The Gear (Oops)

I wrote recently about screwups with the gear.

Equipment(Brain) Malfunction

This just proves there is always a new chapter.

I checked out my monitor the other day, doing a quick eyeball, BP cuff, monitor leads before checking the battery, doing the user test, and then opening up the back and top compartments for check for electrodes, 12-lead connections, capnography filters, spare paper and defib pads. Everything looks good.



Then later on a chest pain call, I asked my partner to put the patient on the monitor.

Small problem, she said.



Seems we were missing part of the cable. (We had the leads, but not the connection that attaches to the monitor. Someone had pulled these two pieces, which are rarely detached from each other, apart, and then misplaced the cable connection piece.)

I ended up having to put the defib pads on the patient to get a strip.

"Don't be concerned by these pads I'm putting on your chest," I told the patient. "Strictly routine, strictly routine."

He didn't look convinced.

Parade

I want to compliment myself because I took a vow quite awhile back that I would stop whining about all the bad things in this job, and I think I have done a pretty good job of it lately. When you start letting things like lengthy triage waits and pompous health care providers (whether hospital, EMS, nursing home, doctor office or visiting nurse) and miserable patients and poor dispatching bother you, your day just feels so much heavier. Let it roll on by and it lightens your load. I also said I would try not to write about large patients in a negative way, and believe I have done so.

I do want to say that I am thankful for the word "bariatric" because today I had a large patient, who I was not quite, but almost a dick to, and I felt bad that I may have let my frustration over the call come through, and possibly may have made the patient feel bad about his weight. So when I had to call the hospital and give my report, instead of saying "morbidly obese," which I think is somewhat of a hurtful phrase, I only had to say that my patient would require a "bariatric" stretcher and that meant the patient didn't have to hear my calling him obese.

Enough on that for the time being.

The following events actually happened in reverse order, but I am going to pretend they happened in the order I am going to write them because I like the ending better this way.

Back to the bariatric call. Suffice to say we carried a man who had not been downstairs since December down the stairs in our stair chair. His complaint was a black thumbnail. He banged his hand a few weeks ago and the nail turned black. Enough said. He can't walk due to his size. Looking at him, I asked how we had gotten him down the stairs the last time. He said we had used the chair. You look bigger, I said. I'm the same size, he said.

That may be, but I didn't recall having such a hard time getting him downstairs as we did. I am sore in places I have never been sore before from lifting. My back, chest wall, groin and legs are sore like I tore millions of tiny muscle fibers. Oh, yeah, and our stair chair is broken. I also have some patient smell transference that is still making me a little nauseous and causing me even now sitting here writing this to feel like the patient is still sitting next to me. Too close.

When we finally got him downstairs and out into the yard where our stretcher was set up, it started to pour rain. No patient likes being out in the pouring rain, and we did our best to keep him dry until we could get him safely on the stretcher and into the back of our ambulance. Fortunately in one way, it stopped raining pretty quick, but in another, I feel like a good soaking would have done all of us good.

I will be curious when he is sent home (presumably by commercial ambulance) how they will get him back upstairs. Or maybe they will refuse. I can see someone becoming a prisoner on a second floor due to weight gain, and thus needing to be carried down, but I can't see someone being carried up stairs to a place they cannot escape from without at least four people and an extended amount of time to help carry them. It's an interesting issue. Can an ambulance crew refuse a carry-up? Would a supervisor go along based on health and safety issues? Would a company back them up? What does the patient do then? I'll be curious to followup. I did warn the commercial crews I saw at the hospital that they may soon be called to take this patient back home. I did not say run for the hills. I just suggested they might want to be on the other side of town so as not to be one of the closest cars when the hospital telephone for transportation for the patient.

On the next call, I had a patient with abdominal pain and vomiting. She seemed okay en route. Stable vitals. Calm. Then just as we pulled into the ambulance driveway, I saw it coming. She gave me no warning. I saw it, recognized it, but there was no time to act. I was puked on, all down my leg and on my boots, warm, chunky puke.

Later, I was called for an intercept with a basic crew, who said they needed me for drugs. I grabbed my narcs, thinking the patient probably had a fracture and they needed me for pain control. When I got in the back of the ambulance, I found them log-rolling a man on a backboard who felt nauseous. He was a dementia patient who had run into a wall while jogging in the hallway and had been unable to slow down. No loss of consciousness. No change in mental status. Stable vitals. Pupils equal and reactive. Just a bruise on his nose. They did say he had already thrown up once. They asked if I could give him some phenergan to stop him from vomiting. They were transporting to a hospital twenty-five minutes away.

What are you going to do? I gave him some Zofran and the ride from there seemed to go well. Then when we got the patient in the hospital room, he said he felt like he was going to throw up, and then there it was. I reached to roll him, and he puked all down my arm and sleeve, and down onto my boots.

Memorial day. I hate doing standbys and parades. Every Memorial Day I am spared the standby because we always get calls and they have to pull us from the standby. Today, right at ten, we got one. Spared again. But it turned out the parade didn't start until 11:30, so when we got back to town, we found ourselves, not just doing the parade standby, but actually being in the parade as the last vehicle.

It was great. As we rolled slowly down the main drag, people lining the parade route stood and clapped and thanked us. Little kids waved and then laughed as we hit the air horn. I recognized some of the people in chairs by the roadside as old patients. They all smiled and waved, and called out their thanks.

It felt good to be a paramedic.

Just a Paramedic

Baby Medic asks in his most recent post Routine about the frustrations of the mundane in EMS:

I would like to know how those who have been doing this job for a long time are able to withstand the mundane. Do they no longer live for the exciting calls? Are they content to relax in the routine, or have they a way to find interest in the subtleties that I may perhaps miss in my eagerness for something new?

Am I missing something?

I've been in EMS now since 1989, a medic since 1993, and a full-time medic since 1995. Here's my take:

I do share the frustration of the mundane to a degree. I have had days where I am doing multiple codes and months where I never touch my laregnyscope. I'll do back to back trauma room calls, and then not have another trauma for three weeks. I'll do ten ALS calls in a row, but none of them more advanced then simple IV, 02, monitor, and transport non-priority.

I guess I manage through the dry spells because for me it has never been primarily about the medicine. I have come to enjoy and appreciate the challenges of the medicine and, as much as anyone, I relish an opportunity to solve a medical puzzle or perform a difference-making skill. But the fact is we are somewhat limited in our diagnostic abilities. We can venture guesses, but often without labs, x-rays and imaging tests, etc, we can't really tell what's going on, and often not knowing, keeps us from taking a stab at treatment(And we really should never be stabbing at treatment unless the situation is quite dire).

Recently I had another patient who's internal defib was going off. The last time it had happened, he had hypomagnesium. I carry magnesium, but there is no way for me to tell that this is why it is happening again, although I can guess it might be. I have amiodarone ready if he goes into a v-tack and starts getting shocked repeatedly as well as some versed to ease the jolts, but his defib never goes off again and we have a nice easy ride in with pleasant conversation.

Working primarily now in a town with a huge elderly population I am constantly faced with the CHF/COPD/Pneumonia conundrum. Some cases are clear cut, but in many in order to determine what is really going on, I need an X-ray and a BNP test. The doctors have that at the ED and I don't so my care is far from definitive. I'll withhold the Lasix, and give them NTG if I feel I have to do something.

The challenge for me then when I am not medically challenged is trying to do the part I can do as well as possible. Yesterday we had a stroke patient, and I judged myself on how well I was able to get the full story of the patient's norm, what happened, etc, collecting all the clues to present to the doctor. The call went okay, but there were some frustrations. I couldn't get a good medical history because the man was visiting relatives and not at his home where his medicine was kept. I had radio problems and so couldn't give a patch to the hospital, and then in transferring the patient over to the hospital's bed, the tape on his IV got caught on his pants and ripped the IV out when we moved him over. Oh, well.

I've had a number of IVs get pulled out in this way over the years. Now whenever I bring a patient to the trauma room, I always wrap kling around the IV site to protect it because they are notorious from yanking out IVs as they try to help you transfer the patient over. I am going to start working on a new method of better securing my lines on all patients and see how long I can go before I get another one yanked out in transfer.

What I like about the routine of the job is the chance to try to do calls perfectly. Even the simplest calls are hard to do perfectly, but I try. I grade myself in many categories from courtesy to the patient, family and staff, efficiency of time, proper gathering of history, getting the patient into a johnny if necessary and putting their removed shirt and jacket in a plastic clothes bag, full assessment, doing a 12-lead, gaining IV access, getting the blood sugar, dotting all the i's and crossing all the t's, limiting time on scene, completing all care by arrival at the hospital, as well as writing my trip card, and cleaning the back as I go, so that when my partner returns the stretcher, there is little to do, but change the sheets. And of course, saying goodbye and wishing the patient well.

If I can do weeks of simple calls as close to perfectly as possible, then when I get the big bad one, I might do it just a little better than I otherwise would have.

For me, though, the biggest thing that keeps me sane through the mundane is the people, the human contact and the stories. That's why I got into this in the first place. If I can come through a day with one good story or moment I can tell about when I get home, then I am happy.

For me yesterday, it was at a retirement home where our patient, a woman with a skin tear on her leg, sat watching the Red Sox game on TV -- unbenownst to her it was a cable rerun of the game the night before. It was now the seventh inning and the pitcher for the Oakland A's had a no-hitter going with one out in the 7th with David "Big Papi" Ortiz up for the Red Sox. We were trying to get her on our stretcher, but she wanted to see how Big Papi was going to do. "I know the way its going, he's going to make an out, but I just want to see him bat," she said.

"He's going to lash a single up the middle," I said.

Sure enough the next pitch, Big Papi broke up the no-hitter with a single up the middle to the woman's great delight.

"You should be a fortune-teller," the woman said.

"No, no, I'm just a paramedic," I said, pleased I had my story for the day.

Book News

This morning's New York Times has an excellent review of Shannon Burke's novel "Black Flies."

In recent days I have heard from a number of paramedics and EMTs who have read the book and they have all given it a thumbs up. I recommend it.

Black Flies: Blood and Guts



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British EMT blogger Tom Reynolds' book, based on his Random Acts of Reality blog has been released in a US edition.



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Eugenia Klopsis, an EMT, who for many years wrote an "EMT Diary" for the New York Sun about her adventures with her partner Bronson on the streets of Brooklyn, has finished a collection of stories, Siren Songs. For those who can't wait for publication, you can sample her work at:

Eugenia Klopsis Archive

She has a wry sense of humor and is an enjoyable read.

Try these:

Dealing With Child Abuse

Park Slope Shooting Gallery

Bronson Steps Up

Wishing for a Seizure

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Katherine Howell's EMS thriller Frantic is available for pre-order from Amazon - Canada.

Frantic, as well as her latest, The Darkest Hour, can be purchased from her publisher Pan Macmillian Australia.

The Asshole

I‘ve been called an "Asshole" by a patient two days running now. I guess I have to reluctantly plead guilty in the first instance. The second, I’m not ready to admit it yet.

Here’s how the calls went down.

***

The first was for a diabetic, altered level of consciousness. 40-year-old man lying in bed with glazed over eyes, cool, clammy skin, no idea what time it is, but he knows he’s an insulin dependent diabetic. His sugar on finger stick is 35.

There are a few different theories on how to treat conscious diabetics with altered mental status. Some medics like to give them orange juice and something to eat. I tend to prefer to go ahead and put a line in and give them the D50 and just take care of the issue. Officially in our protocols, the line is defined by "alert with intact gag reflex." "Alert" is somewhat open to interpretation. Now obviously every medic is going to have a line they draw between their decision to give juice or to give D50. Where another medic draws the line is not as important to this story as this patient is right on my line. I decide to pop a line in. I’d rather just take care of the issue and be done with it than going through trying to get him drink and then waiting for his sugar to gradually come up to a point where he can competently refuse transport, which is what most of diabetics do when they come around. By most diabetics, I am talking about the young, independent insulin diabetics who occasionally drop their sugar when they forget to eat and who have been through the whole ED rigmarole on other occasions and just do not want to be transported.

I put the tourniquet around the man’s arm, spot a vein in his AC and no sooner have I put the needle into the skin, then the man swings his arms and says, “I’m not going to the f-ing hospital. Don’t you stick me with an IV.”

Now I am annoyed that I have now missed the IV on the only vein I could see, so instead of doing the smart thing and saying, “Nobody says you have to go to the hospital,” I start reasoning with him in a way that he cannot understand. I am trying to tell him that while he cannot refuse right now because he is not competent, in a minute after I give him some sugar and make him competent, he can then refuse.

It of course goes right over his head, and then he punches me and calls me an asshole.

Things can get out of hand so quickly.

I grab his arm to keep him from punching me again and the cops then grab him and start yelling at him and everyone is yelling at everyone else. He is screaming "I know my fucking rights. Just let me drink some coke."

There is an open can by his bedside which his roommate had tried to pour in his mouth before our arrival and he manages to break through and then pours half the can on me and himself as he tries to chug it. I find myself hindering his efforts to drink it because I am still pissed that he clocked me, messed up my IV and spilled coke on me.

In the back of my brain unable to get through is a voice that says, "Hey, if he can drink, let him drink, maybe he isn’t as altered as you thought." The other voice is saying, "He can’t talk to you like that. Christ, he hit you, if he’s alert, he’s going to jail. You give him an IV and give him sugar, he doesn’t have to go to jail. He hit you because he was altered."

With the cops yelling at him and me with a good hold on his arm, and him calmed down just a little – maybe the coke did it -- I quickly stick in another IV and push in half an amp of D50 and within another minute, he is apologizing for his behavior, and I am saying that’s okay I have seen worse, and he agrees to eat, refuses to go to the hospital, admits he overslept, says he is a brittle diabetic and should take better care of himself. His sugar is up to 200 now. Etc, etc, we get the refusal.

Outside, I apologize to the officers for not handling myself better. I shouldn’t have antagonized him at first. But what I am really thinking is I walked a fine line between providing the right care and committing assault. Something about it just didn’t feel right. I think what happened is in the course of the call, he went from being not alert to being alert, he crossed my line himself, maybe due from the Coke his roommate had poured in his mouth kicking in, supplemented by the Coke he poured in himself, and I wasn't nimble or ego-free enough to change my course of action. It became about me versus him, rather than me versus appropriate medicine. I think next time my line between IV D50 and giving the patient a chance to drink some juice to see if he can drink it okay has moved closer to the juice side.


***

The second patient who called me an asshole had a history of chronic pain -- back pain, sciatica, fibromyalgia, migraines. You name it, if it had to do with pain, he had it. This is an old patient for me. I used to take care of him years ago. You’d find him one day in bed, unable to move, complaining of pain all over, and acting almost stuporous and then the next week see him out bare-chested showing off his nearly full body tattoos as he mowed his lawn.

Now he says he takes Darvocet, but his new doctor recently reduced the dosage. He tells me he hasn’t had any pain pills for a week. I ask to see the Darvocet bottle but it is nowhere to be found. He has his other pill bottles -- pills for hypertension and gastric upset -- but no Darvocet bottle.

I ask what happened to the pills his doctor gave him last week, but he won’t answer my questions. He just closes his eyes and moans. If he lowered your dosage, you still should have some pills, did you not refill the prescription? Did you lose the pills? Did you take too many? No answer. He can answer other questions, but not these. I ask why we aren’t going to the hospital he normally goes to, and he won’t answer that either.

Admit anything to me – you were in so much pain, you took six a day -- just don’t refuse to answer my questions when you are competent to answer. I am here to help.

But he won’t answer. Whenever we get on a touchy question, he just moans and closes his eyes.

I should just say “whatever" and transport him BLS and let the hospital deal with him, but I keep up asking the questions, my tone getting harsher and harsher. I am clearly starting to get pissed.

He finally opens his eyes, looks right at me, and no slur in his speech, says, “You’re an asshole.”

“If you are alert enough to recognize that I am an asshole," I say, "then you are alert enough to tell me what happened to those pain pills.”

I am into pain relief. I have no problem with being taken by a drug abuser if it means denying someone with legitimate pain relief. I fully understand the devastating effects of chronic pain, and how it can turn otherwise normal, upstanding citizens into drug seekers out of fear they will not have enough medicine when they need it. My bonafides are solid on this issue, but he is getting no inch from me because he will not be straight with me. “You can answer. You want me to help you, answer the questions. What happened at the other hospital and what happened at your doctor’s office. Where are the pills he gave you? Tell me a believable story.”

He won’t look at me. The volunteer riding with me sits across from me looking at me like I am being so mean to this man. I feel like saying, "Go ahead, call me an asshole, too. I know that's what you are thinking."

I give my report at the hospital, and then leave. This morning when I go back, I ask what happened to the man and I am relieved to hear they concurred with my impression. The man was abusing prescription drugs, doctor shopping and when he was told he wouldn’t be getting any medicine, he stormed out of the hospital.

***

I’ve done two calls today and both patients have thanked me afterwards. I do admit to trying to be extra nice today.

Even though I was right about the man with chronic pain being a drug seeker, in retrospect now, I think I was an asshole to him, too.

And no matter what, I don’t ever have a right to be an asshole to a patient.

Trauma Room

I've been bringing quite a number of patients to the trauma room lately. You get hurt in a routine motor vehicle accident, you end up in a regular room in the ED or probably even more likely, a bed in the hallway until they can clear your c-spine, get you off the backboard and send you home with a script for a muscle relaxer. You get hurt in a big crash, you will likely get the trauma room. There, you will get all your clothes cut off and likely get fingers or tubes in all of your orifices, including orifices you didn't know you had.

The rules for who gets the trauma room are constantly changing. They seem to go from permissive to restrictive and back depending on who knows what. There was a time when the biggest complaint paramedics had was "I asked for the trauma room and they didn't give it to me." Now I can't tell you the number of times I have brought in a patient non lights and sirens, wheeled him down the hall, past the open trauma room door where I have seen a fully gowned trauma team, awaiting a patient and I have wondered what they were waiting for, what was coming in? a shooting to the head? a horrific MVA? a high fall with loss of consciousness and multiple fractures? Only to discover they were awaiting my patient -- a woman who had fallen down five stairs and had a headache or a man in a rollover who was ambulatory on scene with no complaint other than a laceration on his arm.

All I ask for is consistency. Depending on the day don't put one patient in the trauma room and his identical brother from an identical accident with an identical complaint in the waiting room after tearing off his c-collar in triage.

Most of my trips lately to the trauma room have fallen into two categories. A) I didn't call for the trauma room, but they decided the patient belonged in the trauma room(usually due to mechanism, in some cases self-reported -- human radar gun patient says the other car was going fifty-sixty miles an hour when it struck his car) and B) Calls where I asked for the trauma room on mechanism only with the patient not showing much in the way of injury.

* There were times in the past (depending on the pendulum) where mechanism really didn't matter, you had to be banged up to get in the trauma room. Nowadays mechanism alone buys you the trauma room most every time.

In each of these categories, I would see disappointment in the trauma team members' eyes as they saw that the trauma really wasn't very interesting -- they had been paged for this? -- much like we sometimes can think we got called for this? when we show up on the site of a supposed bad car wreck to find really no injuries at all.

I feel like the director of a boring movie, the author of a boring book, a boring college professor. I want to say either "I didn't call for the trauma room" or "Hey, I'm just following your protocol."

Then the other day we get called to a motor vehicle accident. I know the location and I say to my partners "this is going to be a real wreck."

We arrive to find a car into a tree with no skid marks. The tree is embedded in the engine. The man sits in the front seat of the car, in which the air bag has deployed. He looks dazed. When I ask how he is, he says, "Anyone else hurt?"

"I think just you," I say.

"Anyone else hurt?" he says again.

"I think only you."

"Anyone else hurt?" he says.

The steering wheel is crumbled. Then I look down at his legs. I see jagged bone ends. His right foot is upside down next to his considerably shortened right leg, hanging by a thin margin of skin and muscle.

"Are you in any pain?" I ask

"Anyone else hurt?" he says.

We rapidly extricate him. He also has bruising on his chest and abdomen. I have to use four trauma dressings just to wrap his legs which in addition to the open fractures have deep lacerations to the subcutaneous layer. His heart rate is in the 120's and I am worried he may soon go into shock.

"Anyone else hurt?" he asks.

Not to mention the question of a brain injury.

I give my report in the trauma room. I feel bad to say so but I feel almost like a celebrity chef unveiling a master dish when I finally unveil the man's grotesquely deformed limb. "Open tib-fib fracture," I say with a flourish.

Their heads nod, their eyes alive with interest.

Complications: A Surgeon's Notes on an Imperfect Science

I'm reading an excellent book, Complications: A Surgeon's Notes on an Imperfect Science. First off, the author is a great writer. The book is thoughtful, easy reading and hard to put down. Second, while written by a surgeon much of it is very relevant to the world of EMS.

Among his subject matter:

Mistakes by doctors: "No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it."

The new science of pain: "Yes, injury produces nerve signals that travel through a spinal-chord-gate, but it is the brain that generates the pain experience, and it can do so even in the absence of external stimuli."

The ability of computers/and or algorithms to become better at diagnosis than doctors: "as 'systems' take on more and more of the technical work of medicine, individual physicians may be in a position to embrace the dimensions of care that mattered long before technology came -- like talking to their patients. Medical care is about our life and death, and we've always needed doctors to help us understand what is happening and why, and what is possible and what is not. In the increasingly tangled web of experts and expert systems, a doctor has an even greater obligation to serve as a knowledgeable guide and confidant. Maybe machines can decide, but we still need doctors to heal."

***

"Medicine reveals itself as a fascinatingly complex and 'fundamentally human endeavor' in this distinguished debut essay collection by a surgical resident and staff writer for the New Yorker. Gawande, a former Rhodes scholar and Harvard Medical School graduate, illuminates 'the moments in which medicine actually happens,' and describes his profession as an 'enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line." Gawande's background in philosophy and ethics is evident throughout these pieces, which range from edgy accounts of medical traumas to sobering analyses of doctors' anxieties and burnout."
-Publishers Weekly

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Note: Since I posted this review I have heard from several people praising Gawande's second book, Better. I have ordered it myself and look forward to reading it.

"A surgeon at the Brigham and Women's Hospital in Boston and an assistant professor at the Harvard School of Public Health, Dr. Atul Gawande succeeds in putting a human face on controversial topics like malpractice and global disparities in medical care, while taking an unflinching look at his own failings as a doctor. Critics appreciated his candor, his sly sense of humor, and his skill in examining difficult issues from many perspectives. He conveys his message—that doctors are only human and therefore must always be diligent and resourceful in fulfilling their duties—in clear, confident prose. Most critics' only complaint was that half of the essays are reprints of earlier articles. Gawande's arguments, by turns inspiring and unsettling, may cause you to see your own doctor in a whole new light."
-Bookmarks Magazine

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The Future of Intubation

I recently taught the bougie station at an airway class for ED physicians. While there I got to sit in on an excellent airway lecture and play with some of the other airway devices in the hospital's difficult airway cart.

There was a vendor there from King Systems helping demonstrate a new product of theirs called the AIRTRAQ.

It is a disposable optical laryngoscope that was amazingly easy to use even on the simulator mannequin's difficult airways. I tend to be resistant to new gizmos, but I was impressed, as were the ED physicians who were introduced to it. The product is $80-$90 now, but will probably come down in the future.

Given that we already have EZ-IO needles that cost $90 a needle for emergency access, I don't think it is unreasonable to see some EMS services stocking a device like this for difficult intubations. I understand some hospitals are using this device to such an extent that their new residents are not acquiring the skills of standard intubation.

I don't know enough about the real life experiences of people using the device to be able to comment about drawbacks or how well it deals with airways full of secretions, etc. but I wouldn't mind having one of these in my kit.

Check out some of the videos of the AIRTRAQ in use at the following link:

AirWay Video Library

I'd love to hear from any medics out there using this or similar devices.

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By the way I have no affiliation or financial interest in this device or any other medical device I may write about it.

Spring Cleaning

In the spirit of Spring cleaning, I am giving this blog a new look. I have decided at least for the time being to strip the blog down to its basics. For a week or so I had a revolving carousel of books at the top banner head that I thought was very nifty, but I got tired of waiting for it to load, and found it distracting.

I have also taken off the Google ads and the extended book offers.

I have added a new sidebar that still promotes EMS books. Additionally, all books and DVDs can be found at this link, which is also located in the sidebar:

EMS Bookstore

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Also, any EMS bloggers out there who would like to be added to my blogroll, please leave a comment or drop me an email. My email is now listed under my profile.

Please also let me know about any new EMS books, fiction and non-fiction true stories, that I don't have listed.

The Church Lady and the Ambulance Attendant

The woman heard a pop as (twisting) she tried to help her (stumbling) mother out of her wheelchair and into the church pew. The pop came from the woman's knee and she crumpled in pain. She screamed again as we tried to pivot her on her good leg onto our stretcher. The entire congregation turned at that sound. I felt like a barbarian in the gates. There had to have been a gentler way to move her, I just didn't anticipate the little bit of movement would cause such pain -- such a loud scream. My partner and I try to talk soothingly and get her all cushioned and comfortable, trying to cover up the memory of that scream, and maybe get her to see us a little less like untrained ambulance attendants (on a work-release program) and a little more like trusted caregivers.

Out in the ambulance, we elevate her leg, and wrap ice around the knee. From the pop, I'm guessing she tore a ligament. I ask the woman how much pain she is in.

"A lot," she says. "Ten of ten. It hurts."

After she tells me she doesn't have any allergies, I say, "I can give you morphine."

She looks at me with an evil eye. I've already caused this church woman pain by my bumbled patient-handling methods, and now I am trying to push morphine on her.

"I'll bear it," she says. "You don't have any Tylenol, do you?"

I shake my head. I start to tell her morphine is really not so bad, but she isn't looking at me. She looks at her iced and elevated knee like she is pissed that life has put her in this situation, forced to ride in the back of the ambulance with a painful throbbing knee that she must bear because she certainly does not trust the man fate has put in the back with her.

I wonder how it would have come out if I had just told her I was going to give her a little something for her pain, and just gone ahead and given her the drug. Naming it probably wasn't the smartest thing. She's a church lady and morphine might as well be the devil to her.

If they are awake and alert, what obligation do we have to our patients to explain how we are treating them? How much detail do we have to use? Do we have to tell them we are giving them medication? Do we have to name the drug?*

If I had just said, "I'm going to give you something for your pain," and hearing no protest, gone ahead and given it to her, she'd be feeling better right now. But maybe if we had been smoother and truly careful with our move, we would have spared her pain, given her no cause for a scream, and she would have taken our morphine on blind faith in her Good Samaritans.

I don't know. As it is, I'm feeling quite guilty. I watch her grimace as we bump down the highway, patient and ambulance attendant.

***

* I think the answer is probably yes to all of those questions. In practice, I tailor my explanation to the patient on a case-by-case basis depending on my guess of the patient's understanding or desire for an explanation. To one patient, I might go in detail about the pharmacokinetics of Cardizem as I prepare to treat them for their rapid afib, to someone else, I might just say, "This will make you feel better." I do know that the word "morphine" has negative connotations to many people. I wish it had a nondescript trade name or better yet a market-researched product name. I'm going to give you Tincture of Unicorn. 5 milligrams of Happiness. A touch of No Worries and you'll be all set.

Celtics Fan

The Boston Celtics are back in the championship hunt. As a kid, I was a huge Celtics fan. I watched them on our small black and white TV and then I'd go out in the driveway and dribble around and shoot against the hoop my father had nailed over the garage door. I pretended I was on the team. Havlicek, Russell, Sam and KC Jones, Satch Sanders and me would battle the Lakers of Jerry West, Elgin Baylor and Wilt Chamberlain.

I watched them for years. I remember the Dave Cowens and JoJo White days, and then on to the great Larry Bird teams. Danny Ainge, Dennis Johnson, Kevin McHale, Robert "The Chief" Parish, Cedrick Maxwell.

Oh, the great matchups. The Sixers. The Lambier/Isiah Pistons. And of course the Lakers with Magic and Kareem and James Worthy.

I used to go to a great bar in Iowa and watch the championship games on the big screen TV in the back room as we drank pitchers of beer and lived and died with every shot.

My girlfriend at the time became a huge Celtics fan. I bought her Celtics jacket for Christmas and even bought her a single share of Celtics stock when they became a publicly traded company. She loved those gifts.

Then the Celtics fell on hard times. It started with the death of Len Bias (cocaine overdose), who I used to watch play when I lived in Virginia and he played for Maryland. The kid was a physical Michael Jordan. And then their All-Star captain Reggie Lewis died (heart arrhythmia). The Celtics leprechaun luck seemed gone for good. They were miserable. A rotten team with rotten coaches and players who didn't know basketball was a team sport. I stopped following the team altogether.

And then this year happened. Somehow Celtics GM Danny Ainge, managed to get old Celtic great and Minnesota GM Kevin McHale to trade superstar Kevin Garnett, and they signed aging All-Star Ray Allen to join All-Star Paul Pierce, and in one year they went from the cellar to the best record in the league with "The Boston Three-Party." Could the home team hoist another banner to the rafters of the Garden? This prodigal fan returned.

The Celtics played the Atlanta Hawks in the first round of the playoffs this year, but instead of sweeping them as many expected, while they clobbered them in home games in Boston, they lost three hard fought road games in Atlanta and were now in Game Seven, back at home and I was at work, but able to watch the game on the big screen TV at the ambulance bay.

It's the third quarter, the Celtics have a nice lead going, when their point guard Raja Rondo is slammed to the ground while trying to score on a breakaway. A dastardly foul! But just then the tones go off and I have to go on a call for back pain. Damn!

The man is lying in bed with back pain (sciatica). He weighs three hundred pounds and lives on the second floor up a narrow windy staircase with furniture and newspapers lining the narrow hall. My partner is on the small side so I ask if the patient is able to walk. He can't even get out of bed the pain is so bad. I ask him if he can sit in a chair, and he says no way. My partner says maybe we'll have to strap him to a board and drag him down the stairs. I look at him like he can't be serious. Our first responder help -- the local police have just left for a fight in progress. There is no way the two of us are going to be able to carry him.

That leaves us with plan M. I give the man five milligrams of morphine, and tell him we'll wait five minutes and see if he can get get up then. Five minutes go by, and he still can't move. I give him another five milligrams. While we are sitting there waiting for the drug to work its magic, I find myself watching the John Travolta movie, Civil Action, on his massive plasma TV screen. This man lives in a dump of a house, but this is some fine TV. But what I'm really thinking it, just how interested in this movie is this man? I mean, if he was really interested, wouldn't he have waited until it was over, until he called for the ambulance?

I debate. I consider saying, I have a deal for you. How about I give you some more morphine and while we wait for it to achieve its full affects, you change the channel for me and we watch the rest of the Celtic game. Got any cold drinks in the fridge? Any chips or wings down in the kitchen?

Aahhhh. I can't bring myself around to asking. It seems somehow improper. I suppose if it was the Red Sox and the World Series, I might get away with it. I stare blankly at the TV. It looks like a really boring movie. I know I must have seen it many years ago, but I don't remember a thing about it.

After ten minutes, I ask the man if he is able to move now, and he sits right up. He says he thinks he can walk, and he stands with help and with barely a grimace. And then with my partner giving him a hand, he walks all the way down the narrow stairs and out to the front steps where our stretcher awaits.

At the hospital, the nurse gives me a hard time about all the morphine I gave him. Why are you always giving so much morphine? she asks. Why don't you just give them Motrin?

He's (f-ing) on Motrin and Flexoril already, I say. (The f-ing part, I only say in my mind right up there with asking to turn the channel). He couldn't get out of bed. Plus, its all about pain relief now days, you know that. (Get with the f-ing program.) How the hell were we going to get him out of his bed on the second floor? He weighs 350 (f-ing) pounds. He was dying, he couldn't get out of bed. He couldn't sit in a chair. I took his pain away.

The patient overhears our conversation, and says, "Miss, you should know these are fine fellows, they took good care, good care of me. They treated me right."

"I assume, you're not feeling any pain anymore," the nurse says.

"That's right. They're good folks."

She shakes her head, and then assigns us a room.

***

Just think how she would have reacted if I had answered. "I gave him the morphine in exchange for a cold Coke, a bag of Doritos, a batch of his Mama's famous recipe buffalo wings, and front row seats at his big screen plasma TV to the last quarter of the Celtics game. You got a problem with that?"

***

After the call I found out the Celtics won by a wide margin. Tonight, in the second round of playoffs, they face Lebron James and the Cavaliers in a game that starts at 8:00 P.M. I'm on duty until 10:00 so I may again face on scene temptation. Hope for no calls for me.

Let's go Celts!

The Darkest Hour

Australian crime writer and former paramedic, Katherine Howell has just published her second novel, The Darkest Hour


Her previous novel Frantic was published last year.

Her books involve a reoccurring police detective, Ella Marconi, and a female paramedic (who will change from book to book) caught up in a suspenseful situation. While primarily crime thrillers, there is quite a bit of EMS background and scene calls that are all convincingly written.

Both novels are hard to put down thrillers that make great ambulance reading (except for getting angry at your dispatcher for giving you another call before you can find out what happens next to the characters).

While her books haven't yet been published in the United States, her first novel is available for preorder from Amazon Canada.

Both books can be purchased today from her publisher Pan Macmillian Australia.

***

Darkest Hour - Synopsis

Paramedic Lauren Yates stumbles into a world of trouble the night she discovers a dead man in an inner city alley, for the killer still lurks nearby. When the murderer threatens to make her life hell if she tells the police, she believes him – he's Miles Werner, her sister's ex and father to Lauren's niece... and a very bad man indeed.

But when a stabbing victim tells her with his dying breath that Werner attacked him too, she finds herself with blood on her hands and Detective Ella Marconi on her back.

Keen to cement her temporary position in the homicide squad, Ella knows Lauren is the perfect witness for the murder since she can testify to the victim's last words. But when Lauren tries to change her statement, Ella realises that Lauren is hiding something big, and, while her colleagues label her suspicion an obsession, she begins her own investigation. The harder she digs into Lauren's past, however, the more Lauren resists, and the worse the threat from Werner becomes.

Will Ella's investigation put her career on the line, just when she's finally got her foot in the door? And as trouble deepens, can Lauren keep her family safe before Werner makes good on his promise, or will they all – Ella included – pay the ultimate price?

Multi-Leads

I was asked a question about using Lead III in the post below about 3rd degree Heart Block. While the strip says "III," it is actually something called "S5," which I neglected to label.

"S5" is done by putting the left leg (red) lead in the fifth intercostal space just to the right of the sternum and putting the left arm (black)lead just below the suprasternal notch. Then run "Lead III" on the monitor, which instead of giving you an inferior view from the left leg to the left arm now gives you a closeup of the right atrium.

I read about this lead in a great book called Taigman's Advanced Cardiology. It is an excellent lead to let you get the clearest view possible of the p wave. I most often use it when I am trying to determine if a patient is in afib or not. I will have to look through my garage for some old strips I have, including one that shows an indistinguishable question afib rhythm that when placed in S5 then shows distinct p waves. I use this view in all heart block patients.

***

Several years ago before we had 12-leads, another medic taught me how to do modified 9-leads, which enabled you to closely mimic a 12-lead while still just using the old 3-lead Life Pack 10.

Just as in the S5 above, you do it by running Lead III on the monitor. In this case, you keep the left arm lead (black) on the left arm, and you then move the left leg lead (red) across the chest in each of the precordial positions. Instead of V1-V6, the leads are labeled MCL1-6. While many have heard of MCL1, I had never heard of MCL 2-6. The leads must be run at diagnostic frequency.

The day after the medic taught me this, I had a patient -- a 32-year-old black male in excellent physical shape, complaining of chest pain. He was warm and dry, ambulatory with perfect vitals. 120/80. heart rate -64, Sat - 100% on room air. No medical history. His only complaint was chest pain. He said it hurt more when he moved.

I thought it was BS and had him walk to my stretcher which was just outside his front step. Fortunately I was working in the suburbs and not just right around the corner from the hospital. On the easy ride in, I decided to work him up. (He did at one point say it felt like someone was sitting on his chest).

He was in a normal sinus with normal STs. Still I gave him some aspirin and put in an IV lock. I decided then to fool around with the new leads I had been taught. I did the MCL4.

He had a massive ST elevation.

I wasn't certain I was doing it right. At triage, I told the nurse, I had just learned how to do this and wasn't certain I was doing it right, but this is what I got and I showed her the strip. I think he's having an anterior MI, I said. She looked annoyed at me, but instead of the patient going to the waiting room where I believe she was planning to put him, he was assigned a room. We took him down to the room, got him onto the hospital's bed, and then I went to write my run form.

As I walked back to the room to leave the form, the nurse came running out screaming that the patient had just coded. They shocked him, got him back, and then rushed him up to the cath lab, where he was found to have a 100% occlusion of the anterior lateral descending artery, also known as "The Widowmaker."

I hate to think if I stuck with my original impression and he had been placed in the waiting roon, what might have happened.

After that I did modified 9-leads on all my chest pain patients. Where the Life Pack 10, which utilized Leads I, II, and III, only could view the inferior and lateral parts of the heart, using the MCL leads, you could see the anterior. Few calls have been more satisfying to me in my career than to be able to pick up an anterior MI with a Life Pack 10, using the modified chest leads.

(I made certain at the time to collect the hospital's 12-lead and compare it to my 9-lead. In most cases, it matched up perfectly. I did have some cases, where there was a difference, but then only in MCL5 and 6.)

Of course, we then got Life Pack 12s which do full 12-leads and come with a computerized readout, which, while they can be wildly wrong (and we are cautioned not to use them), are often right and take some of the pride of accurate interpretation out of it. Is this really your interpreation or did you just read that the machine said ACUTE MI?

There are still some lessons that can be used from the old MCL leads. When pressed for time or if I just want a quick interpretation, I sometimes, run the modified leads MCL4 in the house instead of immediately doing a 12-lead.

Also, to check for a right-sided MI, instead of doing a full right-sided 12-lead, I may quickly move the left leg lead to what is called MCR4 (fourth intercostal space midclavicular on the right side) to take a quick peak to see if the right ventricle is involved. Again, these are read in Lead III on the monitor.

When I get a chance I will do the full 12-leads. If the initial test is positive, it at least tells me what is going on sooner and I can step up the pace of the call.

And as stated above I use the multi-leads for S5 to view the atrium when I want a clearer look at the p waves.

Two gurus behind these multi-leads are Mike Taigman and Bob Page, a popular lecturer on the EMS Conference circuit, who has many more great tips in his 12-lead classes. I haven't read Page's 12-Lead Book yet, but I have heard it is excellent.

***

3rd Degree Heart Block

I had an interesting strip the other day. We were called to a physician's office for an abnormal ECG. The EMD dispatch sent us "hot." But the prearrival instructions indicated no immediate emergency. Patient was alert talking with good color, no pain and no shortness of breath. And as it usually turns out at a doctor's office, the patient was there for a scheduled appointment, rather than an emergency appointment.

We found a fit 86 year-old female who it turns out had had a syncopal episode several days before while working for several hours ( and more strenuously than usual) in her garden. Other than that, she had no complaint. She was fit, drove a car, walked without a cane, and could carry on quite a conversation.

Her blood pressure was 120/60. Her pulse was 32. She was on a beta blocker, but had been for decades.

The doctor showed me the ECG. No ST abnormalities. A 12-lead from two months ago showed a sinus at 64.

I studied my monitor for a moment, but couldn't make a snap call on the rhythm. It was regular. The Ps seemed to have a relation to the QRS, yet there looked to be a second P emerging from the T. There were no dropped beats.






It wasn't until I ran out a long strip that I was able to see it more clearly. It was a 3rd degree block. The QRSs were all equal and the Ps were all equal. There was, in fact, no traditional relationship between the Ps and QRSs. Where it was tricky was the atrial(Ps) rate was 63, where the ventricular (QRS) rate was 33/34. In other words the P rate was not quite double the QRS, so it took awhile for P/QRS separation to become visible. (Only on the 4th strip can I see it.)

I saw the woman later in the ER and was had a long chat as she lay there, waiting to be taken upstairs to get a pacemaker, her heart still beating strong at 34, a standby pacer attached if her rate should suddenly drop.