The Handover Blog

I am now participating in a "blog carnival" called the The Handover.

Every month a different blogger hosts a collection of blog posts from other EMS bloggers on a theme topic.

This month's theme was "Partners".

The carnival was hosted by Paramedic and EMS author Michael Morse at Rescuing Providence.

It can be read at this link:

The Handover: Fourth Edition

I submitted a post I wrote a few years ago about my old partner Arthur.

Old Partners

The June issue of the Handover will be hosted by A Basic's Doc.

The theme will be communication.

All EMS bloggers are welcome to submit.

The deadline for submission is June 22.

See the The Handover blog above for more details.

Work

I came into work yesterday morning and as I always do, switched ambulances. We have three rigs here, and each of the four regular medics are assigned their own (two share one). Every six months or so we switch assignments. Right now I have my own ambulance, but it is the oldest one. Very rough riding. As I get grumpier with each passing year, I find myself constantly wanting to say to my many partner, "Slow the F-- down!" Some partners are great drivers, others not too good. The ambulance offers a driving class taught by a police officer. It is all about defensive driving, keeping your eyes on the road. Etc. Sometimes I want to barge into the class and say, keep one eye on the road and one eye in the rear view mirror watching what is going on in the back. Am I standing? Am I about to stick an IV? Remember that Saturday Night Live spoof of the comfortable car ad where the rabbi does a circumcision in the back. Think about that. If you hit a manhole cover, I go airborne. If you slam on the brakes, I hurtle-slide forward. A week ago after one ride, my back was so jarred, I had to go lay down for an hour. I would gladly have payed Igor to strap me to a dungeon rack and turn the wheel to lengthen me back out. I had the ambulance sent down to the town garage to have the shocks checked, the radio repaired (bumps seem to jar the wires) and the stretcher mounts tightened.

My back feeling strong, and recovered after four days off the ambulance (four days at my clinical coordinator job) and with great hopes that the shocks have been repaired, I climbed onto my ambulance with the medic gear and did my weekly checklist.

The oxygen was bone dry. I wasn't upset by this. There is a leak and if the 02 isn't turned off after every call, the tank will eventually run dry. I got out and changed it. I am lucky most of my partners are good about changing the main, so I don't have to do it too often. We have a new machine that is supposed to make changing the main easier. It is a fancy contraption -- some kind of mechanical lift device. I like doing it the old fashioned way -- just muscling it, hauling out the one big green tank, and then lifting up a new one, getting it all switched over and strapped in. So I changed it. I turned the valve. 2000 psi. Good to go.

I get great satisfaction sometimes about the smallest things. I like to do my start of the week ambulance check, making certain all my equipment is in place and working order. The bulbs on my scope blades are bright, my monitor batteries are fresh, my drugs have not expired, and my ambulance IV tray, which I keep on the bench seat, has enough supplies to do 5 IVs (syringes, saline vials, saline locks, Venaguards, 4X 4s, assorted catheters, roll of tape, alcohol wipes, fresh tourniquet, and there is a bottle of ASA, a NTG spray, and a vial of Zofran all handy.

Nothing quite beats changing the main though for a reminder of the physical element of the job. (I prefer it to lugging 400 lb patients down narrow stairs). I like the manual work. Whether it is using brawn to ready the oxygen for the day's emergencies, using dexterity to insert an IV or using your hand to feel a patient's brow, the physical connects us to the world and our patients in an immediate way that roots us in the reality of our work and its stake -- peoples' well-being.

I know my work as a clinical coordinator is also important, but I don't think I could survive my cubicle if I wasn't able to get out three days and do work that seems more real than reading run forms or writing memos.

There is an interesting article in this Sunday's New York Times called The Case for Working with Your Hands. It is adapted from a new book by Mathew Crawford called “Shop Class as Soulcraft: An Inquiry Into the Value of Work.” Crawford is a former office worker, who now makes his living as a motorcycle mechanic. The article may be about a motorcycle mechanic and his philosophy of work, but it could as well be about a paramedic who finds meaning in his work.

Here's how it begins:

The television show “Deadliest Catch” depicts commercial crab fishermen in the Bering Sea. Another, “Dirty Jobs,” shows all kinds of grueling work; one episode featured a guy who inseminates turkeys for a living. The weird fascination of these shows must lie partly in the fact that such confrontations with material reality have become exotically unfamiliar. Many of us do work that feels more surreal than real. Working in an office, you often find it difficult to see any tangible result from your efforts. What exactly have you accomplished at the end of any given day? Where the chain of cause and effect is opaque and responsibility diffuse, the experience of individual agency can be elusive. “Dilbert,” “The Office” and similar portrayals of cubicle life attest to the dark absurdism with which many Americans have come to view their white-collar jobs.

Is there a more “real” alternative (short of inseminating turkeys)?

High-school shop-class programs were widely dismantled in the 1990s as educators prepared students to become “knowledge workers.” The imperative of the last 20 years to round up every warm body and send it to college, then to the cubicle, was tied to a vision of the future in which we somehow take leave of material reality and glide about in a pure information economy. This has not come to pass. To begin with, such work often feels more enervating than gliding. More fundamentally, now as ever, somebody has to actually do things: fix our cars, unclog our toilets, build our houses.

When we praise people who do work that is straightforwardly useful, the praise often betrays an assumption that they had no other options. We idealize them as the salt of the earth and emphasize the sacrifice for others their work may entail. Such sacrifice does indeed occur — the hazards faced by a lineman restoring power during a storm come to mind. But what if such work answers as well to a basic human need of the one who does it? I take this to be the suggestion of Marge Piercy’s poem “To Be of Use,” which concludes with the lines “the pitcher longs for water to carry/and a person for work that is real.”

Till I One Day Vanish

I work in a diabetic town. There is one particular section of lower middle class homes along the avenue that runs north out of the city that seems to be diabetic central. Many of the older residents came to the United States from Jamaica, and while they continue to enjoy their home cuisine -- jerk chicken and pork, curry goat and ox tail, all served with generous portions of rice and peas (kidney beans)cooked in coconut milk with fried plantain on the side, they no longer exercise or walk the great distances they did and their relatives in Jamaica continue to do in the course of an ordinary day. Consequently obesity, HTN, high cholesterol and diabetes is a common medical history for these residents.

We have quite a number of frequent flyers, although to be accurate, they don't really count as flyers because we rarely transport them. A son or daughter or niece or nephew or grown grandchild finds their elder family member in bed cool and clammy with snoring respirations. They call 911. When we arrive we find their sugar to be low, put in an IV and give them an amp of D50. They wake up, and refuse transport. They forget to eat lunch, their relative fixes them some food and promises to watch over them and to followup with their doctor. The refusal is signed after all the necessary cautions and urges to go to the hospital for further evaluation. We pack up our bags and leave.

There is this one house that has a small garden in the front yard guarded by a small marble toad. I always see it on the way in to the unconscious and on the way out from the diabetic refusal. I have always been comforted by sight of the toad. You work in a town long enough and there comes a certain comfort factor. You feel like you are a part of the town, a part of something. You get to know the neighborhoods and the people and the rhythm of the life. I say good bye to the old woman and she and her niece thank me or whatever other relative is there and I walk out past the toad and back to the ambulance and my job of looking out for the people of the town -- at least while I am on duty.

Recently I discovered a poem called Jamaican Song by James Berry, which I now read often to my little daughter. It goes like this:

Little toad, little toad mind yourself
mind yourself to let me plant my corn
plant my corn to feed my horse
feed my horse to run my race
the sea is full of more than I know
moon is bright like nighttime sun
night is dark like all eyes shut
Mind-mind yu not harmed
somody know bout yu
somody know bout yu

I am writing about all of this because the other day we got called to the same street off the avenue for a cold stiff body in a warm environment. I saw the toad in the garden as I walked in the yard, carrying only my monitor. In the front room I heard a discussion of where she wished to be buried. I went into the bedroom and examined the woman on the bed. She wasn't cold and stiff. Soon my partner was rushing back into the house with my field pack as the first responders and I had now gotten the woman on to the floor and were doing CPR. When I intubated her, the ETCO2 reading was 100 -- indication of a respiratory cause of the arrest.* Within two minutes it was down to 20. When I checked her sugar it was 40. We tried epi, atropine and of course, D50, but we couldn't get her out of asystole, so after twenty minutes, we called the hospital and got permission to presume her.

I can't remember the number of times we had come to her house and brought her around with a simple IV and D50. Always there had been someone who had found her and called us, but this time the discovery was too late. No one was watching over her. Likely, her sugar low, she turned her head the wrong way and occluded her airway. Her heart continued to pump CO2 to her lungs, but since she had an airway obstruction, none of that could be ventilated off. After maybe five minutes, she likely bradyied down to asystole. The grown granddaughter arrived maybe twenty minutes after that and called 911. Not that that explains cold and stiff.

After the code was over, we removed the tube and IV and peeled off the electrodes. We put all our medical waste in a red biohazard bag, gave our condolences to the granddaughter. Her grandmother had lived a long life (she was in her 80's, well-loved, but had been sick lately. Although I didn't say it, it was hard not to think of the old woman and how she used to smile, and thank us for helping her again and how she always invited us to come see her for family dinner on Sunday when she promised she would have heaping portions for us of oxtails with butter beans. And then we would walk out past the small garden, feeling like we had helped.

Little toad, little toad mind yourself
mind yourself let me build my house
build my house to be at home
be at home till I one day vanish
The sea is full of more than I know
moon is bright like nighttime sun
night is dark like all eyes shut
Mind-mind yu not harmed
somody know bout yu
somody know bout yu

***

*ETCO2 (each bar is 30 seconds, the first bar is intubation with CPR, ventilation starts with second. Initial reading 100.)

Beach Ball Bellies

Woman collapsed on the roadside CPR in progress. We arrive and when I get out of the ambulance, I can barely see the woman's face her stomach is so large -- it looks like a beach ball and getting bigger with each squeeze by the first responder of the bag valve mask.

"I think the air is going in her stomach," the responder says.

"Stop doing that," I say.

Green vomit is coming out of her nose and mouth.

So we work the code, get her intubated, get a line, try to do CPR on the small little bit of sternum not on the beach ball. We get her from asystole to PEA to vfib to PEA to vfib to asystole.

You sure the tube's not in the belly one of the staff says at the hospital as we wheel the patient in.

No, it's good. I show the capnography. Good wave form. Numbers in the 30's with CPR. Equal lung sounds. Nothing in the belly. The doctor confirms its good.

First responder bagging, we say.

The patient is called dead shortly later.

This story is fairly typical. Not that it would have changed the outcome. First responders get there. Apply bag valve mask, stomach inflates.

We all complain about how nobody knows how to bag, but it continues. Maybe no one knows how to teach it properly. Teaching it properly goes beyond teacher demonstrating how to tilt the head back to open the airway and hold a good seal -- it goes to the system. We can teach it, but Johnny still can't bag. The stomachs keep blowing up. Maybe we need a new way to teach it or maybe we need another way altogether. It isn't the easiest thing to do or else everyone would be doing right.

One of the principles in Medicine is to do no harm. While there are many first responders out there who do know how to properly ventilate with a bag valve mask, there are so many who don't that I wonder if it might not be easier to give first responders LMAs and let them slip those in the mouth and then ventilate with the LMA.

This, of course, raises the whole drug and gadget debate about what level of service can do what.

On one side there is the argument that letting first responders or basics do things such as give ASA for chest pain, epi for anaphylaxis, nebs for wheezing, narcan for opiate overdoses, or with this suggestion, insert LMAs in cardiac arrests, you may run the risk of keeping communities from upgrading to the paramedic level, thus harming other potential patients who could benefit from quicker access to the higher level of care.

And each time we add another drug or skill to the basic scope, the question is what's next? IOs and epi for first responders to use in cardiac arrests?

And what about the increased educational burden on basics?

I am in my job as a clinical coordinator, working on a proposal to let basics use CPAP. Similar proposals have been approved in many states where CPAP is now considered within the basics scope of practice. One of the towns I oversee is covered by an intermediate service and is some distance from the hospital, requiring lengthy paramedic intercepts. Some like I mentioned argue giving a basic or intermediate service more tools makes the town less likely to upgrade to the higher level, and some would say, needed level of paramedic service. Others would say, if a basic or intermediate can do it safely and the risk outweighs the benefit, let them do it. I tend to fall toward this side.

Once defibrillators were the province of physicians only. Now the lay public has access to them because they save lives.

I don't know what the future holds. I just know I am tired of seeing beach ball bellies.