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.

Micellaneous

A rainy day at work. I'm sitting at the computer and trying to get caught up on email, bills, scheduling, and maybe even this blog.

Here's a couple of recent tidbits.

This morning a first occurred. I occasionally hit my head at work -- most often on the overhanging bright lights above ER beds, and sometimes on a door when I turn suddenly. Today while walking into a house hallway, I ducked to avoid hitting my head and when I raised my head back up, I hit a light-fixture, knocking it from the ceiling, into the arms of a cop, who fumbled it. The glass fixture hit the floor smashing into a 100 pieces. Fortunately, I was working with the boss of our service who was cool about it and the family was very cool about it as well. So no big deal. We gave the unresponsive diabetic some D50, got some slippers on her bare feet, and walked the now awake patient to our stretcher and took them in to the hospital.

***

The last two weeks were big meeting weeks for me, and some of the issues I found were very frustrating. The roadblocks ranged from obstinate obstructionists to people who criticize, but never read the material beforehand, to numbing bureaucracy, to problems too complex for our little committees to be able to solve to the inevitable personal and political agendas (we all have them) behind every best effort to improve patient care. My back was getting a little stiff so I stood for a moment, and then feeling better standing, began to pace a few strides back and forth from my chair. I suddenly felt quite happy and empowered. Could I perhaps attend all meeting and instead of having to sit in a chair, could I just pace while I talked? I had a vision of Robert DeNiro in The Untouchables. I pictured myself carrying a baseball bat...

***

A number of years ago when I full time city medic working nights, I turned down a chanced to be a suburban medic like I am now. I loved the street and wanted to be right in the middle of all the lights and sirens glory, the shootings and stabbings, etc now to mention the sheer craziness of the city at night. I eventually accepted the suburban position when it was offered againa couple years later -- I took it due to changes I saw coming in the way things were happening. While I continued to work quite a bit in the city (on what was then unlimited overtime), I was glad for the change. Now years later, I am equally glad.

I was talking with one of the city medics and the issue became intubations, and while it has been quite awhile since I have done a traumatic arrest, my intubation numbers are much higher than most of the city medics (due to the proliferation of city medics now along with the fact that medics do transfers much more than they used to, which when I started was never unless it was an ALS transfer. We have a number of nursing homes in the town. Two of them, it seems all the patients are DNRs. The other three, it seems most of the patients are full codes. And they keep us busy. I do enjoy intubating.

I know there is a lot of literature out there about how intubations may not in fact benefit the patients and the ET tube may be completely replaced by the LMA, Combitube or other airway device, but I read an interesting presentation (see below) that pointed out most of the literature studying intubation was done before capnography. There is reason to believe that prior to continuous wave form capnography there was quite a high rate of unrecognized misplaced intubations (mainly tubes that had become dislodged)(possibly as high as 1-4) and that this may account for the poor science backing intubation. With wave form capnography, the misplaced tube should be nonexistent, and outcomes should improve.

Check out this powerpoint:
Making Waves Continuously in the Big Apple

***

The above powerpoint comes from the annual Gathering of Eagles Conference. The Eagles are a group of big city EMS Medical Directors, who are pretty cutting edge. Check out their site. There are many more powerpoints available there on many, many interesting EMS topics.

***

So anyway, back to my suburban job. I am the contact paramedic on a busy suburban volunteer ambulance. But not so busy that I didn't have the opportunity to ride my bike around our industrial circle (0.7 miles)for 12 miles on Sunday and another 12 today. Yesterday, I watched the Boston Marathon on the big screen HD TV, but unfortunately I only got to see miles 1-22. Duty calls. I was back in time to watch the end of the Red Sox 12-1 win. 4 in a row!

Tonight I am hoping to be able to watch all of American Idol. This year on the Tuesdays I have worked (I work till 10:00 P.M.) we have seemed to get a call every time at the stroke of 8 just when the show is starting. I do have it taped for me at home, but I like watching it live. For those idol heads out there, I am rooting for Allison, but am also a big fan of Adam (I likely won't buy his records, but he is entertaining and has a voice from outer space).

***

Anyway, the best part of being out here in the suburbs in our new stretcher. Now, when I started in EMS we had the two man stretcher. You basically deadlifted your patient (one EMT on each side) into the ambulance. I resisted the one man stretcher when it debuted for about a week. So with the past, all I had to do was watch the video for the new power stretcher to be sold. There are some drawbacks -- it is heavier and harder to maneuver by yourself, lugging it into a house, but you just push a button and it raises and lowers itself. It adjusts to just the right level for sliding patients on and off the bed. It is a levitation machine. I love it!

Paramedic Block

I have had trouble posting lately. I go through phases with the job and with the blog and am in one now.

The reason I started writing about EMS in the first place was to capture the human side -- the view of life and people the job provides.

To a lessor extent I like writing about the medicine or the systems issues.

I am still working 40 hours a week and doing calls, but I just don't feel as close to the people as I did.

Part of this may be because I am precepting again, and the nature of precepting, standing back somewhat keeps me from fully engaging the patient. (I am also struggling with precepting because I feel so far removed from being a new paramedic that I have trouble seeing the job through a new medic's eyes anymore. I may assume they know what they don't or assume they don't know what they do. I don't think I am doing as good a job at it as I once did. It was a pride of mine.)

Another reason may be that I am so busy with the two jobs and other obligations (like family where in my 15-month-old daughter I have true happiness) that I don't have the time to just write and see what develops. Some of my favorite stories have come from just writing and as I write about the call, the lessons of it start to come out in a way they would not if I weren't examining it closely and the best way for me to examine a call is to write about it.

A third reason is I don't want to repeat myself, to write the same story over and over again. I could argue that every story, every patient is different if you look closely, but since I am not looking closely, they seem the same.

As far as the systems and medicine, I do have some interesting subjects yet to write about. One is cardiocerebral resuscitation - the variation on the new CPR where instead of ventilating, medics put a nonrebreather on the patient, who is then passively ventilated by the CPR. Very interesting and promising.

What is holding me back about writing about systems issues right now is there seem to be so many in which politics plays a bigger factor than patient care. I know it is naive of me to think that patients should come first ahead of various groups self-interest even when that self interest has the best intentions, but that is how is has always been in all fields. I am all in favor of the new evidenced based medicine, but I am seeing too much research that has its own agenda. Studies funded by drug companies or studies that advance the preexisting ideas of the authors. And too many policies promulgated or blocked based on reasons other than outcome.

I am at one of these crossroads where I want to write truthful things, but am finding myself uncertain of what to believe in.

I want this job and this field to matter, and I want to write about why it matters.

The only real truth I know is to try to do my job as well as I can and treat my patients as best as I can, but I have written multiple versions of this over the years to the point it seems repetitive. That should just be a given. It shouldn't have to be written or held up as a standard. It should just be the standard.

I have overcome these periods in the past, and hope to again write and work with inspiration.

But in the meantime I (as a paramedic and a writer) struggle to find meaning between silence and noise.

Thanks for listening.

A Profession

Over the past year we had pretty prolonged and at times nasty debate over whether to change unions, which we ended up doing. While I wasn't happy with the previous union's representation( they in fact screwed me on the one issue I needed them to grieve for me), having sat in on the last contract negotiations I had to give them and the negotiating committee serious props for being hard-asses and fighting for a decent contract. Based on that, I supported the old union, as did most of the senior people. We lost. That's life.

Over the past year there was a lot of tough talk about striking if we had to, and how we were going to win a decent contract, particularly after an incident where the company was accused of possibly bugging our negotiations.

Of course, as everyone knows the economy has taken a nose dive, unions are giving back all over the country and many people are losing their jobs. While our company appears to be recession proof, who is to say? I don't know their finances. I wasn't in on the negotiations, and I give credit to anyone who spends their time fighting for their union brothers and sisters.

That said the contract that was finally agreed to, without getting into any of the dollar figures -- and dollar figures aside -- screwed the senior medics and screwed future employees. Not that the people in the middle got a gold mine, but they apparently got something to vote for. All the senior people I talked to said they were voting no (and from the results they did). At the same time many of the people who had done tough-talking about getting a new union to get a better contract were now counseling others to vote for the contract because the public would not be on our side if we voted to strike. A contract vote is either to approve the contract or authorize a strike. It doesn't mean there will be a strike. Last go around we voted the contract down, voting to authorize a strike, went back to the table, and won a fair contract. Many don't like the idea of public safety personnel going on strike, but the right to strike is one of the few bargaining chips unions have to win fair contracts. Everyone has to have their line in the sand. Once a contract is signed, the contract forbids work-actions during the course of the contract. In the end this contract was approved with something like a 70-50 vote. I guess people were scared or else they thought they were getting a good enough deal for their situations, considering everything.

Now it doesn't impact me directly all that much as I am extremely fortunate now to have a second job with better health insurance (I didn't even mention the insurance changes in the new contract), and don't have to compete for what has become nonexistent overtime.

Nevertheless, the episode has left me saddened. I heard one younger medic saying if we went on strike, her kids would starve, and I felt like saying, if we approve this contract, which destroys the concept of increased pay for seniority and lowers what future medics can expect to make, you eventually will need to find another job(another profession), so you might as well start looking now.

I almost didn't take my new second job as a clinical coordinator because I love being a paramedic. Even working as a medic three days (40 hours) a week, I miss being out there on the other days (back when overtime was plentiful). I feel like a half-medic. I feel bad for my long-time coworkers with families who can't live on a 40 hour week salary and who can't get the overtime they relied on because in this economy there is a seemingly endless stream of new and part-time EMTs to take those shifts. Some of them -- good medics- are going to have to quit the jobs they love.

Its just got me down. I thought for awhile we were getting ahead as a profession.