would be better."
When I open his mouth to intubate, it is like opening the lid on a bottle of dark fruit punch. Filled to the brim. With each compression, it splashes over. Mixed in with the juice are some thicker chunks.
I don't know if it is an outer body experience or not, but on calls sometimes its like I'm watching myself and I'm saying "Well, here I am on this call and it has surprise turned out to be a code, and not just a code, but a bloody, nasty one, and this sort of sucks. This may not go well." I guess it is a mechanism that lets you stay calm outwardly, while your nervous self is removed to a safer seat in the commentator booth.
"I found the inhaler," the woman says.
"Good. How are you coming on that piece of paper?"
"Right," she says.
By this time another responder has arrived and I'm telling him to get the stretcher and a board into the house.
I manage to see the epiglottis, but when I lift up with the laryngoscope, I don't see the chords underneath -- just a lot of blood. I hand the tube to my partner and using my right hand, try to apply crick pressure. With one finger I push down like I am playing the flute and the chords come into view. I have my partner put her finger right there and then give me the tube back. I pass it. "Feel it?" I say.
"Yes, I do," she says.
I look over at the capnography and there is a wave form.
That went well enough.
Blood comes flying back up the tube, but the bagging is easy. I have lung sounds on each side and nothing over the belly. The CO2 filter clogs. I put another on and I still have the wave form and the gook coming up out of the tube is less.
I get an IV and push some epi and we keep doing CPR, but we get no pulses. He is still PEA on the monitor.
"He went out right in my arms," the woman says. She is back standing in the doorway. "He lost a lot of blood. He has some allergies."
"The prognosis is very grim right now," I said. "We are breathing for him and pumping his heart for him."
"So you are," she says.
This lady is freaking me out. I have had this happen before -- a relative has no idea their family member is basically dead.
We get him onto the board and up onto our stretcher.
"You'll be taking him to city hospital?" she says.
"No, we're going to the closest hospital."
I often stop and have the family members gather around the patient so they can say goodbye before we leave the house.
"You want to say good bye. It might be your last chance."
"No, I'm coming down to the hospital. I'll see him there."
I nod to my crew to head on toward the door, and we go out doing CPR the entire way. More epi, more fluid on the trip in, but no change. At the hospital, they work him for about fifteen minutes and then call it.
When I am turning in my paperwork, I see the woman coming down the hall looking at a hand mirror as she applies powder to her cheeks.
Later the crew fills me in on a few details I missed. The kitchen sink evidently was filled with blood and thick clots. The woman who I thought was the patient's wife was actually his next door neighbor/friend.
"She was incredibly calm," my partner says.
"She certainly was." I'm thinking more that she was just plain clueless. But now, on afterthought, maybe her reaction was her defense mechanism, too. Maybe she did know her friend was dying, and just couldn't let herself show it. She had to step outside herself. I guess I'll never know. Just another EMS mystery.
I wonder what she will do tonight? Will she play bridge with friends? Will she rent an old comedy and watch it while eating popcorn? Before bed, when she looks into the mirror at the deep lines in her face, will she wonder how much time she has left? Will she cry into her pillow? Will her sleep be dreamless?
Odd.
Just before we get there we hear the first responder call for backup saying "There is a lot of blood here."
I make certain to grab a pair of gloves before I enter the house. The door is ajar. I step in and call out hello. I see an elderly woman standing in the living room. "What's going on?" I ask.
"He's in here," she says nonchalantly. "We were at the doctor yesterday."
I'm looking about for blood but I don't see any. When I get to the kitchen, I see the first responder standing holding a man up in a chair. The man's head is leaning forward. He is quite pale.
"What's going on?" I say again.
"He's out."
"He passed out?"
"No, no, he's out." I notice the responder has a finger on the man's neck. "He doesn't have a pulse."
"Well, let's get him on the ground." I grab the legs and the first responder holds under the shoulders and we lay the man down. It's then I see the blood. It is coming out of his nose and the corners of his mouth.
"We were at the doctor just yesterday," the woman says. "He has an aneurysm. The doctor had a hard time getting a pressure yesterday at the office."
"We're having a hard time too," I say. "He isn't breathing and his heart doesn't seem to be working." We already have his shirt off and are starting CPR. I put the monitor on and there is a PEA at 60.
"He uses an inhaler," the woman says. "Do you want me to look for it?"
"If you could write his name and date of birth on a piece of paper for us, that would be better."
When I open his mouth to intubate, it is like opening the lid on a bottle of dark fruit punch. Filled to the brim. With each compression, it splashes over. Mixed in with the juice are some thicker chunks.
I don't know if it is an outer body experience or not, but on calls sometimes its like I'm watching myself and I'm saying "Well, here I am on this call and it has surprise turned out to be a code, and not just a code, but a bloody, nasty one, and this sort of sucks. This may not go well." I guess it is a mechanism that lets you stay calm outwardly, while your nervous self is removed to a safer seat in the commentator booth.
"I found the inhaler," the woman says.
"Good. How are you coming on that piece of paper?"
"Right," she says.
By this time another responder has arrived and I'm telling him to get the stretcher and a board into the house.
I manage to see the epiglottis, but when I lift up with the laryngoscope, I don't see the chords underneath -- just a lot of blood. I hand the tube to my partner and using my right hand, try to apply crick pressure. With one finger I push down like I am playing the flute and the chords come into view. I have my partner put her finger right there and then give me the tube back. I pass it. "Feel it?" I say.
"Yes, I do," she says.
I look over at the capnography and there is a wave form.
That went well enough.
Blood comes flying back up the tube, but the bagging is easy. I have lung sounds on each side and nothing over the belly. The CO2 filter clogs. I put another on and I still have the wave form and the gook coming up out of the tube is less.
I get an IV and push some epi and we keep doing CPR, but we get no pulses. He is still PEA on the monitor.
"He went out right in my arms," the woman says. She is back standing in the doorway. "He lost a lot of blood. He has some allergies."
"The prognosis is very grim right now," I said. "We are breathing for him and pumping his heart for him."
"So you are," she says.
This lady is freaking me out. I have had this happen before -- a relative has no idea their family member is basically dead.
We get him onto the board and up onto our stretcher.
"You'll be taking him to city hospital?" she says.
"No, we're going to the closest hospital."
I often stop and have the family members gather around the patient so they can say goodbye before we leave the house.
"You want to say good bye. It might be your last chance."
"No, I'm coming down to the hospital. I'll see him there."
I nod to my crew to head on toward the door, and we go out doing CPR the entire way. More epi, more fluid on the trip in, but no change. At the hospital, they work him for about fifteen minutes and then call it.
When I am turning in my paperwork, I see the woman coming down the hall looking at a hand mirror as she applies powder to her cheeks.
Later the crew fills me in on a few details I missed. The kitchen sink evidently was filled with blood and thick clots. The woman who I thought was the patient's wife was actually his next door neighbor/friend.
"She was incredibly calm," my partner says.
"She certainly was." I'm thinking more that she was just plain clueless. But now, on afterthought, maybe her reaction was her defense mechanism, too. Maybe she did know her friend was dying, and just couldn't let herself show it. She had to step outside herself. I guess I'll never know. Just another EMS mystery.
I wonder what she will do tonight? Will she play bridge with friends? Will she rent an old comedy and watch it while eating popcorn? Before bed, when she looks into the mirror at the deep lines in her face, will she wonder how much time she has left? Will she cry into her pillow? Will her sleep be dreamless?
Friday, March 28, 2008
Mistakes
The hospitals have been really overcrowded lately. I had two calls the other day that are becoming increasingly common.* The first was for a woman with a low oxygen saturation called in by the visiting nurse who was concerned the 90-year-old woman's oxygen saturation was at 90, her heart rate 100, and her BP 180/90. The woman herself had no complaint other than the effects of age. She spent most of her day in front of the TV and didn't want to be a bother to anyone, but she did require a good deal of assistance just standing and pivoting onto our stretcher.
The second patient was a sixty-seven-year old woman with arthritis who's right knee was quite badly swollen. Unfortunately for us she lived on the second floor in one of those houses where the stairway had two flights just to get to the second floor. She wasn't able to walk herself and her son had called us only after being unable to move her himself.
When I told the triage nurse that the 90-year-old woman had no complaints herself and that her saturation on a few liters of oxygen was now 100 and that we had only been called because the visiting nurse was concerned, I saw immediately in the triage nurse's eyes that this patient could be dismissed as another bother to be put in the hallway. I tried to reemphasize the woman was weak, frail and had a history of CHF, but the nurse was too busy typing the patient's meds into her computer. We were told to put her in the hallway. Of course we had to then find a bed, make a bed and then find an oxygen tank for the bed. When I came back two hours later, she was still there and had yet to be seen. She was frightened since she was there by herself and had no one to advocate for her. I mentioned to the nurse that no one had seen her yet. She asked me if she was stable and I couldn't say she wasn't and the nurse quickly said, we're really busy. And they clearly were. Over head I heard a page for two more incoming medical alerts.
The woman with the swollen knee, taken to the other hospital, was dispatched immediately by wheelchair to the waiting room. She could sit up so better out there than taking up a scarce bed in the main ED. We found a couple pillows that helped better cushion her in the chair and left her at the desk after giving the external triage nurse a quick report.
Four hours after leaving the woman in the waiting room we were dispatched back to her house for a fall. The dispatch didn't seem right as we had just been there and transported the woman of the same age they were saying this patient was. Dispatch confirmed it was the proper address. When we got there we found the same woman and her son in the living room. She was on the ground leaning against the wall. Evidently, she had been discharged with a prescription for pain medicine and sent home. Somehow her son had managed to get her up the front steps and into the house, but when he'd told her to wait by the door while he ran upstarirs and got her commode, she had lost balance, fallen and hit her head. She was trembling to such a point that I did not think she recognized me. Her neck, back and right shoulder hurt. We c-spined her and as we were carrying from the house on a board, two of her other sons arrived and began yelling at the son who had been with her, blaming him for everything that had happened to the point where this tall strong son was in tears.
As for the 90-year-old woman, I learned the next week that an ambulance crew of ours picked her up at home the next day this time for shortness of breath. She had been sent home after a six-hour wait only to now the next day be back at the hospital, finally admitted for pneumonia. the visiting nurse, who knew the patient, was on to the fact that something was going wrong. The message got lost in the system.
I have titled this post "Mistakes" and I am not saying neccessarily that there were mistakes made on the initial care of these two women, although clearly you could have wished for better prompter care, care more aware of the patients as people -- holistic care.
My point is that in today's world with rising medical costs and short staffing, high taxes, rising poverty, an aging population and a host of other factors, the environment is not forgiving. A growing pneumonia can be missed, a woman can be sent home to a home that she can not live in safely.
Ambulances and ERs maybe shouldn't be the clearinghouses for all medical and social problems, but it doesn't change the fact that's what they have become.
I could have advocated more strongly for the 90-year-old woman and won her a better placement in the ER, but that might have come at the expense of another borderline patient. I could have thought to point out to the son of the woman with the swollen knee that in the likely event his mother was sent home, he should make sure he had more help there to get her in the house. I could have ofered to have him call us to help him carry her back into the house. Niether neccessarily my jobs, but both of these patients could have had better outcomes if more responsibility had been taken for them beyond wanting to, in the words of one ED physician, "move'em in and move'em out."
This is all a preface to an article I read in the New York Times called A Doctor's View of Medical Mistakes which is an interview with a doctor whose life was devestated by a mistake made by his medical team many years before. The Day Joy Died is the article he wrote about it.
There are mistakes of many degrees. Fortunately the catastrophic mistake made by the doctor's team -- an esophageal intubation -- is much harder to do nowdays because of capnography's ability to detect bad intubations. Long ago in one of my books, I wrote about an asthmatic patient I had who was in respiratory arrest when I arrived on scene, and who I had a very diffciult time bagging and then intubating. She arrested, but we got her back, athough she suffered an anoxic brain injury. To this day I still think if only I had been better at my job she might be living a full life rather than dying a few years later of an infection in a nursing home after never regaining the ability to even recognize people. Being less than perfect has its consequences.
The other day I was working on a city ambulance and needed to give my patient Zofran for their nausea. As we traveled through the streets toward the hospital, instead of getting up and reaching for my house bag (the med kit) which was beyond my initial reach, I reached into one of the cabinents and took out the small plastic bin of spare drugs and fished out a green topped drug vial. I was just about to clip off the cap when I noticed the color scheme was a little off. The cap was too green. I looked harder at the vial. Vasopressin. Oops. While I did not even open the top, with a sudden distraction, I might have committed a fatal error. Vasopressin and Zofran are in different areas of my med kit. I would never mistake them. But here, by slightly altering my routine I exposed myself to a situation that with other alterations, could have led to disaster. The patient suddenly vomiting, might have caused me to forget the important step of reading the vial label instead of just assuming I had the right med due to its size and near same color(the light in the ambulance was distorted and caused the green to not be as distinct). And then you inject the wrong medicine and there you are in the midst of it -- your patient crashing and then you look down and see the empty vial and reading it, think oh f----!
What does this all mean? There are degrees of mistakes and none of us are infalliable or seers of the future, but as busy as we get, we need to always be vigilant and always consider what is at stake. It can't be, despite the load upon us, just a matter of moving'em in and moving'em out. We forget sometimes that our "calls" are people even when we are treating them well in the moment. Our responsibility goes beyond a smile and pleasant manner. Who is going to look out for the 90-year-old woman by herself after we go? How is that woman with the swollen knee going to get back in her house with just her son? What happens if I stop double-checking my meds as a part of my normal routine because it has never been a problem before?
And the same goes for looking out for ourselves. A little mistake, a moment's innattention can wreak havoac on our lives as well, whether it's suddenly getting creamed in an accident or to not be vigilant to our own or someone else's medical error and the resulting burden upon so many lives.
We are far from perfect, but the stakes in this game require our daily efforts to be perfect despite all the obstacles we face.
Best of luck and fortune to all of us and our patients.
Here's an old post I wrote on EMS Mistakes, which also gets into the topic of ambulance safety.
* multiple ambulance calls and ED stays.
The second patient was a sixty-seven-year old woman with arthritis who's right knee was quite badly swollen. Unfortunately for us she lived on the second floor in one of those houses where the stairway had two flights just to get to the second floor. She wasn't able to walk herself and her son had called us only after being unable to move her himself.
When I told the triage nurse that the 90-year-old woman had no complaints herself and that her saturation on a few liters of oxygen was now 100 and that we had only been called because the visiting nurse was concerned, I saw immediately in the triage nurse's eyes that this patient could be dismissed as another bother to be put in the hallway. I tried to reemphasize the woman was weak, frail and had a history of CHF, but the nurse was too busy typing the patient's meds into her computer. We were told to put her in the hallway. Of course we had to then find a bed, make a bed and then find an oxygen tank for the bed. When I came back two hours later, she was still there and had yet to be seen. She was frightened since she was there by herself and had no one to advocate for her. I mentioned to the nurse that no one had seen her yet. She asked me if she was stable and I couldn't say she wasn't and the nurse quickly said, we're really busy. And they clearly were. Over head I heard a page for two more incoming medical alerts.
The woman with the swollen knee, taken to the other hospital, was dispatched immediately by wheelchair to the waiting room. She could sit up so better out there than taking up a scarce bed in the main ED. We found a couple pillows that helped better cushion her in the chair and left her at the desk after giving the external triage nurse a quick report.
Four hours after leaving the woman in the waiting room we were dispatched back to her house for a fall. The dispatch didn't seem right as we had just been there and transported the woman of the same age they were saying this patient was. Dispatch confirmed it was the proper address. When we got there we found the same woman and her son in the living room. She was on the ground leaning against the wall. Evidently, she had been discharged with a prescription for pain medicine and sent home. Somehow her son had managed to get her up the front steps and into the house, but when he'd told her to wait by the door while he ran upstarirs and got her commode, she had lost balance, fallen and hit her head. She was trembling to such a point that I did not think she recognized me. Her neck, back and right shoulder hurt. We c-spined her and as we were carrying from the house on a board, two of her other sons arrived and began yelling at the son who had been with her, blaming him for everything that had happened to the point where this tall strong son was in tears.
As for the 90-year-old woman, I learned the next week that an ambulance crew of ours picked her up at home the next day this time for shortness of breath. She had been sent home after a six-hour wait only to now the next day be back at the hospital, finally admitted for pneumonia. the visiting nurse, who knew the patient, was on to the fact that something was going wrong. The message got lost in the system.
I have titled this post "Mistakes" and I am not saying neccessarily that there were mistakes made on the initial care of these two women, although clearly you could have wished for better prompter care, care more aware of the patients as people -- holistic care.
My point is that in today's world with rising medical costs and short staffing, high taxes, rising poverty, an aging population and a host of other factors, the environment is not forgiving. A growing pneumonia can be missed, a woman can be sent home to a home that she can not live in safely.
Ambulances and ERs maybe shouldn't be the clearinghouses for all medical and social problems, but it doesn't change the fact that's what they have become.
I could have advocated more strongly for the 90-year-old woman and won her a better placement in the ER, but that might have come at the expense of another borderline patient. I could have thought to point out to the son of the woman with the swollen knee that in the likely event his mother was sent home, he should make sure he had more help there to get her in the house. I could have ofered to have him call us to help him carry her back into the house. Niether neccessarily my jobs, but both of these patients could have had better outcomes if more responsibility had been taken for them beyond wanting to, in the words of one ED physician, "move'em in and move'em out."
This is all a preface to an article I read in the New York Times called A Doctor's View of Medical Mistakes which is an interview with a doctor whose life was devestated by a mistake made by his medical team many years before. The Day Joy Died is the article he wrote about it.
There are mistakes of many degrees. Fortunately the catastrophic mistake made by the doctor's team -- an esophageal intubation -- is much harder to do nowdays because of capnography's ability to detect bad intubations. Long ago in one of my books, I wrote about an asthmatic patient I had who was in respiratory arrest when I arrived on scene, and who I had a very diffciult time bagging and then intubating. She arrested, but we got her back, athough she suffered an anoxic brain injury. To this day I still think if only I had been better at my job she might be living a full life rather than dying a few years later of an infection in a nursing home after never regaining the ability to even recognize people. Being less than perfect has its consequences.
The other day I was working on a city ambulance and needed to give my patient Zofran for their nausea. As we traveled through the streets toward the hospital, instead of getting up and reaching for my house bag (the med kit) which was beyond my initial reach, I reached into one of the cabinents and took out the small plastic bin of spare drugs and fished out a green topped drug vial. I was just about to clip off the cap when I noticed the color scheme was a little off. The cap was too green. I looked harder at the vial. Vasopressin. Oops. While I did not even open the top, with a sudden distraction, I might have committed a fatal error. Vasopressin and Zofran are in different areas of my med kit. I would never mistake them. But here, by slightly altering my routine I exposed myself to a situation that with other alterations, could have led to disaster. The patient suddenly vomiting, might have caused me to forget the important step of reading the vial label instead of just assuming I had the right med due to its size and near same color(the light in the ambulance was distorted and caused the green to not be as distinct). And then you inject the wrong medicine and there you are in the midst of it -- your patient crashing and then you look down and see the empty vial and reading it, think oh f----!
What does this all mean? There are degrees of mistakes and none of us are infalliable or seers of the future, but as busy as we get, we need to always be vigilant and always consider what is at stake. It can't be, despite the load upon us, just a matter of moving'em in and moving'em out. We forget sometimes that our "calls" are people even when we are treating them well in the moment. Our responsibility goes beyond a smile and pleasant manner. Who is going to look out for the 90-year-old woman by herself after we go? How is that woman with the swollen knee going to get back in her house with just her son? What happens if I stop double-checking my meds as a part of my normal routine because it has never been a problem before?
And the same goes for looking out for ourselves. A little mistake, a moment's innattention can wreak havoac on our lives as well, whether it's suddenly getting creamed in an accident or to not be vigilant to our own or someone else's medical error and the resulting burden upon so many lives.
We are far from perfect, but the stakes in this game require our daily efforts to be perfect despite all the obstacles we face.
Best of luck and fortune to all of us and our patients.
Here's an old post I wrote on EMS Mistakes, which also gets into the topic of ambulance safety.
* multiple ambulance calls and ED stays.
Wednesday, March 26, 2008
LINGUAL NITRO
Received a fascinating comment on my 29 Ways to Lift Your Tongue post.
"Check into this but from what I was just told by my mentor is that Nitro Spray doesn't have to go under the tongue. You can just spray it like breath spray or aim for a cheek. I haven't checked but it's even says it on the insert."
I went to the insert myself and here's what it said:
"...spray onto or under the tongue."
and later:
..."preferably onto or under the tongue."
Here's a web site for NITROLINGUAL that says the same thing.
But my Emergency and Critical Care Pocket Guide
says:
Nitrogylcerin spray (NITROLINGUAL) 1-2 sprays 90.4 - 0.8 mg) under the tongue.
However, the American Heart Association ACS Guideline says nitro "sublingual, spray or IV" which suggests sublingual and spray are not one and the same. It later says, "patients with ischemic chest discomfort may receive up to three doses sublingual or aerosol nitroglycerin..."
I did a random sample of several medics today and everyone told me they spray NTG under the tongue. It's supposed to be sublingal, they said.
Yeah, that's what I always thought, but...
While I haven't talked to a ED doctor yet, the evidence based on the insert and the AHA is pretty clear to me that spraying on the tongue (Lingual)is acceptable.
While I may continue to ask patients to lift up their tongue. If they don't. I'm just going to spray their tongue. Barring of course any new information or edicts from my medical control. I'll post an addendum after I've had a chance to ask them.
Thanks again to the commentator for pointing this out. You learn something new everyday it seems.
I am curious how many other medics out there knew about this. In the days before the spray everything was always sublingual. When we got the spray, maybe we all assumed Nitro was still sublingual. For you newer medics, what were you taught in school?
"Check into this but from what I was just told by my mentor is that Nitro Spray doesn't have to go under the tongue. You can just spray it like breath spray or aim for a cheek. I haven't checked but it's even says it on the insert."
I went to the insert myself and here's what it said:
"...spray onto or under the tongue."
and later:
..."preferably onto or under the tongue."
Here's a web site for NITROLINGUAL that says the same thing.
But my Emergency and Critical Care Pocket Guide
says:Nitrogylcerin spray (NITROLINGUAL) 1-2 sprays 90.4 - 0.8 mg) under the tongue.
However, the American Heart Association ACS Guideline says nitro "sublingual, spray or IV" which suggests sublingual and spray are not one and the same. It later says, "patients with ischemic chest discomfort may receive up to three doses sublingual or aerosol nitroglycerin..."
I did a random sample of several medics today and everyone told me they spray NTG under the tongue. It's supposed to be sublingal, they said.
Yeah, that's what I always thought, but...
While I haven't talked to a ED doctor yet, the evidence based on the insert and the AHA is pretty clear to me that spraying on the tongue (Lingual)is acceptable.
While I may continue to ask patients to lift up their tongue. If they don't. I'm just going to spray their tongue. Barring of course any new information or edicts from my medical control. I'll post an addendum after I've had a chance to ask them.
Thanks again to the commentator for pointing this out. You learn something new everyday it seems.
I am curious how many other medics out there knew about this. In the days before the spray everything was always sublingual. When we got the spray, maybe we all assumed Nitro was still sublingual. For you newer medics, what were you taught in school?
Tuesday, March 25, 2008
Medicine for Paramedics
I think I am finally getting over my illness, although I am still dragging a bit. Since going most of the winter without being sick, this one has hit me hard. I think I may in fact have been knocked down by one bug and then been dinged by another on top of it.
Here's what I have given myself at various points in the last two weeks to keep myself up right and walking:
Tylenol
Vicks Day Quill
Afrin
Benadryl
Motrin
Musinex
Peptobismal
Immodium
Gatorade
Pedilyte
I've managed, with well-timed days off (spent laying in bed), to not miss a scheduled day of work.
Of course, the only patients I have had during this time, for the most part, have been patients with the flu and or stomach bugs themselves.
Here's what I have given them:
Oxygen for their labored breathing
some neb treatments for those wheezing
Lots of bags of normal saline for vomiting, diarrhea, dehydration
Lots of vials of Zofran for nausea, upset stomachs
Some I have even carried down from the third floor. Almost all of them, I have fluffed their pillows and handed them Kleenex and/or emesis basins.
Some days I wish I could carry myself down three floors.
A 20 gauge in my arm wouldn't be bad either -- a liter or two of saline would beat the Pedilyte. And then of course after napping for a few hours on a bed in the hospital hallway, I could carry myself on back home.
This is becoming an annual topic:
Sick 2007
Sick 2006
Here's what I have given myself at various points in the last two weeks to keep myself up right and walking:
Tylenol
Vicks Day Quill
Afrin
Benadryl
Motrin
Musinex
Peptobismal
Immodium
Gatorade
Pedilyte
I've managed, with well-timed days off (spent laying in bed), to not miss a scheduled day of work.
Of course, the only patients I have had during this time, for the most part, have been patients with the flu and or stomach bugs themselves.
Here's what I have given them:
Oxygen for their labored breathing
some neb treatments for those wheezing
Lots of bags of normal saline for vomiting, diarrhea, dehydration
Lots of vials of Zofran for nausea, upset stomachs
Some I have even carried down from the third floor. Almost all of them, I have fluffed their pillows and handed them Kleenex and/or emesis basins.
Some days I wish I could carry myself down three floors.
A 20 gauge in my arm wouldn't be bad either -- a liter or two of saline would beat the Pedilyte. And then of course after napping for a few hours on a bed in the hospital hallway, I could carry myself on back home.
This is becoming an annual topic:
Sick 2007
Sick 2006
Friday, March 21, 2008
29 Ways To Lift Your Tongue
We can't use digital cameras on the ambulance, which if you leave aside the patient's important right to privacy, is a shame because I could really post interesting pictures about this line of work.
I was thinking yesterday while trying to spray some nitro under a patient's tongue about doing a photo montage/art exhibit called "29 Ways to Lift Your Tongue so the Medic Still Cannot Spray Nitro Under It."
Some people can't follow directions. Some people apparently have limited use of their tongue muscles. Some also can contort their tongues in amazing ways that still nonetheless obstruct the medic from spraying the medicine under their tongues.
"Lift up your tongue. Don't Stick it Out. No, no, lift it up so I can spray -- No, I need to spray this under your tongue. No, LIFT, LIFT Up your tongue. Touch your tongue to the roof of your mouth. No, NO, not like that. Like this. No NO, Like this. Don't Stick it out. Lift it. I need to spray under, UNDER your tongue. Behind your bottom front teeth. LIFT. LIFT. NO. NOT LIKE THAT. NOT LIKE THAT."
The contortions.
The endless, bizarre tongue contortions.
Sometimes I end up grabbing their tongue with my gloved hand and lifting it up myself so I can spray the nitro under it.
In the old days when we had nitro tablets, you could stick a straw under their tongue and drop the tablet down that way. On this day, just as I get a space to squirt the nitro in, the patient's tongue comes down and the nitro sprays on top of their tongue, causing them to make all kinds of sour faces as they complain about the awful taste.
I just shake my head.
If we could use digital cameras, I'd have some pictures, some real beauties.
At the opening of my exhibit in New York, I'd be the bearded man in a beret leaning against the wall, watching as beautiful people, sipping wine, wandered about looking at my photographs. Genius, they'd whisper reverently. Pure genius.
I was thinking yesterday while trying to spray some nitro under a patient's tongue about doing a photo montage/art exhibit called "29 Ways to Lift Your Tongue so the Medic Still Cannot Spray Nitro Under It."
Some people can't follow directions. Some people apparently have limited use of their tongue muscles. Some also can contort their tongues in amazing ways that still nonetheless obstruct the medic from spraying the medicine under their tongues.
"Lift up your tongue. Don't Stick it Out. No, no, lift it up so I can spray -- No, I need to spray this under your tongue. No, LIFT, LIFT Up your tongue. Touch your tongue to the roof of your mouth. No, NO, not like that. Like this. No NO, Like this. Don't Stick it out. Lift it. I need to spray under, UNDER your tongue. Behind your bottom front teeth. LIFT. LIFT. NO. NOT LIKE THAT. NOT LIKE THAT."
The contortions.
The endless, bizarre tongue contortions.
Sometimes I end up grabbing their tongue with my gloved hand and lifting it up myself so I can spray the nitro under it.
In the old days when we had nitro tablets, you could stick a straw under their tongue and drop the tablet down that way. On this day, just as I get a space to squirt the nitro in, the patient's tongue comes down and the nitro sprays on top of their tongue, causing them to make all kinds of sour faces as they complain about the awful taste.
I just shake my head.
If we could use digital cameras, I'd have some pictures, some real beauties.
At the opening of my exhibit in New York, I'd be the bearded man in a beret leaning against the wall, watching as beautiful people, sipping wine, wandered about looking at my photographs. Genius, they'd whisper reverently. Pure genius.
Thursday, March 20, 2008
Ten Feet Tall Again
Rick is standing against the wall of the EMS room when I walk in to write my report.
“My hero,” he says.
“No, you’re my hero,” I say.
Rick has been a medic a few years longer than I have, but he has been in EMS way more years. He started as a boy and dates back to the Cadillac days. When I started as a medic in the city in 1995, back when our smaller ambulance company covered the entire town, I was a medic in the north end and Rick was a medic in the south end. We never had more than six medics on at a time, and occasionally just had the two of us. Sometimes I went south to help him on a bad car wreck or he’d come north to back me up on a multiple patient shooting.
Things have changed. We got bought out by a large national company and our new company ceded the south end to another service as part of a politically negotiated settlement. Our company has a lot more medics now (it isn't unusual to have 15 on at a time) as well as a dispatch policy that often doesn’t seem to differentiate between ALS and BLS units so we are as likely to be doing a transfer as a 911 call. Instead of being posted in the same location when we weren't on a call – for Rick it was Area 4 - the city hospital, for me it was Area 3 -- the catholic hospital, we are now constantly on the move from street corner posting to street corner posting, from town to town. Some days we can drive for two hours and never do a call or reach a destination. Area 9, no make that 13. Area 16. Back to 9. Go Downtown. Head to this suburb. Head for 8. Back to 13. It takes a toll on an older body.
We get to talking about work. It’s just not like the old days, he says. I share the same complaints. The calls aren’t as good. There are a lot of new medics who seem to practice only out of the cook book (To be truthful, I have heard this complaint ever since I started). Half the time you are working with a new partner who doesn’t know the streets. People aren’t as passionate. It’s a business now.
We talk about some of the medics and EMTs we used to work with. Two are doctors, one is a lawyer. There are a few nurses. Some left the medical field all together to do sales or work construction. A few are in mental institutions. A few have dropped off the face of the earth. Several are dead. And then there are those of us still out here on the streets, a little blurry, worse for wear and tear.
I ask him if he is burned out and he says, “No, I still love my job.” It’s just that the good calls don’t seem to be as good as they used to be and there aren’t as many of them.
I tell him some stuff is for the better. We have twelve leads now. Capnography. CPAP and the EZ IO Drill. He just shakes his head and says nothing and I get the sense he thinks when it really comes down to it, technology is all a lot of toys.
Some days I watch him, as I wait in the triage line with my patient, and he walks by with a new partner, wheeling their stretcher into the hospital to pick up a patient upstairs going to a nursing home for rehab or taking someone home to a distant town, and I think what a waste of talent. Not like the old days when I’d be standing in the midst of chaos and look up and see him step out of his ambulance like John Wayne with a smile on his face – the cavalry come to save the day. “Good to see you,” he’d say, walking over to shake my hand. “What do you have for me?”
Today, his pager buzzes. He looks down and reads it. I can see his eyes straining to make out the message. “Transfer coming out,” he says.
“My hero,” I say to him as he leaves.
“And you are mine,” he says.
Oh, for the old days. To be ten feet tall again.
“My hero,” he says.
“No, you’re my hero,” I say.
Rick has been a medic a few years longer than I have, but he has been in EMS way more years. He started as a boy and dates back to the Cadillac days. When I started as a medic in the city in 1995, back when our smaller ambulance company covered the entire town, I was a medic in the north end and Rick was a medic in the south end. We never had more than six medics on at a time, and occasionally just had the two of us. Sometimes I went south to help him on a bad car wreck or he’d come north to back me up on a multiple patient shooting.
Things have changed. We got bought out by a large national company and our new company ceded the south end to another service as part of a politically negotiated settlement. Our company has a lot more medics now (it isn't unusual to have 15 on at a time) as well as a dispatch policy that often doesn’t seem to differentiate between ALS and BLS units so we are as likely to be doing a transfer as a 911 call. Instead of being posted in the same location when we weren't on a call – for Rick it was Area 4 - the city hospital, for me it was Area 3 -- the catholic hospital, we are now constantly on the move from street corner posting to street corner posting, from town to town. Some days we can drive for two hours and never do a call or reach a destination. Area 9, no make that 13. Area 16. Back to 9. Go Downtown. Head to this suburb. Head for 8. Back to 13. It takes a toll on an older body.
We get to talking about work. It’s just not like the old days, he says. I share the same complaints. The calls aren’t as good. There are a lot of new medics who seem to practice only out of the cook book (To be truthful, I have heard this complaint ever since I started). Half the time you are working with a new partner who doesn’t know the streets. People aren’t as passionate. It’s a business now.
We talk about some of the medics and EMTs we used to work with. Two are doctors, one is a lawyer. There are a few nurses. Some left the medical field all together to do sales or work construction. A few are in mental institutions. A few have dropped off the face of the earth. Several are dead. And then there are those of us still out here on the streets, a little blurry, worse for wear and tear.
I ask him if he is burned out and he says, “No, I still love my job.” It’s just that the good calls don’t seem to be as good as they used to be and there aren’t as many of them.
I tell him some stuff is for the better. We have twelve leads now. Capnography. CPAP and the EZ IO Drill. He just shakes his head and says nothing and I get the sense he thinks when it really comes down to it, technology is all a lot of toys.
Some days I watch him, as I wait in the triage line with my patient, and he walks by with a new partner, wheeling their stretcher into the hospital to pick up a patient upstairs going to a nursing home for rehab or taking someone home to a distant town, and I think what a waste of talent. Not like the old days when I’d be standing in the midst of chaos and look up and see him step out of his ambulance like John Wayne with a smile on his face – the cavalry come to save the day. “Good to see you,” he’d say, walking over to shake my hand. “What do you have for me?”
Today, his pager buzzes. He looks down and reads it. I can see his eyes straining to make out the message. “Transfer coming out,” he says.
“My hero,” I say to him as he leaves.
“And you are mine,” he says.
Oh, for the old days. To be ten feet tall again.
Monday, March 17, 2008
"I Want the Wide Stretcher"
I had an interesting scenario this weekend that I think could be a harbinger of things to come in EMS.
With the growing obesity in the population, ambulance companies have started putting bariatric ambulances on line. The ambulances come equipped with special wide load stretchers that more comfortably accommodate the larger patient.
Years ago before these ambulances came on line, we often had to move the stretcher mounts on the ambulance from the side to the center to enable the patient (bulging over the sides of the stretcher) to fit in the back of the ambulance provided the stretcher could bear the patient's weight. If the stretcher couldn't bear the weight we sometimes put the patient in a fire department Stokes basket or, in rare cases, the patient was transported to the ambulance on the back of a flatbed truck.
Now that these bariatric ambulances are out on the road, some interesting dilemmas have come up.
When I work in the city, our company has one bariatric ambulance that sometimes is out on a call and is not immediately available when I arrive on scene to find a larger patient. So what do I do? Delay transport until the big ambulance is available or follow the old stokes/flatbed routine? Obviously, it depends on the patient size and condition.
I described such a scenario back in 2005.
"You're Going to Need a Bigger Ambulance"
Now three days a week I am contracted to a suburban service that does not have a bariatric ambulance. What do we do? Again it depends on the patient condition.
Here's what happened this weekend.
We are called for chest pain. We arrive to find a large patient, estimated by the nursing home to be just under 400 pounds, who tells us he has been having chest pain for a week. The pain increases on palpation of his sternum. The patient appears quite stable, is in no distress, and is in fact, eating lunch when we arrive. I have had this patient before, so on seeing him, I know what to expect.
"I'm not getting on that stretcher," he says looking at our regular size stretcher.
"You are if you are having chest pain and want us to take you to the hospital," I say.
"I'm not getting on it. Bring the wide stretcher."
"This stretcher is certified for up to 500 pounds."
"I'm not getting on it."
To be fair to the patient, it is not just an issue of pounds, the patient is as wide as he is long. The stretcher appears to be easily less than a third of his width. More of him will hang off each side of the stretcher than be centered on it.
This is also my third encounter with this same patient. On one occasion, I was working for the suburban service. On the other, I was working for the commercial service. In both cases the patient was stable, and the call was more of a request for transportation for evaluation than an immediate need for treatment.
I go back and forth with the patient.
"You should buy a wide stretcher for patients like me."
"A point to be considered," I say, "But that doesn't change the fact that right now, we don't have a wider stretcher. This is it."
I again fully advise him of the dangers and consequences of his refusing to let us put him on our stretcher.
"I want the wide stretcher."
I finally tell him I will call the commercial service and see if they can send out their big ambulance with its wide stretcher for him.
"That's what you should have done in the first place instead of arguing with me," he says.
I go to the nurses's station and call the commercial service. I explain the situation("You need to understand -- he will not let us put him on our stretcher. He is alert, competent and refusing us.") They finally agree to send out the big ambulance. They add it will be about 90 minutes before they can get there.
After sharing this information with the patient, I again advise him to let us transport him on our stretcher.
"That's fine. I'll wait. I'm not getting on your stretcher."
We tell him and the staff to call back should he change his mind or if they feel his situation is deteriorating. He signs a refusal and goes back to eating his lunch.
This is just what happened when I worked for the suburban service the last time. In the one instance when I worked for the commercial service, I had to convince our dispatcher to send out the big ambulance because, despite the fact the patient was just under 400 pounds and did not meet the weight criteria mandating the larger ambulance, he simply would not get on our stretcher. In both cases, the big ambulance eventually came and the patient was transported non-priority.
Now as more and more large size patients become aware of the wider stretchers, similar scenarios can be expected to play out.
"I'm not getting on it. Bring the wide stretcher."
It is not too much of a stretch to imagine that all ambulance services, commercial and volunteer, large and small, will one day have to provide the wider stretcher due not just to the burgeoning size of the population but to the simple availability of a more comfortable, and in some cases, more humane, stretcher.
In the meantime, I just worry about the time when the patient is in true distress and still refuses to get on the stretcher.
With the growing obesity in the population, ambulance companies have started putting bariatric ambulances on line. The ambulances come equipped with special wide load stretchers that more comfortably accommodate the larger patient.
Years ago before these ambulances came on line, we often had to move the stretcher mounts on the ambulance from the side to the center to enable the patient (bulging over the sides of the stretcher) to fit in the back of the ambulance provided the stretcher could bear the patient's weight. If the stretcher couldn't bear the weight we sometimes put the patient in a fire department Stokes basket or, in rare cases, the patient was transported to the ambulance on the back of a flatbed truck.
Now that these bariatric ambulances are out on the road, some interesting dilemmas have come up.
When I work in the city, our company has one bariatric ambulance that sometimes is out on a call and is not immediately available when I arrive on scene to find a larger patient. So what do I do? Delay transport until the big ambulance is available or follow the old stokes/flatbed routine? Obviously, it depends on the patient size and condition.
I described such a scenario back in 2005.
"You're Going to Need a Bigger Ambulance"
Now three days a week I am contracted to a suburban service that does not have a bariatric ambulance. What do we do? Again it depends on the patient condition.
Here's what happened this weekend.
We are called for chest pain. We arrive to find a large patient, estimated by the nursing home to be just under 400 pounds, who tells us he has been having chest pain for a week. The pain increases on palpation of his sternum. The patient appears quite stable, is in no distress, and is in fact, eating lunch when we arrive. I have had this patient before, so on seeing him, I know what to expect.
"I'm not getting on that stretcher," he says looking at our regular size stretcher.
"You are if you are having chest pain and want us to take you to the hospital," I say.
"I'm not getting on it. Bring the wide stretcher."
"This stretcher is certified for up to 500 pounds."
"I'm not getting on it."
To be fair to the patient, it is not just an issue of pounds, the patient is as wide as he is long. The stretcher appears to be easily less than a third of his width. More of him will hang off each side of the stretcher than be centered on it.
This is also my third encounter with this same patient. On one occasion, I was working for the suburban service. On the other, I was working for the commercial service. In both cases the patient was stable, and the call was more of a request for transportation for evaluation than an immediate need for treatment.
I go back and forth with the patient.
"You should buy a wide stretcher for patients like me."
"A point to be considered," I say, "But that doesn't change the fact that right now, we don't have a wider stretcher. This is it."
I again fully advise him of the dangers and consequences of his refusing to let us put him on our stretcher.
"I want the wide stretcher."
I finally tell him I will call the commercial service and see if they can send out their big ambulance with its wide stretcher for him.
"That's what you should have done in the first place instead of arguing with me," he says.
I go to the nurses's station and call the commercial service. I explain the situation("You need to understand -- he will not let us put him on our stretcher. He is alert, competent and refusing us.") They finally agree to send out the big ambulance. They add it will be about 90 minutes before they can get there.
After sharing this information with the patient, I again advise him to let us transport him on our stretcher.
"That's fine. I'll wait. I'm not getting on your stretcher."
We tell him and the staff to call back should he change his mind or if they feel his situation is deteriorating. He signs a refusal and goes back to eating his lunch.
This is just what happened when I worked for the suburban service the last time. In the one instance when I worked for the commercial service, I had to convince our dispatcher to send out the big ambulance because, despite the fact the patient was just under 400 pounds and did not meet the weight criteria mandating the larger ambulance, he simply would not get on our stretcher. In both cases, the big ambulance eventually came and the patient was transported non-priority.
Now as more and more large size patients become aware of the wider stretchers, similar scenarios can be expected to play out.
"I'm not getting on it. Bring the wide stretcher."
It is not too much of a stretch to imagine that all ambulance services, commercial and volunteer, large and small, will one day have to provide the wider stretcher due not just to the burgeoning size of the population but to the simple availability of a more comfortable, and in some cases, more humane, stretcher.
In the meantime, I just worry about the time when the patient is in true distress and still refuses to get on the stretcher.
Friday, March 14, 2008
The Cat that Didn't Move
The patient -- a forty-year-old man -- says his back is killing him. He has sciatica. He is on Oxycodone, but his vial is empty and his doctor won't give him a refill.
I look at the vial. It was filled six days ago. You should still have pills left, I say.
"You won't believe this," he says, "but I didn't take the pills. I have trouble opening the bottles so I leave the tops off my meds. The cat knocked the bottle over a couple days ago and the pills went into the kitty litter and got covered with kittycrap."
"You called your doctor and told him about it?"
He nods.
"He didn't believe you, huh?"
"Nope."
"Did the cat eat any of the pills?"
His eyes suddenly brighten.
"Yeah, you know, come to think of it," he says. "I noticed there was something wrong with the cat. He didn't move for two days, and he just started coming around this morning."
"Really?"
"The darn cat must have got into the pills."
"Well, you be sure to tell them that at the ER."
"I will. I should have told that to the doctor. I just wasn't thinking. There's the proof."
We take him to the ER and leave him in the waiting room. As I give the registrar his name and information, I look back at him. He looks hopeful.
I look at the vial. It was filled six days ago. You should still have pills left, I say.
"You won't believe this," he says, "but I didn't take the pills. I have trouble opening the bottles so I leave the tops off my meds. The cat knocked the bottle over a couple days ago and the pills went into the kitty litter and got covered with kittycrap."
"You called your doctor and told him about it?"
He nods.
"He didn't believe you, huh?"
"Nope."
"Did the cat eat any of the pills?"
His eyes suddenly brighten.
"Yeah, you know, come to think of it," he says. "I noticed there was something wrong with the cat. He didn't move for two days, and he just started coming around this morning."
"Really?"
"The darn cat must have got into the pills."
"Well, you be sure to tell them that at the ER."
"I will. I should have told that to the doctor. I just wasn't thinking. There's the proof."
We take him to the ER and leave him in the waiting room. As I give the registrar his name and information, I look back at him. He looks hopeful.
Wednesday, March 12, 2008
Whispering Old Ladies, Kleenexes and Placebos
I had a patient a few days ago who I found very annoying. She was a woman in her late sixties with cold and flu symptoms. What was annoying to me was she refused to speak in anything but a whisper. I can't hear you, I would say. But she would keep whispering. I asked her why she was whispering and she whispered it was because she had laryngitis. I didn't argue with her. I just stopped talking to her.
I hate it when patients whisper. You're in the back of a noisey ambulance bumping down the road and they make you lean forward right into their faces so you can hear them, when laryngitis or not they could easily speak more audibly. I'm not saying I have the best hearing. I'm almost fifty and I have years of sirens assaulting my ear drums not to mention attendance at some excellent rock concerts in my day. Still that shouldn't make me have to stick my ear down inches from a patient's mouth to make out their "I'm so sick I have to whisper, poor, infirm me" lines.
The other thing that was annoying about her was every time she'd blow her nose, she's try to hand me the moist Kleenex. I took it the first time, but after that I gave her an emesis basis and told her to put the Kleenexes in there. Then when we reached the hospital, she tried to hand me the emesis basin. Her mouth was moving and she was holding it out for me to grab it, but I didn't take it.
Why am I mentioning all of this? Because I had gone all winter without even a hint of a cold while all around everyone has been dropping with the flu. I was thinking it was my sensible workout program, as well as taking Airborne at the first hint of a cold. This was going to be my first winter without a cold in probably my whole life. I was proud and excited of that impending fact. The older you get the more important it is to believe you are indestructible.
On the Airborne issue, you may have heard, but I guess they are saying Airborne doesn't work -- there was no science behind their claims that taking it at first hint of a cold will make the cold go away. Rebates are being offered,as part of a class action suit -- Airborne Settlement. I filed as part of the suit (free money) and hope to be paid $63 dollars even though I have always found Airborne to do the job for me.
But not this time. I took Airborne at the first hint of a tickle in my throat, even though I knew now that it was proven not to work. And it didn't get the job done. I guess it was probably the placebo effect in the past, and with that gone, I am now defenseless against whispering old ladies and their Kleenexes.
So the bottom line is I'm sick. Stuffy nose, minor headache and great chest-rattling cough. I'm off for a few days so hopefully I'll be feeling better before I have to go back in.
It may not be a bad thing -- getting sick once a year -- just to remind me how crappy a person with just cold and flu symptoms can feel. Still I don't feel crappy enough to whisper. Not yet.
I hate it when patients whisper. You're in the back of a noisey ambulance bumping down the road and they make you lean forward right into their faces so you can hear them, when laryngitis or not they could easily speak more audibly. I'm not saying I have the best hearing. I'm almost fifty and I have years of sirens assaulting my ear drums not to mention attendance at some excellent rock concerts in my day. Still that shouldn't make me have to stick my ear down inches from a patient's mouth to make out their "I'm so sick I have to whisper, poor, infirm me" lines.
The other thing that was annoying about her was every time she'd blow her nose, she's try to hand me the moist Kleenex. I took it the first time, but after that I gave her an emesis basis and told her to put the Kleenexes in there. Then when we reached the hospital, she tried to hand me the emesis basin. Her mouth was moving and she was holding it out for me to grab it, but I didn't take it.
Why am I mentioning all of this? Because I had gone all winter without even a hint of a cold while all around everyone has been dropping with the flu. I was thinking it was my sensible workout program, as well as taking Airborne at the first hint of a cold. This was going to be my first winter without a cold in probably my whole life. I was proud and excited of that impending fact. The older you get the more important it is to believe you are indestructible.
On the Airborne issue, you may have heard, but I guess they are saying Airborne doesn't work -- there was no science behind their claims that taking it at first hint of a cold will make the cold go away. Rebates are being offered,as part of a class action suit -- Airborne Settlement. I filed as part of the suit (free money) and hope to be paid $63 dollars even though I have always found Airborne to do the job for me.
But not this time. I took Airborne at the first hint of a tickle in my throat, even though I knew now that it was proven not to work. And it didn't get the job done. I guess it was probably the placebo effect in the past, and with that gone, I am now defenseless against whispering old ladies and their Kleenexes.
So the bottom line is I'm sick. Stuffy nose, minor headache and great chest-rattling cough. I'm off for a few days so hopefully I'll be feeling better before I have to go back in.
It may not be a bad thing -- getting sick once a year -- just to remind me how crappy a person with just cold and flu symptoms can feel. Still I don't feel crappy enough to whisper. Not yet.
Monday, March 10, 2008
Men's Health: Does EMS Need to Call 911?
I am a big fan of Men's Health magazine. I often read it in the ambulance. I also get emails from them almost every day with workout, diet and other fitness tips.
Today I clicked on an article called How to Break Through a Rut: Reach the Next Level.
A sidebar on the page happened to catch my eye. I clicked on it:
Emergency Question!
Have you ever waited a long time for an ambulance to arrive? Tell us the story.
Here's what it said:
Does EMS Need to Call 911?
There's no question the average civilian thinks of an efficient ambulance service as equally essential to the public welfare as police and fire departments. But thus far, paramedics and EMTs don't seem to have the resources and staffing enjoyed by their public safety counterparts, leaving all of us at risk. In an effort to try and gauge the depth of the problem, we're looking for people who have waited—and waited—for an ambulance. If you or a loved one has suffered through that wait, or if you are an EMS professional willing to share a story about what it's like to get a call from the dispatcher telling you to drive to a cardiac patient 20 minutes or more away, please let us know. We might like to talk to you for an upcoming story.
Please write to Men's Health at mhonline.com. Put "Ambulance Stories" in the subject line.
***
The article had quite a list of reader comments from EMS professionals irked at the story's possible implication. Without knowing more clearly how their article will be written, I am hesitant to judge, but I did send in the following comment to help them understand, in my view, many of the factors that might contribute to an ambulance being late on a rare occasion.
***
People expect an ambulance in their moment of need, and most of the time, in a matter of moments, a paramedic is at the door to help. Sometimes the ambulance doesn’t come as quickly as the patient or their family would like, so they complain about it.
Here is the crux of the problem:
People most often use 911 for routine transport to a hospital, not time dependent life-threatening emergencies. Vomiting all night, a psychiatric patient not taking her medicine, a fall with knee pain. With an aging population and doctors who no longer make house calls, and nursing homes unable to care for what they term “unstable” patients, elderly patients with general sickness make up a large percentage of 911 calls. Additionally, many younger patients with non-critical symptoms fail to call their doctor before calling 911 when their doctor will often tell them to come to their offices and not the ED. Many don’t have doctors so they use the ED as their doctor and the ambulance as their taxi.
Calls come in at random. You can sit for hours doing nothing and then ten calls come in at once. While companies try to staff to meet expected peak periods of demand, sometimes “the shit just hits the fan.”
Traffic does not yield for ambulances delaying responses, and police do not enforce traffic laws requiring people to yield.
People do not mark their houses with numbers that can be seen from the street. Then once you arrive at the right curbside addresses, it often takes even longer to get to the patient’s side due to locked doors, faulty elevators, and in the cases of some companies, policies requiring the ambulances to use service entrances. Once you arrive at a patient’s side, many patients are not ready to go. They have to get their coats, wait for their neighbor to come over, turn off all the lights, feed the dog, call their relatives, etc.
With the growing obesity of today’s population, it is not uncommon for two ambulances to be required to provide manpower to carry a heavy patient from a house.
Ambulances are required to transport anyone who requests an ambulance whether or not their call is an emergency. Ambulances are not allowed to leave (abandon) a patient with a minor complaint even if a serious emergency occurs just doors down. Ambulances are required to take the patient to their hospital of choice (provided it is within the ambulances service area as opposed to the closest hospital. This can add twenty minutes to a transport. Sometimes hospitals are on diversion, requiring further time transporting to a hospital that is open.
Few transports to the hospital are done lights and sirens because lights and sirens are inherently unsafe to crew and patient and other traffic. The ambulance patient compartment is not designed to any reasonable safety standard. Ambulance personal are maimed in traffic accidents on a startling basis. Better to take 30 minutes to get to a hospital than get into an accident and not arrive at all. This is not to say that lights and sirens are not used when the patient presents with a condition in which the hospital can do something the paramedic cannot that will make a difference in the patient's outcome in the time saved by going lights and sirens.
Due to hospital overcrowding, ambulance crews often spend more time with their patient at the hospital waiting to get through the hospital triage line and then get a bed for a patient than they spend responding to a call, treating and transporting a patient.
To top it off, many people don’t have insurance to pay for their ambulance bill and even Medicare rarely pays for the true cost of ambulance service. In some critical calls the cost of supplies and medicine alone far exceeds what the ambulance company can bill.
While it is easy for people, politicians and the media to complain about late ambulance responses, no one is calling for higher taxes or realistic proposals to cut other government programs to pay for more ambulances, more hospital beds, better reimbursement rates and fundamental changes in the way health care is provided in this country.
Peter Canning, EMT-P
Today I clicked on an article called How to Break Through a Rut: Reach the Next Level.
A sidebar on the page happened to catch my eye. I clicked on it:
Emergency Question!
Have you ever waited a long time for an ambulance to arrive? Tell us the story.
Here's what it said:
Does EMS Need to Call 911?
There's no question the average civilian thinks of an efficient ambulance service as equally essential to the public welfare as police and fire departments. But thus far, paramedics and EMTs don't seem to have the resources and staffing enjoyed by their public safety counterparts, leaving all of us at risk. In an effort to try and gauge the depth of the problem, we're looking for people who have waited—and waited—for an ambulance. If you or a loved one has suffered through that wait, or if you are an EMS professional willing to share a story about what it's like to get a call from the dispatcher telling you to drive to a cardiac patient 20 minutes or more away, please let us know. We might like to talk to you for an upcoming story.
Please write to Men's Health at mhonline.com. Put "Ambulance Stories" in the subject line.
***
The article had quite a list of reader comments from EMS professionals irked at the story's possible implication. Without knowing more clearly how their article will be written, I am hesitant to judge, but I did send in the following comment to help them understand, in my view, many of the factors that might contribute to an ambulance being late on a rare occasion.
***
People expect an ambulance in their moment of need, and most of the time, in a matter of moments, a paramedic is at the door to help. Sometimes the ambulance doesn’t come as quickly as the patient or their family would like, so they complain about it.
Here is the crux of the problem:
People most often use 911 for routine transport to a hospital, not time dependent life-threatening emergencies. Vomiting all night, a psychiatric patient not taking her medicine, a fall with knee pain. With an aging population and doctors who no longer make house calls, and nursing homes unable to care for what they term “unstable” patients, elderly patients with general sickness make up a large percentage of 911 calls. Additionally, many younger patients with non-critical symptoms fail to call their doctor before calling 911 when their doctor will often tell them to come to their offices and not the ED. Many don’t have doctors so they use the ED as their doctor and the ambulance as their taxi.
Calls come in at random. You can sit for hours doing nothing and then ten calls come in at once. While companies try to staff to meet expected peak periods of demand, sometimes “the shit just hits the fan.”
Traffic does not yield for ambulances delaying responses, and police do not enforce traffic laws requiring people to yield.
People do not mark their houses with numbers that can be seen from the street. Then once you arrive at the right curbside addresses, it often takes even longer to get to the patient’s side due to locked doors, faulty elevators, and in the cases of some companies, policies requiring the ambulances to use service entrances. Once you arrive at a patient’s side, many patients are not ready to go. They have to get their coats, wait for their neighbor to come over, turn off all the lights, feed the dog, call their relatives, etc.
With the growing obesity of today’s population, it is not uncommon for two ambulances to be required to provide manpower to carry a heavy patient from a house.
Ambulances are required to transport anyone who requests an ambulance whether or not their call is an emergency. Ambulances are not allowed to leave (abandon) a patient with a minor complaint even if a serious emergency occurs just doors down. Ambulances are required to take the patient to their hospital of choice (provided it is within the ambulances service area as opposed to the closest hospital. This can add twenty minutes to a transport. Sometimes hospitals are on diversion, requiring further time transporting to a hospital that is open.
Few transports to the hospital are done lights and sirens because lights and sirens are inherently unsafe to crew and patient and other traffic. The ambulance patient compartment is not designed to any reasonable safety standard. Ambulance personal are maimed in traffic accidents on a startling basis. Better to take 30 minutes to get to a hospital than get into an accident and not arrive at all. This is not to say that lights and sirens are not used when the patient presents with a condition in which the hospital can do something the paramedic cannot that will make a difference in the patient's outcome in the time saved by going lights and sirens.
Due to hospital overcrowding, ambulance crews often spend more time with their patient at the hospital waiting to get through the hospital triage line and then get a bed for a patient than they spend responding to a call, treating and transporting a patient.
To top it off, many people don’t have insurance to pay for their ambulance bill and even Medicare rarely pays for the true cost of ambulance service. In some critical calls the cost of supplies and medicine alone far exceeds what the ambulance company can bill.
While it is easy for people, politicians and the media to complain about late ambulance responses, no one is calling for higher taxes or realistic proposals to cut other government programs to pay for more ambulances, more hospital beds, better reimbursement rates and fundamental changes in the way health care is provided in this country.
Peter Canning, EMT-P
Saturday, March 08, 2008
Damsels in Distress
I grew up reading books like King Arthur and His Knights. Thus when I was a young boy watching EmergencyI imagined a paramedic as a sort of knight errant rescuing people in distress. The job of a paramedic seemed like noble work with the added reward of being thanked by rescued damsels – whether the rescue was saving them from an auto crash or merely getting their kitten out of a tree.
Years later when I became a paramedic I soon learned that not all patients were damsels nor were they all in distress.
The town I regularly work in has an extremely high elderly population. It is not unusual to have four patients all over the age of 85 in one day. Some days it is all cardiac calls, other days all falls or difficulty breathings; some days it is high temps and vomitings. Most days it is a mixture of old age related complaints.
This week I worked some overtime in the city where the population and call nature is more diverse. The patients tend to be younger and the call nature includes a larger percentage of non-fall trauma (i.e. assaults), psychiatric emergency, substance abuse, and BS (calls that should’t require an ambulance).
I had an unusual day in the city – I cannot in fact recall any similar days. Not only were all my patients damsels (young females between 20 and 25) -- they were all damsels in distress. Not one was a slobbering drunk. Not one a crack whore. No foul mouthed feline in police custody. None feigning unresponsiveness following an argument with their boyfriends. And if any of them had tattoos, they were in discrete tasteful areas beyond my view.
The first young lady had neck pain from a motor vehicle accident in which she was rear-ended. Her vehicle actually had rear end damage. The second young lady had painful upper right quadrant abdominal pain with a genuine past diagnosis of gallstones, according to her doctor who called us to his office to aid the young woman. The third young lady was a jazz dancer who it seemed threw out her back, and only called 911 after an unsuccessful attempt to transport her by private car.
I treated them all as if I were treating my daughter. I was respectful, kind, and went the extra mile to see to their comfort. I let the first patient use my cell phone to call her boss. I gave the second patient Zofran for her nausea and at the ER when we had to find a bed for her, I chose not the old thin mattressed bed I found first, but a new thicker mattressed model, and then, I wandered the halls until I found her a pillow. The third patient I gave eight milligrams of morphine, along with some phenergan until she was quite comfortable—so comfortable I had to have her professor sign the back of her run form because the injured dancer was now blissfully asleep. I received vociferous thanks from the first two damsels, and the professor – not far from damsel status herself -- assured me both she and the dancer were grateful for my kindness and care.
And then I saddled my steed – an old rattley ambulance – one of the oldest in the fleet – and drove out to our post to await my next dragon to slay.
The next day, surprisingly I had two more female patients of the same age group, although they had long lost damsel status. The first young woman, like the young woman the previous day, had neck pain from a motor vehicle accident, but her car had much less visible damage. Surprisingly she ended up in the trauma room when my new BLS partner became concerned about her apparent change in mental status (falling asleep and suffering from faulty memory) during transport as he teched the call. The reason for her altered consciousness became clear after they cut her clothes off. She had an ounce of marijuana in her brassiere and a plastic bag containing crack peering out of her long lost maidenhood. The next patient was a rather unclean track marked young woman complaining of abdominal pain and crying quite theatrically. Instead of the trauma room, she was sent to the waiting room where she ended up leaving on her own steam, and leaving behind a classic stream of profanity after it was determined this was her fourth hospital stop in one day and seventh stop at the same hospital in the last few weeks, all seeking narcotics for abdominal pain of questionable etiology.
Alas, not every day is a fairy tale in the life of a paramedic, but with the right attitude, we can try to make it a good day.
Now I am back in the realm of the suburbs and the first call of distress in our kingdom comes from an old woman who has fallen and cannot get up.
I walk though the door and seeing her on the carpet, introduce myself bowing slightly and waving my right arm with a flourish. “How may I be of service?
Soon on her feet again, and showing no sign of injury from her unfortunate slip, she thanks us prodigiously for coming to her aid. The old woman, a damsel still at heart, waves us farewell as we leave, but not without our first promising to return should she ever find need to call again for our help.
Thus when I was a young boy watching EmergencyI imagined a paramedic as a sort of knight errant rescuing people in distress. The job of a paramedic seemed like noble work with the added reward of being thanked by rescued damsels – whether the rescue was saving them from an auto crash or merely getting their kitten out of a tree.Years later when I became a paramedic I soon learned that not all patients were damsels nor were they all in distress.
The town I regularly work in has an extremely high elderly population. It is not unusual to have four patients all over the age of 85 in one day. Some days it is all cardiac calls, other days all falls or difficulty breathings; some days it is high temps and vomitings. Most days it is a mixture of old age related complaints.
This week I worked some overtime in the city where the population and call nature is more diverse. The patients tend to be younger and the call nature includes a larger percentage of non-fall trauma (i.e. assaults), psychiatric emergency, substance abuse, and BS (calls that should’t require an ambulance).
I had an unusual day in the city – I cannot in fact recall any similar days. Not only were all my patients damsels (young females between 20 and 25) -- they were all damsels in distress. Not one was a slobbering drunk. Not one a crack whore. No foul mouthed feline in police custody. None feigning unresponsiveness following an argument with their boyfriends. And if any of them had tattoos, they were in discrete tasteful areas beyond my view.
The first young lady had neck pain from a motor vehicle accident in which she was rear-ended. Her vehicle actually had rear end damage. The second young lady had painful upper right quadrant abdominal pain with a genuine past diagnosis of gallstones, according to her doctor who called us to his office to aid the young woman. The third young lady was a jazz dancer who it seemed threw out her back, and only called 911 after an unsuccessful attempt to transport her by private car.
I treated them all as if I were treating my daughter. I was respectful, kind, and went the extra mile to see to their comfort. I let the first patient use my cell phone to call her boss. I gave the second patient Zofran for her nausea and at the ER when we had to find a bed for her, I chose not the old thin mattressed bed I found first, but a new thicker mattressed model, and then, I wandered the halls until I found her a pillow. The third patient I gave eight milligrams of morphine, along with some phenergan until she was quite comfortable—so comfortable I had to have her professor sign the back of her run form because the injured dancer was now blissfully asleep. I received vociferous thanks from the first two damsels, and the professor – not far from damsel status herself -- assured me both she and the dancer were grateful for my kindness and care.
And then I saddled my steed – an old rattley ambulance – one of the oldest in the fleet – and drove out to our post to await my next dragon to slay.
The next day, surprisingly I had two more female patients of the same age group, although they had long lost damsel status. The first young woman, like the young woman the previous day, had neck pain from a motor vehicle accident, but her car had much less visible damage. Surprisingly she ended up in the trauma room when my new BLS partner became concerned about her apparent change in mental status (falling asleep and suffering from faulty memory) during transport as he teched the call. The reason for her altered consciousness became clear after they cut her clothes off. She had an ounce of marijuana in her brassiere and a plastic bag containing crack peering out of her long lost maidenhood. The next patient was a rather unclean track marked young woman complaining of abdominal pain and crying quite theatrically. Instead of the trauma room, she was sent to the waiting room where she ended up leaving on her own steam, and leaving behind a classic stream of profanity after it was determined this was her fourth hospital stop in one day and seventh stop at the same hospital in the last few weeks, all seeking narcotics for abdominal pain of questionable etiology.
Alas, not every day is a fairy tale in the life of a paramedic, but with the right attitude, we can try to make it a good day.
Now I am back in the realm of the suburbs and the first call of distress in our kingdom comes from an old woman who has fallen and cannot get up.
I walk though the door and seeing her on the carpet, introduce myself bowing slightly and waving my right arm with a flourish. “How may I be of service?
Soon on her feet again, and showing no sign of injury from her unfortunate slip, she thanks us prodigiously for coming to her aid. The old woman, a damsel still at heart, waves us farewell as we leave, but not without our first promising to return should she ever find need to call again for our help.
Thursday, March 06, 2008
My Death
I almost died today.
As we approached the intersection I looked up and I saw my death coming at me. It was a large box truck. I quickly calculated that at its rate of speed eastbound on Park and at our rate of speed southbound on Broad, there was going to be collision. The box truck was going to strike our ambulance on the front passenger door (where I sat). I was going to get pulverized -- my bones smashed to dust.
As we hurtled toward my death I saw my baby at home that morning in her swing looking up smiling at the little birdies chirping on the mobile that went round and round. I looked at that oncoming truck and saw that is was still coming and not slowing nearly enough. There was no chance that it would stop until after it had snowplowed us.
I started screaming. It began with “Lookout!" I have no idea what else it included (likely profanities mixed with just plain scared I don’t want to die guttural exclamations). My shouting did not stop until we stopped and the big truck roared on past.
If the truck driver saw us or made an attempt to stop at all, I do not know. I have no idea who had the light. I really wasn’t paying attention to anything other than suddenly recognizing that we needed to decelerate. It wasn’t important in that moment that we stop before our nose crossed onto Park Street, because that clearly wasn't going to happen. We just had to stop before reaching the lane the truck was in. I don’t think the truck driver even saw us coming. If he did, he must have known he wasn’t going to be able to stop.
This was a serious incident. This was no routine, boy, we almost had an accident. This was my death.
I don’t know if my partner would have stopped on his own if I hadn't shouted. Maybe. Maybe he had it all under control and was already getting ready to hit the brakes.
I don’t know. Maybe I was hallucinating. Maybe I was like one of those old guys who shouts incoming! and tucks while everyone else at the nursing home is peacefully enjoying the snap crackle pop of their morning Rice Crispies. Maybe it was all a sort of daydream nightmare. But it was awful real.
Someone blew the light. The truck or the ambulance? I don't know. Who was wrong doesn't matter to me right now. My partner and I didn't talk about it. One of us might have said "Where did he come from?" Or "That was close." Or "I thought he was going to stop." I don't remember clearly. And we didn’t dwell on it. I did not feel like talking. And we were, after all, still on a call. I couldn’t get out and light a cigarette with shaking hands (I don’t smoke) or stagger into a Park Street bar and order six bourbons and six beers. We had a job to do. So we carried on like nothing had happened. Priority one. Difficulty breathing. We had blocks to go before we could stop.
We were on a complete cross town response. We were going from the north end to the south end into the territory of another company whose cars were all tied up. I don’t know who passed the call to us – the other company or the police. But when we got to the address the first thing I noticed was there was no fire engine out front. What that told me was the fire department wasn’t dispatched because it probably wasn’t a serious enough emergency for them to be bothered. They aren’t dispatched to all calls. They don't go to routine sick calls. But they are dispatched to difficulty breathing calls. So why weren’t they there? Maybe it wasn’t really a priority one call? If they are not dispatched, and we are sent priority one, when we walk in, it is almost always bullshit. Somebody knew something about the call that we didn’t because the fire department wasn’t deemed necessary to respond. Someone wasn't sharing information. They just said fuck it, coded it for us as difficulty breathing and put us in the line of fire -- in the path of that oncoming truck.
When we walked into that building and down the hall into apartment number three, we found an old guy sitting by the window smoking a cigarette. The story was he had terminal cancer and the home aide who stopped by earlier discovered he was taking 3 morphine pills three times a day, instead of three morphine pills in a day(one morphine pill three times a day). He was taking nine pills instead of three, but he had no complaints and he wasn't having a hard time breathing. He wasn’t even slightly altered. He was just an old guy with cancer sitting by the window having a smoke. God bless him. They just wanted him checked to see if taking the extra medicine was harming him. We walked him out to the ambulance.
Afterwards, I wanted to pick up the phone at the hospital and call dispatch and say "Hey, who took that call? This is me calling from the grave. I died on Park Street today and I want to know WHY I was sent lights and sirens and the fire department was not dispatched. I want it known that I died for BS. I was killed for BS. I want it known! I want an investigation that will change the way ambulances are dispatched in this city, in this state and in this country. I want it known!"
Click on this web site:
Ambulance Crash Log
Every day EMS people die on our streets. How many of those people die for BS?
I’m all for safe driving practices and I am not pointing my finger at my partner because I wasn’t paying attention and when I did, I was too scared to see anything or know anything other than the big box truck was coming too fast. It wasn’t going to be able to stop. And if a miracle didn’t stop us, I would be dead. He’s coming. We’re not stopped. He’s still coming. We’re still moving. He’s still coming. We’re still moving. We may be slowing, but we’re still moving and he may be slowing, but he isn’t going to be able to stop. We’re the only ones who can avoid this. Please Stop!!!! Not just slow, but STOP! Stop completely before we cross the center line and I am knocked into the great void.
Like I said, I am all for safe driving practices, including coming to a full and complete stop at all intersections whether the light is red or green. But having that policy doesn’t take away from the fact that driving lights and sirens is inherently dangerous and it is so soo unnecessary just about all of the time.
I was going to take another shift tomorrow. Frankly, with just one of us working right now with the baby still so new, we need the cash. But after that incident, I said forget it. I told myself tonight I’m going to go home, I’m going to walk right into the kitchen and open up the refrigerator door and take out the one cold bottle of Red Stripe I have in the house. I am going to pop the top and then down it – guzzle it empty in one long I am alive chug. And then I’ll go back to the bedroom, change out of my working clothes, take a shower, put on some jeans and a clean t-shirt, come back, fix everyone dinner, and then later I am going to sit on the couch and hold my little daughter in my arms, and talk to her in our own little father daughter language and never raise my voice above a whisper.
Maybe tomorrow, we’ll go to the park. It’s supposed to be a nice day.
Saturday I'll be back at work. The sad thing is that a week from now I am going to post that ambulance crash web site again and there will be at least one new story about an ambulance crashing and one of us dying or being badly hurt. One of us will sit there helpless as death hurtles toward us, only we won't be able to stop, and we'll know it, and then there will be the impact. A young life will come to an end.
Be safe out there.
As we approached the intersection I looked up and I saw my death coming at me. It was a large box truck. I quickly calculated that at its rate of speed eastbound on Park and at our rate of speed southbound on Broad, there was going to be collision. The box truck was going to strike our ambulance on the front passenger door (where I sat). I was going to get pulverized -- my bones smashed to dust.
As we hurtled toward my death I saw my baby at home that morning in her swing looking up smiling at the little birdies chirping on the mobile that went round and round. I looked at that oncoming truck and saw that is was still coming and not slowing nearly enough. There was no chance that it would stop until after it had snowplowed us.
I started screaming. It began with “Lookout!" I have no idea what else it included (likely profanities mixed with just plain scared I don’t want to die guttural exclamations). My shouting did not stop until we stopped and the big truck roared on past.
If the truck driver saw us or made an attempt to stop at all, I do not know. I have no idea who had the light. I really wasn’t paying attention to anything other than suddenly recognizing that we needed to decelerate. It wasn’t important in that moment that we stop before our nose crossed onto Park Street, because that clearly wasn't going to happen. We just had to stop before reaching the lane the truck was in. I don’t think the truck driver even saw us coming. If he did, he must have known he wasn’t going to be able to stop.
This was a serious incident. This was no routine, boy, we almost had an accident. This was my death.
I don’t know if my partner would have stopped on his own if I hadn't shouted. Maybe. Maybe he had it all under control and was already getting ready to hit the brakes.
I don’t know. Maybe I was hallucinating. Maybe I was like one of those old guys who shouts incoming! and tucks while everyone else at the nursing home is peacefully enjoying the snap crackle pop of their morning Rice Crispies. Maybe it was all a sort of daydream nightmare. But it was awful real.
Someone blew the light. The truck or the ambulance? I don't know. Who was wrong doesn't matter to me right now. My partner and I didn't talk about it. One of us might have said "Where did he come from?" Or "That was close." Or "I thought he was going to stop." I don't remember clearly. And we didn’t dwell on it. I did not feel like talking. And we were, after all, still on a call. I couldn’t get out and light a cigarette with shaking hands (I don’t smoke) or stagger into a Park Street bar and order six bourbons and six beers. We had a job to do. So we carried on like nothing had happened. Priority one. Difficulty breathing. We had blocks to go before we could stop.
We were on a complete cross town response. We were going from the north end to the south end into the territory of another company whose cars were all tied up. I don’t know who passed the call to us – the other company or the police. But when we got to the address the first thing I noticed was there was no fire engine out front. What that told me was the fire department wasn’t dispatched because it probably wasn’t a serious enough emergency for them to be bothered. They aren’t dispatched to all calls. They don't go to routine sick calls. But they are dispatched to difficulty breathing calls. So why weren’t they there? Maybe it wasn’t really a priority one call? If they are not dispatched, and we are sent priority one, when we walk in, it is almost always bullshit. Somebody knew something about the call that we didn’t because the fire department wasn’t deemed necessary to respond. Someone wasn't sharing information. They just said fuck it, coded it for us as difficulty breathing and put us in the line of fire -- in the path of that oncoming truck.
When we walked into that building and down the hall into apartment number three, we found an old guy sitting by the window smoking a cigarette. The story was he had terminal cancer and the home aide who stopped by earlier discovered he was taking 3 morphine pills three times a day, instead of three morphine pills in a day(one morphine pill three times a day). He was taking nine pills instead of three, but he had no complaints and he wasn't having a hard time breathing. He wasn’t even slightly altered. He was just an old guy with cancer sitting by the window having a smoke. God bless him. They just wanted him checked to see if taking the extra medicine was harming him. We walked him out to the ambulance.
Afterwards, I wanted to pick up the phone at the hospital and call dispatch and say "Hey, who took that call? This is me calling from the grave. I died on Park Street today and I want to know WHY I was sent lights and sirens and the fire department was not dispatched. I want it known that I died for BS. I was killed for BS. I want it known! I want an investigation that will change the way ambulances are dispatched in this city, in this state and in this country. I want it known!"
Click on this web site:
Ambulance Crash Log
Every day EMS people die on our streets. How many of those people die for BS?
I’m all for safe driving practices and I am not pointing my finger at my partner because I wasn’t paying attention and when I did, I was too scared to see anything or know anything other than the big box truck was coming too fast. It wasn’t going to be able to stop. And if a miracle didn’t stop us, I would be dead. He’s coming. We’re not stopped. He’s still coming. We’re still moving. He’s still coming. We’re still moving. We may be slowing, but we’re still moving and he may be slowing, but he isn’t going to be able to stop. We’re the only ones who can avoid this. Please Stop!!!! Not just slow, but STOP! Stop completely before we cross the center line and I am knocked into the great void.
Like I said, I am all for safe driving practices, including coming to a full and complete stop at all intersections whether the light is red or green. But having that policy doesn’t take away from the fact that driving lights and sirens is inherently dangerous and it is so soo unnecessary just about all of the time.
I was going to take another shift tomorrow. Frankly, with just one of us working right now with the baby still so new, we need the cash. But after that incident, I said forget it. I told myself tonight I’m going to go home, I’m going to walk right into the kitchen and open up the refrigerator door and take out the one cold bottle of Red Stripe I have in the house. I am going to pop the top and then down it – guzzle it empty in one long I am alive chug. And then I’ll go back to the bedroom, change out of my working clothes, take a shower, put on some jeans and a clean t-shirt, come back, fix everyone dinner, and then later I am going to sit on the couch and hold my little daughter in my arms, and talk to her in our own little father daughter language and never raise my voice above a whisper.
Maybe tomorrow, we’ll go to the park. It’s supposed to be a nice day.
Saturday I'll be back at work. The sad thing is that a week from now I am going to post that ambulance crash web site again and there will be at least one new story about an ambulance crashing and one of us dying or being badly hurt. One of us will sit there helpless as death hurtles toward us, only we won't be able to stop, and we'll know it, and then there will be the impact. A young life will come to an end.
Be safe out there.
Tuesday, March 04, 2008
You Don't Have to Put on Your Red Lights
The hot line rings. Two-thirty in the morning. The dispatcher says, 80 Dorchester. That's all. Just the address. That's all we need to know.
Calvin.
I don't work the nights as much as the other guys, but I know Calvin. We take our time getting up. Take a leak. Walk out to the ambulance. Drive over to 80 Dorchester.
There are the same three cars in the driveway -- not three cars up on cement blocks or sitting rusting on the lawn -- three working cars belonging to family members, who no doubt are just where we were ten minutes before, faces resting against their pillow cases.
Calvin meets us at the front door. He's got his jacket on, and his headphones. We don't even have conversation anymore. We have a trip card all made up with all the info we need.
Name name. Thirty-three years old. Sickle Cell Anemia. State Welfare number.
He walks out slow. He's a tall guy, maybe six-three, on the thin side. He's a touch inebriated from his night out clubbing. I can hear the music coming through his Walkman. With his sunglasses, he reminds me of Eddie Murphy in “48 Hours” where he's singing "Roxanne" oblivious to everyone around him.
One of the medics looked it up and said we have transported him over 180 times. Years ago, we used to take him to the closest city hospital, about quarter mile down the road from the town border. Then we went to the next city hospital, three miles down the road, and then to the hospital in the South end. Now we go almost twenty miles away to the farthest hospital in our service area.
Sickle Cell Anemia is a cruel, ruthless disease. I wouldn't wish it on anyone. During a crisis, the cells obstruct blood flow and it is extremely painful. Most sickle cell patients are on morphine all the time. They develop a dependence that requires more and more morphine to take the pain away.
Calvin is on a solid dose of morphine. At night he sometimes wants just a little more to ease him. Some would say he needs it to dull the pain, others say he just wants to get high. The other hospitals got tired of seeing him all the time so they gradually stopped giving him that little extra, so he's now on his fourth and last hospital.
My partner drives rougher than normal tonight. He's tired from working all day and doesn't care for Calvin.
Calvin takes off his sun glasses and glares at me. "He's driving a little rough."
"The roads are bad," I say.
Calvin doesn't look in any distress. I've emptied out my morphine vials for sickle cell patients before, but I've never seen Calvin in that degree of pain. Maybe he isn't in that great of pain or maybe he just does a good job of hiding it.
I patch to the hospital. The other medic told me when he patches for Calvin, he just says, "CH7." Translated it means, "We're bring you Calvin Homes. We're seven minutes out." The nurses know Calvin, too.
I stare at him on the stretcher, his feet hanging off the end. He's got his shades back on now and he is moving his head from side to side like Stevie Wonder.
One of the other guys wrote a song about Calvin. It went something like: "He's six foot three, he's a big pussy, Calvin Holmes." The medic said he wrote six verses one night.
What upsets the other medic about Calvin is that after a night out on the town, instead of having his friends drop him off at the hospital, Calvin has them drop him off at home, and then Calvin calls us. He just sits on our stretcher. We never do anything for him, but give him a ride. We've talked about refusing to take him to the faraway hospital, but it is hard to change the rules for one, and not for all.
"One of these days, we won't be taking him anymore," the other medic says. "He's not looking too good lately."
And that's true. He's moving slower tonight than the last time I took him in. His skin looks sickly. He's only thirty-three, but sickle cell disease has its way of wearing a person down.
When he dies, someone here will cut his obit out and post it on the bulletin board.
***
Postscript: One morning I walk into work and there it is, tacked right next to the schedule. Rest in Peace, CH.
What is Sickle Cell Anemia?
Calvin.
I don't work the nights as much as the other guys, but I know Calvin. We take our time getting up. Take a leak. Walk out to the ambulance. Drive over to 80 Dorchester.
There are the same three cars in the driveway -- not three cars up on cement blocks or sitting rusting on the lawn -- three working cars belonging to family members, who no doubt are just where we were ten minutes before, faces resting against their pillow cases.
Calvin meets us at the front door. He's got his jacket on, and his headphones. We don't even have conversation anymore. We have a trip card all made up with all the info we need.
Name name. Thirty-three years old. Sickle Cell Anemia. State Welfare number.
He walks out slow. He's a tall guy, maybe six-three, on the thin side. He's a touch inebriated from his night out clubbing. I can hear the music coming through his Walkman. With his sunglasses, he reminds me of Eddie Murphy in “48 Hours” where he's singing "Roxanne" oblivious to everyone around him.
One of the medics looked it up and said we have transported him over 180 times. Years ago, we used to take him to the closest city hospital, about quarter mile down the road from the town border. Then we went to the next city hospital, three miles down the road, and then to the hospital in the South end. Now we go almost twenty miles away to the farthest hospital in our service area.
Sickle Cell Anemia is a cruel, ruthless disease. I wouldn't wish it on anyone. During a crisis, the cells obstruct blood flow and it is extremely painful. Most sickle cell patients are on morphine all the time. They develop a dependence that requires more and more morphine to take the pain away.
Calvin is on a solid dose of morphine. At night he sometimes wants just a little more to ease him. Some would say he needs it to dull the pain, others say he just wants to get high. The other hospitals got tired of seeing him all the time so they gradually stopped giving him that little extra, so he's now on his fourth and last hospital.
My partner drives rougher than normal tonight. He's tired from working all day and doesn't care for Calvin.
Calvin takes off his sun glasses and glares at me. "He's driving a little rough."
"The roads are bad," I say.
Calvin doesn't look in any distress. I've emptied out my morphine vials for sickle cell patients before, but I've never seen Calvin in that degree of pain. Maybe he isn't in that great of pain or maybe he just does a good job of hiding it.
I patch to the hospital. The other medic told me when he patches for Calvin, he just says, "CH7." Translated it means, "We're bring you Calvin Homes. We're seven minutes out." The nurses know Calvin, too.
I stare at him on the stretcher, his feet hanging off the end. He's got his shades back on now and he is moving his head from side to side like Stevie Wonder.
One of the other guys wrote a song about Calvin. It went something like: "He's six foot three, he's a big pussy, Calvin Holmes." The medic said he wrote six verses one night.
What upsets the other medic about Calvin is that after a night out on the town, instead of having his friends drop him off at the hospital, Calvin has them drop him off at home, and then Calvin calls us. He just sits on our stretcher. We never do anything for him, but give him a ride. We've talked about refusing to take him to the faraway hospital, but it is hard to change the rules for one, and not for all.
"One of these days, we won't be taking him anymore," the other medic says. "He's not looking too good lately."
And that's true. He's moving slower tonight than the last time I took him in. His skin looks sickly. He's only thirty-three, but sickle cell disease has its way of wearing a person down.
When he dies, someone here will cut his obit out and post it on the bulletin board.
***
Postscript: One morning I walk into work and there it is, tacked right next to the schedule. Rest in Peace, CH.
What is Sickle Cell Anemia?
Monday, March 03, 2008
Rusty
My preceptee got cut loose so I am back at work having to carry my own gear again. My rhythm is a little off, but I think I’ll get it back soon enough. Not much interesting so far – just the meat and potatoes of EMS in this town.
1) An old man with pneumonia in a nursing home, just put on antibiotics four days ago, but family wants him taken to the hospital anyway.
2) A middle-aged hyperventilating woman complaining of chest pain in the church lobby. At the hospital, the triage nurse asked me what I had. I answered if the correct diagnosis would advance me to the next round of the million dollar bonanza, I would wager anxiety. If I was being graded on being a thorough, prudent paramedic, I would have to say rule out cardiac considering she was obese and diabetic.
3) A minor motor vehicle with the driver complaining of neck and back pain.
4) An old woman who lives alone not feeling well for a month with vomiting today.
This last patient is the one that tries me the most. When I ask her what medical problems she has, she says she doesn't know. Her neighbor says she has dementia. The patient keeps saying she is cold as she lays in bed and tries to pull the covers back over her arms as I feel her steady pulse. She is very needy and her voice is high and very whiny and she is somewhat hard of hearing. Her apartment is crowded and we have to stair chair her down after moving a large bookcase.
I try to tell her I think she has the flu ( fever, headache, vomiting, chills -- a lot of it going around), but she insists she doesn't because her doctor told her she didn’t, but she can’t tell me when she last saw the doctor. I have to raise my voice to communicate with her, but I can’t quite get the soft tone I want. I hear annoyance in my own voice.
Some patients just get on your nerves, and I am struggling to stay nice. I am trying to figure out why she – particularly her voice -- is affecting me so. About halfway through the call, I remember her. I haven't had her for quite awhile, but I have taken her in multiple times in the past. Her voice is like fingernails on a chalkboard.
The whole trip is "my arm hurts," "my back hurts," "I’m going to throw up." "I’m cold." "I’m uncomfortable.”
All the while I’m trying to do my ALS assessment, IV, O2, monitor, and also write my report, clean the back and radio to the hospital. On routine calls with 15 minute transport times, I like to hit the hospital if I can with the back cleaned up, my gear in order and the run form mostly written, including billing and signature, but I fumble through this one. Reaching for the emesis basin. Repositioning her. Turning the heat up. Repeating myself every time I speak because she says "What?"
I know I have been nicer to her in the past. I've been able to contain myself, not had to struggle this hard.
"I've taken you in before," I say.
"Yes, you have. I remember you," she says.
"You have chronic pain, don't you?"
"What?"
"You pretty much hurt all the time, don't you!"
"Yes," she says.
When we get to the hospital, I tuck my unfinished run form on the back of the stretcher, and then, after too much hesitation, get another blanket on her and wrap a towel around her head, giving her the Mother Theresa look. I finally earn a deserved or not “thank you” from her. I guess at least I can claim I hid my annoyance from her. But then again, she has dementia, and probably can't detect it anyway or maybe she does detect it.
"I used to live in a big house," she says when I say goodbye to her. "Back when we had money."
Maybe she thinks if I know she has been rich once I would have treated her nicer. Or maybe she is just feeling sorry for herself.
Either way, it makes me feel bad about what life does to people.
In addition to working on unrustying my call skills, I have to get my empathy back into shape.
Its hard to do the job long without it.
Here’s an old post about her.
Hurt
1) An old man with pneumonia in a nursing home, just put on antibiotics four days ago, but family wants him taken to the hospital anyway.
2) A middle-aged hyperventilating woman complaining of chest pain in the church lobby. At the hospital, the triage nurse asked me what I had. I answered if the correct diagnosis would advance me to the next round of the million dollar bonanza, I would wager anxiety. If I was being graded on being a thorough, prudent paramedic, I would have to say rule out cardiac considering she was obese and diabetic.
3) A minor motor vehicle with the driver complaining of neck and back pain.
4) An old woman who lives alone not feeling well for a month with vomiting today.
This last patient is the one that tries me the most. When I ask her what medical problems she has, she says she doesn't know. Her neighbor says she has dementia. The patient keeps saying she is cold as she lays in bed and tries to pull the covers back over her arms as I feel her steady pulse. She is very needy and her voice is high and very whiny and she is somewhat hard of hearing. Her apartment is crowded and we have to stair chair her down after moving a large bookcase.
I try to tell her I think she has the flu ( fever, headache, vomiting, chills -- a lot of it going around), but she insists she doesn't because her doctor told her she didn’t, but she can’t tell me when she last saw the doctor. I have to raise my voice to communicate with her, but I can’t quite get the soft tone I want. I hear annoyance in my own voice.
Some patients just get on your nerves, and I am struggling to stay nice. I am trying to figure out why she – particularly her voice -- is affecting me so. About halfway through the call, I remember her. I haven't had her for quite awhile, but I have taken her in multiple times in the past. Her voice is like fingernails on a chalkboard.
The whole trip is "my arm hurts," "my back hurts," "I’m going to throw up." "I’m cold." "I’m uncomfortable.”
All the while I’m trying to do my ALS assessment, IV, O2, monitor, and also write my report, clean the back and radio to the hospital. On routine calls with 15 minute transport times, I like to hit the hospital if I can with the back cleaned up, my gear in order and the run form mostly written, including billing and signature, but I fumble through this one. Reaching for the emesis basin. Repositioning her. Turning the heat up. Repeating myself every time I speak because she says "What?"
I know I have been nicer to her in the past. I've been able to contain myself, not had to struggle this hard.
"I've taken you in before," I say.
"Yes, you have. I remember you," she says.
"You have chronic pain, don't you?"
"What?"
"You pretty much hurt all the time, don't you!"
"Yes," she says.
When we get to the hospital, I tuck my unfinished run form on the back of the stretcher, and then, after too much hesitation, get another blanket on her and wrap a towel around her head, giving her the Mother Theresa look. I finally earn a deserved or not “thank you” from her. I guess at least I can claim I hid my annoyance from her. But then again, she has dementia, and probably can't detect it anyway or maybe she does detect it.
"I used to live in a big house," she says when I say goodbye to her. "Back when we had money."
Maybe she thinks if I know she has been rich once I would have treated her nicer. Or maybe she is just feeling sorry for herself.
Either way, it makes me feel bad about what life does to people.
In addition to working on unrustying my call skills, I have to get my empathy back into shape.
Its hard to do the job long without it.
Here’s an old post about her.
Hurt
Saturday, March 01, 2008
Ethical Question
Baby Medic just posted about doing three codes in two days. He includes this snippet:
Thirty-nine years old, the family said, and they thought she was alive this morning but they couldn't be sure. Someone thought they heard her get up and make coffee. "The lady deserves a chance at that age," the doctor said over the radio after refusing your request to discontinue resuscitation. "Bring her on in."
In our region, we have certain criteria in which a paramedic can discontinue resuscitation on their own -- found in asystole and no response after 20 minutes of ACLS resuscitation, including tube, IV and three rounds of meds. Anything else you have to call for permission to cease. In the future, it is my understanding, we will be complying with a forthcoming statewide guideline that will require us to call a physician to discontinue any resuscitation. Note: This does not include people with rigor mortis and dependent lividity, etc. Under the current guideline the only age restriction is 18 years of age. If your patient is under 18, you must call to cease even an asystole resuscitation.
See Discontinuation of Prehospital Resuscitation Protocol page 160 of protocols or 162 of Adobe reader.
North Central EMS Protocols
Without having talked to Baby Medic or knowing anything about his call, if the patient was found asystole and not responding after 20 minutes of ACLS, it sounds like he was going above and beyond the guideline by calling in.
My question is this: How much should age factor into your decision to cease a resuscitation?
From personal experience, I have worked babies who were rigored -- I worked them more for the parents and the other first responders and maybe even for myself than through any hope of bringing them back. I have also worked 90 years olds and been secretly upset when I have gotten pulses back in the 20th minute of resuscitation (seeing a blip on the monitor when I was looking for a final asystole to allow me to finally cease) because now I have to transport a living corpse, broken ribs and all to the hospital where once the epi wears off, the patient will surely be pronounced dead.
So where does the line lie?
Here's a generic scenario:
Unknown down time. Asystole, but still warm with no rigor. No sign of drug intoxication, trauma, drowning or electrocution. You work them for 20 minutes and they are still asystole. The scene is a private apartment. There is no family. There is no significant medical history beyond the norms for their age(meaning a 2-year-old has no medical problems, a 80-year-old has expected chronic problems).
At what age limits (within this scenario) do you feel comfortable ceasing a resuscitation on your own?
Ethically should 2-year-olds, 20-year-olds, 36-year-olds, 55-year-olds, 78-year-olds and 99-year-olds be treated differently?
At what age do people, to paraphrase the physician in Baby Medic's story, deserve a chance to live?
Should we have more rigid guidelines to make these determinations for us or should we just continue to use our judgement based on everything we see and feel?
And is it wrong that different medics or different physicians will produce different responses to the same cases?
To resolve the ambiguity should we go backwards to the old days of transporting everyone in cardiac arrest even though the science shows people in asystole after 20 minutes have virtually no chance of meaningful survival?
On a corollary, I have found that with the new CPR, I am having more and more initially asystolic patients develop electrical activity and or pulses deeper into the 20 minutes -- once even after I have told the patient's physician and family that I am terminating the resuscitation.
The Man Who Wouldn't Die Part II
No easy job -- this one of ours.
Thirty-nine years old, the family said, and they thought she was alive this morning but they couldn't be sure. Someone thought they heard her get up and make coffee. "The lady deserves a chance at that age," the doctor said over the radio after refusing your request to discontinue resuscitation. "Bring her on in."
In our region, we have certain criteria in which a paramedic can discontinue resuscitation on their own -- found in asystole and no response after 20 minutes of ACLS resuscitation, including tube, IV and three rounds of meds. Anything else you have to call for permission to cease. In the future, it is my understanding, we will be complying with a forthcoming statewide guideline that will require us to call a physician to discontinue any resuscitation. Note: This does not include people with rigor mortis and dependent lividity, etc. Under the current guideline the only age restriction is 18 years of age. If your patient is under 18, you must call to cease even an asystole resuscitation.
See Discontinuation of Prehospital Resuscitation Protocol page 160 of protocols or 162 of Adobe reader.
North Central EMS Protocols
Without having talked to Baby Medic or knowing anything about his call, if the patient was found asystole and not responding after 20 minutes of ACLS, it sounds like he was going above and beyond the guideline by calling in.
My question is this: How much should age factor into your decision to cease a resuscitation?
From personal experience, I have worked babies who were rigored -- I worked them more for the parents and the other first responders and maybe even for myself than through any hope of bringing them back. I have also worked 90 years olds and been secretly upset when I have gotten pulses back in the 20th minute of resuscitation (seeing a blip on the monitor when I was looking for a final asystole to allow me to finally cease) because now I have to transport a living corpse, broken ribs and all to the hospital where once the epi wears off, the patient will surely be pronounced dead.
So where does the line lie?
Here's a generic scenario:
Unknown down time. Asystole, but still warm with no rigor. No sign of drug intoxication, trauma, drowning or electrocution. You work them for 20 minutes and they are still asystole. The scene is a private apartment. There is no family. There is no significant medical history beyond the norms for their age(meaning a 2-year-old has no medical problems, a 80-year-old has expected chronic problems).
At what age limits (within this scenario) do you feel comfortable ceasing a resuscitation on your own?
Ethically should 2-year-olds, 20-year-olds, 36-year-olds, 55-year-olds, 78-year-olds and 99-year-olds be treated differently?
At what age do people, to paraphrase the physician in Baby Medic's story, deserve a chance to live?
Should we have more rigid guidelines to make these determinations for us or should we just continue to use our judgement based on everything we see and feel?
And is it wrong that different medics or different physicians will produce different responses to the same cases?
To resolve the ambiguity should we go backwards to the old days of transporting everyone in cardiac arrest even though the science shows people in asystole after 20 minutes have virtually no chance of meaningful survival?
On a corollary, I have found that with the new CPR, I am having more and more initially asystolic patients develop electrical activity and or pulses deeper into the 20 minutes -- once even after I have told the patient's physician and family that I am terminating the resuscitation.
The Man Who Wouldn't Die Part II
No easy job -- this one of ours.
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