Regional Meetings

On the second Tuesday of every month, I spend four hours at our regional educational standards and medical advisory meetings. I am not a meeting guy, but we have a good group of people and we get things accomplished, although as with any group sometimes it seems we are always rearguing the same issues.

In the educational standards meeting the discussion has been about our yearly skill sessions which each medic is required to take. We have sessions scattered throughout the year -- usually one in April, one in June, one in September and one in December -- but inevitably people wait until the last one in December. This year we had to add a third session to the two we already had scheduled to accommodate the stragglers. Each session is limited to 40 people.

Each year we try to figure out how to avoid the December rush and how to hold people accountable for getting the sessions taken. My position has always been whatever we do, we have to let the paramedics know what is expected of them. Too often we make decisions, but neglect to tell anyone. We had a big arguement about paramedic accountability. I argued that instead of trying to create hoops for paramedics, we should try to make it easier for them. What is wrong with just having an extra session in December? Other people wanted to assign people to specific sessions based on their birthdays. I made the motion we keep the setup the same. I lost. While we didn't vote on what the new system would be, the new system proponents will have to come up with a plan for a new system. We'll see if anything happens. We have the same vote every year.

We also have the same periodic discussion as to the purpose of the skill sessions -- are they to be used to teach people or to drill people. We usually have six or seven stations -- a megacode, an airway station that includes use of the bougie, combitube, LMA, an IV station that includes an IVs and the IO, a crich station, a BLS station that has spinal immobilization and KED, and then specialty sessions such as child birth, and the one I taught this year, which was the AHA update. Most people feel the skill sessions are pointless -- why do I need to stick a needle in an IV arm when I do it everyday on real people? One arguement has been this is neccessary so the MDs can sign off on people's National Registry forms. Some say we need to prove people can do the skills, yet I believe the way we do them anyone who sleeps at a Holiday Inn Express can walz through. No one has ever failed a skills session. I prefer to think of the skill sessions as a chance to learn new information or to practice skills we don't do much such as the needle crich.

We argue back and forth each year. Sometimes some of us switch sides of the arguement, and we always end up doing it the same way.

Still, we do get work accomplished. The education group is made up of the clinical coordinators from each hospital in the region, and a couple educators and myself.

The Medical Advisory or MAC also includes the medical directors from each hospital. For the last three meetings we have been redoing our protocols, which is a very tedious process. We go page by page, arguing over every little wrinkle and wording. Each year the pressure that we can give Nitro at changes or at least is discussed. Its 100 now. It has been as high as 120 and as low as 90. This year we moved the blood glucose number for "low blood sugar" from 80 down to 70, although since these are guidelines, you can still give D50 to someone with an altered Mental status and a Blood glucose of 73.

I don't mean to be critical because all of the discussion is neccessary and I think we have decent protocols, but like I said, the discussion can get tiresome. Whenever the debate gets too heated, we just table the topic to the next meeting when either side of the arguement will have either cooled down or not been able to attend due to other committments. Sometimes we pass a measure easily one meeting, and then it gets brought up and vigorously redebated the next. This has happened repeatedly with morphine for abdominal pain this year. We couldn't give it, then it was on standing orders, and now it is requires online control. In the end it is all about consensus. We never meet our rollout deadline on January 1, but we get it done.

Here are some of the changes we have agreed on at least for now:

Incorporating the new AHA Cardiac guidelines.
Increasing dose for morphine we can give on standing orders from 0.1 mg/kg to 0.15mg/kg.
Permitting MS on standing orders for certain back pain.
Adding undifferentiated abdominal pain as an indication for medical control orders for MS.
Adding torodol as a medical control option.
Putting Solumedrol on standing orders for asthma and allergic reactions.
IV Magnesium for severe asthma.
Putting epi on standing orders for asthma if the patient is under 50 and has no cardiac history.
Putting up to 2 mg of Ativan on standing order for nonviolent anxiety.
Putting Dopamine and fluid boluses on standing order for cardiogenic shock (None of us had realized medics required online medical control to do either in this scenario.)
Clarifying the indications for narcan to a person with altered mental status with RR less than 10, who is hypoventilating.
Adult IO.
Increased use of capnography.
Changing eye irrigation from NS to Lactated Ringers
We are able to now mix Haldolol and Ativan in the same syringe for violent psychs.
Standing orders for nitro paste for pulmonary edema.

We have also done a lot of language change in the guidelines, and reordering steps.

Some things still being debated, include:

Adding zofran for nausea.
A Taser policy
Relooking at indications for spinal immobilization
Adding some new procedure sheets.
Changing fluid thresholds for Trauma patients.

I think we have a few more months of meetings until we are done.

What I like about the committee and the process is that in the end our work hits the street and makes a difference to the patients.

Musings

It's been very busy lately(five days in a row) -- nothing exceptional, just the meat and potatoes of EMS -- vomiting, hip fractures, asthma, hypoglycemics, lift assists, seizures, TIAs, MVAs.

***

Some of our syringes have retracting needles. After you use them, you hit a button and the needle zips back into the syringe. I noticed that if there is any fluid left in the syringe, it zips out the front when you hit the button. Now whenever I draw up saline to flush a lock, I draw up 5 cc, but only use three ccs to flush the lock. Then I point the syringe toward my partner driving and hit the button. Just like a squirt gun. Some of my partners have figured it out, some don't notice the fluid landing on their right arm, others are puzzled where the water is coming from.

***

The public probably doesn't think this happens -- ambulances getting lost on the way to the hospital -- but we have all been there. I can't count how many times I have been in the back treating a patient and then looked out the window and wondered where the hell we were, or why we were heading in the direction we were. "Where are you going?" I shout or "We're going to X hospital not Y!"

Not every person driving has been on the road twenty years. With the turn over at commercial services and the sheer number of people at volunteer services who don't work that much, it happens a lot. I've looked out and been crossing the river going East when the hospital is on the West side.

To be fair, even when I drive, sometimes I tune out and make a wrong turn or forget where I am going.

One thing I do hate, even when I know where I am going, is when the family member who is following in their car, sees you at the hospital later and tells you "You went the long way." Its like we should know the way everyone who has lived at one address for twenty years uses to go to their hopsital of choice at each particular time of day. One day when I was in an irritable mood, I said, "Sorry, I don't know your little 'secret' route." Point taken. Once when I did make a wrong turn, and the patient's family member said, "You sure went the long way." I said, "The normal route was shut down due to an accident." Yeah.

As long as we get there and the patient doesn't die because of the extra time, everything is all right.

I did do a shooting once in the city, went right by the hospital. "Where the...!!!"

New EMT just bombing down the road, lights and sirens wailing, no idea where they are going, no idea they are lost.

It can be a little stressful, telling them how to go when you have a critical patient.

I wish I had a 100 cc syringe with a retracting needle just for those occasions.

Hey!

***

There is a new oriental restaurant in town -- a sort of fushion between Japanesse, Thai and Chinnese. We got the lunch box special. $8 bucks for teriyaki shrimp, a California roll, beef gyzo, miso soup, rice, and salad. Not bad. The Shrimp was outstanding.

The day before I went to a place where I hadn't been for four years -- a Southern food cafeteria. I used to go there all the time, and then one day I had the serious runs after eating there -- running to the bathroom on the hour, and then praying I didn't get a call. So I went back -- it was good, barbecue -- pulled pork, black-eyed peas and collard greens with a slice of cornbread. Plus when I walk in the door, the proprietor goes, "Why Looky here -- there's a tall fine-looking white man standing in the door. Isn't that something? My, my. I've seen you before, haven't I? You've been in here before." "Yes, I have," I said. I didn't tell her why I had been away. "Well, good to see you again. Now what can Mae, dish up for you?"

Someday I am going to write a Paramedic's Guide to Eating Out. One of the best parts of this job is the array of food choices. Puerto Rican, Domminican, Jamaician, Southern, Oriental, Italian, Brazilian. Not to mention all the different hospital cafeterias -- each with their own specials -- one has great pasta specials, another a super cheap salad, another a great sandwich bar, another with great lunch deals.

***

In the last couple days I have done a couple IVs where I had to use 24 gauge needles to get into real tiny veins. While I got both, I noticed I had to really, really squint to see the needle and the vein together. I have never needed reading glasses, but maybe I should get my eyes checked. At least my hands aren't shaking yet.

***

I didn't get to bed until late last night. I was tired this morning with a possible cold coming on. I checked out my gear, and then got in bed. Three hours later, the buzzer goes off. I'm only allowed to sleep until eight, but it was nine. No one said anything. Let the man sleep. I snagged a coke on the way out the door. Off to a hip fracture.

***

It's pouring rain today. I am sure glad it isn't snow. It's January 8 and still no snow. Fine by me.

The polar ice caps may be melting, global warming destroying the planet, but the good news is I don't have to shovel snow.

***

I'm off tomorrow for my monthly regional EMS meetings, which means I can stay up late and watch the NCAA football championship game, have a beer or two, and then sleep late and still get to the gymn.

***

A Paramedic's life is okay.

Helpless

A week ago I responded to a fall, a little eighty-year-old lady with failing balance, tripped and fell on the bedroom carpet. She was laying on her right side and couldn’t get up, she said. Her right arm was at an odd angle, but when I repositioned her arm, she had full range of motion. When I pressed against her hips, I thought I saw a slight grimace. She had some screws in her right hip from an old hip fracture, she said, but denied any pain. She was able to move the leg. There was no shortening or rotation. One of my partners, an eighty-year-old woman herself, said our ambulance had transported the woman's husband to the hospital a few days before. The woman said her husband wasn’t doing well. She didn’t really want to go to the hospital, she said, could we put her back in to bed?

My partner convinced her to let us take her to the hospital and get checked out. With her husband sick, it was best to make certain she was okay, instead of leaving her alone.

In the ambulance, I asked her again about the pain and she said, matter-of-factly -- zero on the one to ten scale. While I wrote up my paperwork, she and my partner chatted about old days in the town where they both lived most of their lives, and knew all of the same people.

Today I saw my partner and she said she had followed up on the woman who was now in a local nursing home. She had gone and visited her and found out she had broken her leg in three places, but since her bones were so frail they would be unable to operate. They hadn’t even let her go to her husband’s funeral. She told my partner she had been in a great deal of pain and had known that she had broken her leg, but hadn’t told us. She told my partner she didn’t want me to see she was helpless.


There is a town in north Ontario,
With dream comfort memory to spare,
And in my mind
I still need a place to go,
All my changes were there.

Blue, blue windows behind the stars,
Yellow moon on the rise,
Big birds flying across the sky,
Throwing shadows on our eyes.
Leave us

Helpless, helpless, helpless
Baby can you hear me now?
The chains are locked
and tied across the door,
Baby, sing with me somehow.

Blue, blue windows behind the stars,
Yellow moon on the rise,
Big birds flying across the sky,
Throwing shadows on our eyes.
Leave us

Helpless, helpless, helpless.
- Helpless
Neil Young

Baby Medic - EMS Blog

I ran into a medic yesterday who tipped me off to a new EMS blog being written by an EMT/medic student who works for us. I have just read all the entries -- it is excellent. So far it is about his ride time as a medic student, but I am hoping he continues it throughout his promising medic career.

Check it out at:

Baby Medic

Here are three of the best posts:

Shooting

Footprints

Morgue

Bare Wrist

90-year-old man, unresponsive. The medical dispatch updates us, unresponsive, aides not certain if he is breathing.

As I walk across the dark lawn in the rain I see in the picture window two large police officers lifting an old man out of a wheelchair and starting to lower him toward the floor.

"The aide says he's a DNR, but they can't find the bracelet -- they took it off a couple days ago," one officer tells me. The other officer has put a pillow under the old man's head because of the kifosis in his spine. There is no question he is dead, but he is warm and his jaw is limber.

"Do they have paperwork?" I ask.

"No paperwork," he says.

"All right, we have to work him then. Start CPR."

***

Now until recently I would have handled this differently. I would have said, he's 90, they say he's a DNR. Asystole. I'll just walk out to the ambulance, call medical control and get permission not to resuscitate. I do that, and then walk back in, and tell everyone, and record the time and that's that. Put a sheet on him, console the family, make a comment about dying at home with dignity, surrounded by loved ones.

I may have mentioned recently a newer medic who tried to do just that. Walked out to the ambulance, called the hospital, said the patient was old, terminal cancer, just returned from hospice with DNR papers signed by the patient, but not the doctor. A slipup. The medical control doctor then told him to immediately commence CPR with full ALS resuscitation, and transport. So he had to walk back into the house and explain this to the horrified family who then had to witness a resuscitation, and transport of their family member, who had wanted to die at home.

The state regs (I have discovered) are clear. Unless a person has a valid DNR or are beheaded, transected, burnt beyond recognition or have dependent lividity with rigor mortis, you must at least begin CPR before calling to get permission to cease resuscitation. But why have to call? What can a doctor miles away bring to the situation that a medic on scene can't acertain for himself? This person shouldn't be worked. Some medics say they just do pseudo CPR -- pretend CPR -- while the call is made. That rubs me wrong too, although I have done it and understand it.

Here's what I do this time:

***

I drop a 7.0 tube, put in an IV and hit him with 3 epis and 2 atropines. If I am going to be told I have to work the code, then I am going to work it from the start. The ETCO2 is low and I notice the officer is doing delicate CPR. Like this I say. I do a couple compressions, but then instead of my hand rebounding, the chest gives way and my hand sinks as I feel ribs break off. I wince. "Well, do the best you can," I say.

An aide hands me the phone. It is the patient's daughter, who wants to know what is going on. I apologize that we are trying to resuscitate her mother, but the DNR bracelet wasn't on and there was no paperwork. She tells me they keep the bracelet by the bed in the other room. She is understanding as I explain the law. She wants to know how her father is doing and I say he is not responding and I will soon be presuming him dead, so he won't be transported to the hospital. She says she will be there in about thirty minutes. I tell her to drive safely.

After our 20 minutes of ACLS is up, the patient is still asystole, I call the time. I extubate him, take out the IV, and pick up all the wrappers and put them in the big plastic bag the ambu-bag came in.

An aide comes into the room now and shows me the DNR bracelet. They had cut it off because his wrists had been swelling in recent days.

We lay a sheet over him.

I wait around with the police officers for the daughter to arrive so I can apologize and explain again why we did what we did.

I keep looking at the sheet. He's not in his bed or his wheelchair, but it doesn't look too terrible -- him on the floor of his living room beside his wheelchair. I mean at least, he's still in his house, and aside from his ribs, isn't too much the worse for the wear and tear of the code. I think well he was after all dead anyway.

The daughter still hasn't arrived, but it is past crew change and my partner needs to get home, so after ten minutes, we express our condolences to the aides again, shake hands with the cops and wish them Happy New Year, and then carry our stuff back out into the night, across the yard and through the rain to where our truck, its red lights still flashing, waits for us.

***

I liked the way I used to do it better.