What I learned this week

 Experience is one of the main components of a paramedic’s smarts. Others include, but are not limited to, book learning, common sense, and mental acuity.

To put experience mathematically, a paramedic is only as smart as all the calls he has ever done minus those he has forgotten about. Thus a paramedic who is working consistently should continue to get smarter provided he continues to do new calls faster than he forgets old calls.

I am smarter this week than I was last week. Here is what I learned:

A young person who presents like a text book case of kidney stones, cool, diaphoretic, with cramping flank pain is likely having kidney stones even if their 12-lead shows mild elevation in Leads V2 and V3 with depression in III and AVF. A 12-lead, while useful, is not a perfect test.

A call that comes in as an MVA, is updated as "a person thrown from the back of a pickup truck and is now unconscious," that the dispatcher repeatedly asks for your ETA and whether or not you are a paramedic unit, and when you get there you find the patient sprawled on the sidewalk and only agonally breathing, may not necessarily be a trauma. Be thankful after you scooped and ran that you and your partner, after finding no bruising, indentations or abrasions, checked their pupils, saw they were pinpoint and gave narcan waking him up before you made it the four minutes to the hospital. Hope that next time you check the patient's pupils before you call in a trauma alert. (The patient you later learn was pulled from the back of a pickup truck by bystanders who found him unresponsive).

Do not, particularly in the midst of a bad call, let a anyone who is unfamiliar with how your stretcher works, try to unload your patient, no matter how well intentioned they may be. Be thankful that the worse did not happen, and the patient stayed on the stretcher and the stretcher did not completely tip over.

When someone tells you the woman you are treating is a “Madea”*, do not be surprised in cutting their clothes off to discover the woman has a penis. (*Madea is large grandmother character played by Tyler Perry).

While your protocol calls for you to consider termination of a cardiac arrest after twenty minutes with no success, if the patient still has a decent end tidal, it is not a bad idea to continue the resuscitation as they may come back after 30 minutes (and stay back at least until hospital admission to the ICU).

When carrying a patient on a scoop stretcher down incredibly narrow stairs with tight turning stairwells, a good approach is to stand them straight up at the bottom of each landing, pivot the scoop, and then continue carrying. This will save smashed hands, ruptured backs and much sweating and grunting.

While as a rule, confrontations should be avoided, when questioned about pain management, it never feels bad to politely point out that your dosing is correct and that the patient remains hemodynamically stable and is still in pain, and could benefit from redosing. Additionally, if the health care provider has fewer years of experience than you, it is acceptable to tell them that instead of assuming everyone is a drug seeker, the health care provider should inspect the patient for themselves before making judgments.

If you are posted at Blue Hills and Tower in the morning, don’t forget the Mount Sinai cafeteria is open in the hospital basement and the oatmeal is only 60 cents for a small.

Also, the ackee and saltfish at Sisters Restaurant north on Main Street is excellent, although you cannot get it in a small portion.

Vaginas have glands that can become swollen. They are evidently capable of being quite painful as a young person with swollen vaginal glands found them too painful to walk the two blocks to the hospital and called for us instead.

When a doctor tells you a boil on a patient’s bottom is draining and malodorous, malodorous is an apt word.

There is a new splash pad in the Sigourney Street Park that makes an excellent midday destination stop on hot humid, sweating through your clothes, ambulance AC is not getting the job done kind of days. Don’t forget to bring a towel to dry your head.

Things I forgot this week:

I don’t know, but the good thing about forgetting things is that they are not always lost forever. Some of the things I learned this week I had learned and forgotten before. Old lessons are around you all the time just waiting to be refound.

Get Another Job

 We were dropping off a regular patient at one of the hospitals the other day. A chronic PCP user. The “crusty” old nurse in the psych ward threw a fit complaining that she had just dealt with him two nights before. The fit was not good-natured banter, but clearly a I’m being imposed upon and you are a piece of shit fit. I felt like saying to her you are either (despite your age) brand new or you have been here too long. Burn out is an occupational hazard, which I have found infects either the relatively new or those whose lives outside of work have grown unpleasant. I will give everyone a period to outlast their burnout, but then you need to find another job or take time off to fix your own life Repeat patients are the territory in emergency medicine. No one likes working with miserable people. I’ll accept burnout a little more in EMS than in nursing because it seems to me nurses have more options to seek employment than EMS. Tired of the urban ER, go work in a Dr.s office or a walk-in clinic in a suburb or take a 9-5 job in endoscopy. To newer EMS burnouts, whose burnout has lasted longer than 3 months, get out now and find something that makes you less miserable because you don’t get a pass forever.

I am sitting in my ambulance outside a McDonald’s right now (using their free wi-fi). I am watching one of their employees, quite possibly even their manager, walking around the outside of the building, picking up every stray scrap of paper on the ground he can find. He has a broom and dustpan. When he is done, he will get a hose and wash the sidewalks down. He does this every morning. You can’t find a cigarette butt in his parking lot. This man has a good work ethic. I am the only one watching him, but he is performing like he is before a sellout audience in Carnegie Hall.

Who you work with is important not only to your health but the health of your organization. I have been doing this over twenty years and can say that burnout is not an isolated problem. It is an infectious contagion. At times I have seen in EMS and in EDs burnout become almost a badge of honor, as if being burnout makes you an official member of the tribe. When I first started I thought the crusty old burned out triage nurse was a great character. Some I liked to think had hearts of gold, others clearly were just plain mean. One nurse would punch everyone having chest pain, if they groaned, she put them in the waiting room. You can’t have musculoskeletal pain and a real medical problem at the same time, she seemed to think.

Recently, I heard a triage nurse chastise a patient for wasting the system’s resources. The nurse was quite nasty and aggressive about it. It took me aback because it had been years since I had heard something like that where years ago it was much more common place. I almost said to the nurse, you could get fired for talking like that to someone. EMS used to talk like that all the time. I even talked like that a few times many years ago, but I don’t do it anymore, and it is rare in my organization. There is something positive to be said for manners and correctness.

I go into many hospitals and they all have their own vibe, the same I think is true of ambulance services. A paramedic from one service recently was fired from his part-time job at another service. The reason was attitude. Doing what was permissible and part of the culture at one service was clearly not at the other service. To which I say, bravo.

If you are miserable and hate our patients, I don’t want you working with me. My best partners have always been the most pleasant people. If I have a partner who bitches all day, i find myself bitching as well and go home feeling miserable.

I wonder what the guy here at McDonald’s thinks as he sweeps up the cigarette butts. Is he thinking “f-ing slobs. I hate these f-ing people.” Or is he is thinking, “My sidewalk is glistening, the sky is blue, today is going to be a good day.”

Handsome Boy

 A handsome boy plays guitar in his garage band, thick black hair down to his shoulders. Man is he in to the music. The drummer in the background is also smiling, the kid on the bass is into it too. The photo colors are faded. I’m thinking 1970. In front of the 3X5 photo in the drug store frame sitting on the book shelf like an offering is one guitar pick. The guitar itself—-a Stratocaster--is hung on the wall like a museum piece. Next to it is a glass framed psychedelic 60’s era poster. Bright wavy yellows, purples and greens. Iron Butterfly at the Fillmore. I can hear those kids now playing at their high school dance. In-da-gadda-da-vida, baby. All the chicks digging it.

I look at the books neatly lined in the cases. Herman Hesse, Carlos Castenada, Hemingway, the Anarchists’ Cookbook, Jack Kerouac, all books I own myself. On another shelf there are others. How to Win in the Sport of Business, Effective Marketing Strategies, The Power of Habit. There is a purple bong that looks like it hasn’t been used in decades either, set up on the top shelf. Memories.

The living room is freshly vacuumed. The Electrolux sits by the door, its electric chord neatly wrapped in place. The superindendent who let us into the apartment stands there waiting patiently.

A middle-aged man in a bathing suit with his arm around three smiling children(maybe seven, twelve, and fourteen), poses on a beach, the Caribbean sea behind them. On the wall in the small open kitchenette the police officer is looking at a framed poster that says “My Kid Made This.” There is a 1st grade drawing of a man and woman and a house and a dog and a great big sun.

On the coffee table in front of the couch is a lap top computer, still open, its screen gone black, a pair of eyes glasses, neatly folded next to it. A glass of what looks like scotch with only one last drink left in it. A neatly typed sheet of paper is also laid there titled “Instructions.”

Down the hall there is a bottle of aerosol on the ground by the half open bedroom door. There is another bottle on the ground by the bed and one on the bed stand. The bed is neatly made. The man lays supine on the bedspread, his arms holding a black garbage bag wrapped around his head.

My young partner runs the strip. Six seconds of asystole. Then he looks at his watch and calls the time.

Where I Stand (Today)

I promised more columns on enhanced BLS, but I have instead been silent for the last two weeks as I have struggled to come to a clear understanding of the issue. The most successful commentators all stake out clear positions (whether they believe them or not). But I continue to struggle with this one.

Just when I think I have it settled in my mind, I talk to someone else and they convince me otherwise. Enhanced BLS will harm the advancement of paramedic services and that would harm patients. Go ahead and train and equip them, but it is going to cost dollars and there might not even be a need. Some EMTs are capable of these advanced treatments, but others, oh, no, look out! I admit I could see their points.

This week I put Enhanced BLS on the agenda of our regional medical advisory committee, and we addressed it on Tuesday. I have no set position, I told them, my position keeps changing. I am conflicted, but this is an issue we will need to address. Help me out, what do people think?

We had some good conversation. Many on the committee felt just like I did, torn and confused. But talking about it with them, and learning I was not alone in my conflicted view, helped me find some clarity. So while reserving my right to change my mind, here is where I stand today:

I believe there are a number of medications and interventions that BLS can be taught to do outside of becoming paramedics themselves that will benefit patients, enhance the public’s experience of EMS and cause little to no harm.

Having said that I believe each of these items needs to be approved by the services’s medical director and weighed carefully against any number of factors, including great benefit versus little risk to patient, cost, need, resources, service area and ability to train and oversee.

Here is my menu:

Medications:

Epi-Pen
ASA
IN Narcan
IM Glucagon
Combivent
Zofran ODT
Tylenol PO
Benadryl PO
IM Versed injector (for status epilepticus)
Morphine injector (for distant rural services)

Interventions

CPAP
Selective Spinal Immobilization
12-Lead Transmission
Supraglottic Airway

If I were to redesign the nation’s EMS system, I would expand the basic EMT course to see that all of these interventions and medications were properly and as thoroughly covered as needs be. (I would also redesign the paramedic class to make paramedics more advanced practice practioners with treat and release as part of their scope). But that is a little beyond my abilities and powers. So what will I do for the world today?

I will do a needs assessment in each particular area to see if there is an unfilled need for any of these interventions – a need that will justify the expense and training involved. I think that needs assessment might reveal some interesting answers. (While doing research on the need for BLS 12-lead acquisition, contrary to my expectation, in our region, I have found it is very rare for a BLS unit to bring a STEMI into a non-PCI center. And the likelihood of BLS bringing in a STEMI to a PCI center was actually greater for urban BLS than rural BLS, who most always eventually can meet up with a paramedic on the way to the hospital due to the length of time they have to meet up. BLS heads to the hospital and paramedics come out to greet them, in most cases far enough from the hospital for the STEMI to be identified and the PCI center notified in advance. BLS, in the city, on the other hand, is close enough to the hospital if no medic was initially available to respond, BLS may make it to the hospital before they can hook up with a medic.)

But first a diversion. In Connecticut there is a bill before the legislature to require that all BLS ambulances carry Diastat – rectal Valium. Where did the bill came from? I do not know. Certainly not from any of the EMS medical directors in the state. My guess is that it came from a mother of a child who suffers from seizures, who likely approached a powerful legislator and convinced him that requiring rectal Valium in every ambulance will ensure that her child will get relief if the child has a seizure away from home. There is also another bill that would allow school bus drivers to inject students with the student's own Epi-Pens should they suffer an anaphylactic reaction on the bus. Should we be concerned that in the confusion of the legislative process, bus drivers will end up permitted to administer rectal valium not just for seizures but also to calm down disruptive children?

While the goal of the legislation, as the goal of enhanced BLS, is laudable, we cannot lose sight of the big picture and ask the needs question? How many kids in Connecticut have suffered permanent harm from the failure of BLS ambulances to have rectal Valium? And how many kids have been spared permanent harm by not having rectal Valium inappropriately applied?

While I don’t have the answers, I can say that in the areas I work in and in the areas I oversee, it is very rare for a truly seizing child to not get treated by a paramedic. Our paramedics give medication to seizing kids very rarely. You can count the number of times in a year they give it on one hand, and this is over a sizable multi-town area. Pediatric seizure is a fairly common call, but it rarely turns out to be true status epilepticus. It more often falls into these categories: seizure over by your arrival, never a seizure in the first place or a pseudo seizure, the political correct term for a patient having a seizure for emotional reasons and not due to abnormal electrical activity in the brain. Rectal Valium costs about $300 a pop. It comes with an expiration date, would require a large amount of training, as well as requiring lock boxes and controlled substances policies. A lot of money, a fair amount of risk, many manpower hours of training, and not really a proven need – at least not in our area. Might I approve it for an area where the closest paramedic was two hours away? I possibly would. Although I would insert IM Midazolam for rectal Valium.

What I would approve in an urban setting and what I would approve for a rural area would be different depending on a multiplicity of factors. The two BLS enhancements I feel strongest about no matter the setting are the Epi-Pen and CPAP. I want to see all basics carrying these. They will save lives whether the patient is in a 3rd floor walkup apartment a block from the hospital or a hour away in a farmhouse. They are used for extremely time dependent conditions (anaphylaxis and impending respiratory failure). Both I believe have strong literature behind them supporting their benefit.

I guess if I could summarize my position it would be this: The distinction between ALS and BLS should not be an artificial one where BLS gives no medication and does nothing invasive where ALS does. The distinction should be a common sense one made by medical oversight after weighing risk/benefit, cost, and need. BLS shouldn’t necessarily carry a medicine or do an intervention simply because they can. In our current system, they should be allowed to do these enhancements only if there is a demonstrated need.

* *

Of note, Connecticut is nearing approval of CPAP for basics with the approval of the service's medical control. Epi-pen is currently mandated in all BLS ambulances. Connecticut is also nearing approval of a pilot project for the acquisition and transmission (not the interpretation) of 12-leads by BLS in the Northwest rural area of the state. IN Narcan is the next enhanced BLS issue that is expected to be taken up by our state committees.

This ends my commentary on enhanced BLS, at least until I change my mind again. 

King of the World

 I work Sunday, Monday and Tuesday, 12-hour city shifts. I took the day off today (Tuesday) to go to the monthly regional EMS meetings for my clinical coordinator job that fall on the 2nd Tuesday of every month. I was excited for the meeting because we were going to be voting of our new spinal immobilization guideline to limit the use of long boackboards for certain patients, but the meetings were cancelled due to the storm we had this past weekend. Friday night we were hit with a blizzard that dumped anywhere from two to three and a half feet on towns in the area. The storm plus the nightmare of cleanup stressed enough of us with backlogged work and still messy road conditions that the meeting was put on hold.

I woke up Saturday morning to this site in my driveway:

Fortunately, I had a good helper with the shoveling.

Sunday and Monday at work were challenging as many of the streets in the city had yet to be plowed. We got as close to the call locations as possible and then either hiked in or had the patients meet us on street corners. The mother with the sick kid and the woman with the full body rash met us on the corners, the unresponsive hypoglycemic and the weakened dialysis patients who missed their scheduled appointments we had to go get.

Monday was complicated by people trying to drive to work and by a cold rain that turned the streets to slosh and ice. We dealt with more blocked streets, and cars that were stuck on ice with skidding wheels that we had to get out and help push out of the way. All day long, it seemed I was stepping out into snowbanks and doing crazy arm whirling balance dances when my own boots failed to grip the ice.

So a part of me was relieved that instead of dealing with more of the mess today, I was in my warm office at my computer, weating a comfortable sweater and reading run forms on the computer instead of doing the actual calls myself.

…instead of doing calls myself!

I do like my office job with the nice state benefits and great boss and chance to work on systems issues, but I also like doing calls myself. Really there’s nothing like it.

I found myself daydreaming, remembering the day before, how on one call to keep from blocking the road completely and leaving room for the arriving fire truck, I was wedged up against a giant snowbank. I squeezed out of the passenger door, and started climbing. I climbed to the very top of that snow bank. I was up higher than the ambulance roof, higher than the big fire truck. I was higher than everyone on the street. I could look all the way down the avenue, at all the life of the winter city digging out. I stood on the snowbank a moment, and pounded my chest like old King Kong. I was the King of the World! Then I climbed down to follow my paramedic preceptee and our EMT partner into the apartment house where on the third floor we took care of an old man with swollen legs, carried him down in a stair chair, and out through the snow and into our warm ambulance and transported him safely to the hospital.