Surprises

 I work in a high volume system.  It is not unusual to do 10 transports in a 12-hour shift.  I’m lucky if one of the calls is a good call.  By “good” I mean a call where I get to be a paramedic in a way more than routine.  Routine paramedic is asthma (duoneb), abd pain (maybe fentanyl), vomiting (zofran), chest pain with normal ECG (ASA), hip fracture (fentanyl), psych (versed only if violent or extremely anxious) type of call.  While these normal calls can all be rewarding in their own way, they are not memorable and are not worthy of a response when someone says, “Do anything good?”  A “good” call is one where when someone asks you that question, you can respond with “Yes, I did.” Sometimes a good call can be summed up in just a few words.  I did a code, used CPAP on a CHFer, gave 10 of Versed to take a duster down, did an open tib fib.  Good calls, but not worth elaborating on because the story is a known.  We have all done these calls.  The true good calls are ones that are more than a sentence fragment for a response.  True good calls are worth another paramedic’s listen.

Recently I had two calls that fell into the good category, and within that category, I would tag them with the surprise label.  Surprise is a special category of good call that I particularly enjoy doing and telling about.  By surprise I mean they turned out to be good when my expectations were for same old same old.  You can be dispatched to a shooting to the head or a CPR in progress and know you will likely have a call where you will have to earn your pay, but when you get dispatched to a city chest pain or a simple bee sting without initial symptoms of an allergic reaction, you are most likely going to end up with a routine call.

So I get dispatched to a chest pain a couple blocks from hospital.  The address is a rundown apartment building.  Our patient - a large fortyish woman wearing a do-rag -- comes out of the front door with her boy friend who is wearing a New York Knicks jacket and a Yankee baseball cap with a shiny round sticker on the bill.  (I do not mean to stereotype by this description, but in my mind at the time I am making judgments based on the stereotype which is based on experience). The woman says she has been having chest pain for about five days, and she answers my first question by saying yes she has been coughing up green phlegm.  Same old story, right?

I have a hard time getting a pulse -- she does have fat wrists,  I but think nothing of it.  When I put her on the monitor -- just part of the routine -- I do the classic double take.  Say what?  She is cranking at 220.  Holy Moly!

Later, I get dispatched for a 60 year old man stung by a bee.  He too walks over to the ambulance as we pull to the curb.  The first responders say the only reason he called is his wife got stung by a bee once and had an anaphylactic reaction.  He was stung by bees once ten years ago, and remembers some swelling at the time. He has no itching or hives.  No dyspnea.  His lungs are clear.  The first responder tells me his blood pressure is 140/90.  I feel his forehead and note it is clammy, but it is also humid out, and he was working in his garden  In the ambulance, I take his blood pressure.  100/60.  I ask him what his pressure normally runs and he says around 130.  I ask about meds and hear he is on beta blockers.  I tell him, I will be rechecking his pressure periodically on the way to the hospital.  I retake his pressure a few minutes later.  It is 82/40.  He is looking a little grey and he tells me he feels nauseous.  I check the monitor.  Heart rate is in the 60’s still.  He looks very grey now and says he is nauseous.  I take my the med bag out of my gear and set it next to me on the bench.  Interesting, I am thinking.  I take his pressure again.  I can’t hear anything.  He has delayed cap refill and is starting to look motley.  I’ll be...

What made these two calls “good” was for all the bullshit and boring repetition of many calls, sometimes someone actually turns out to be having a real problem.  We are supposed to put chest pains, even ones we think are muskuloskeletal,  on the monitor.  We are supposed to take repeat vitals signs.  9 out of 10 patients, maybe even 39 out of 40 show no change at all.  But you do your job, your routine and all of a sudden, there it is before you.  Paramedic time.

I wonder if this is how bird watchers feel when all of a sudden their binoculars focus on a rare speckled breasted winged creature or how antiquers feel when they discover a rare treasure at a neighborhood garage sale.  Or how a seven year soccer player feels when suddenly the ball is on her foot and the goal is open and she is unguarded and she kicks it straight and it goes in the goal and the team explodes with cheer.

Sometimes I love my job!

So instead of, the nurse saying hey did you know that BS chest pain patient you brought in was in a rapid afib at 200, or your BLS partner screaming up to you from the back that the bee sting dude just went into cardiac arrest, you actually get to be the one controlling the narrative.  Patient one gets 25 of Cardizem, which works like a charm.  The 190-220 rate comes down to the 70s, and she feels much better.  Patient 2 gets 0.3 epi IM, 50 Benadryl,  4 Zofran and 125 Solumedrol IV, along with a 300 cc fluid bolus.  And while he still feels a little nauseous, his pressure comes back and the mottling goes away.  His face is no longer grey.  His skin is warm and dry..

And I have two calls that are worth a listen, and a job that constantly reminds me it is never as boring as it can sometimes seem.

Assembly Line

 Many years ago, I worked on assembly lines in factories. I put together and or packaged everything from Christmas Tree stands and door knobs to fast food store deli sandwiches and grocery store beef ribs.

The key to the assembly line was to go a little bit faster than you were comfortable going.  You had to work hard and pay attention to keep up. If the line went too slow you were not as productive as you could be, or if it went too fast and people couldn't keep up the line fell apart and everybody had to stop and start all over at a loss of time and production.

At one of the hardware plants I worked at there were two competing inspectors. The time keeper studied your movements and taught you how to be move faster and more efficiently so more could be produced. At the other end was the quality guy and he got pissed if things were not put together right. The time keeper and the quality guy had different bosses and they hated each other. The foreman didn't care for either.  She just wanted to get the product out in as much volume and quality as possible. I was just a worker bee, paid by the hour, with the pay check coming every Friday as long as I decided to keep coming to work. I would listen to the time keeper and nod and do what he said, and then the quality guy would yell at me, and I would nod and do what he said, and then the time guy would yell at me, and then the time guy and quality guy would yell at each other and I would go back to working, trying to find my own balance between speed and quality.

The best example of this was packaging doorknobs.  They would lay a big thick cardboard sheet on the line.  On the sheet was the backing for thirty-two door knob packages. I had a big bin full of door knobs and I would try to lay them down as neatly as possible, while another guy laid down the package of screws that went with the knob.  There were several of us doing the same thing. The sheet would whip by and we would furiously lay the knobs and screws down. The sheet would go into a machine to get plastic wrapped, and then another machine -- the cutter-- cut and separated the sheet into 32 individual packages, which were then quickly hand packed into boxes of eight knobs each. If the knobs were not laid directly in the center of their package. the wrapper would wrap them and then they would get cut off-center and be unusable, provoking the quality guys anger.

What is the point of all this?  It reminds me of health care today. Whether EMS or hospital setting, there is the clash between time and quality and the two task masters aren't always working for the same person.  A friend of mine worked as a PA for a hospital walk-in clinic.  She was a great PA, a former paramedic with a great medical mind, but when her annual review came up, the only issue that mattered was coding and the number of patients she saw per hour.  On the ambulance, the conflict is often between dispatch who needs to get the calls off their board in the quickest amount of time and get cars to clear as fast as possible and the quality people who want to get the appropriate car to the appropriate call (i.e. paramedic to priority one, BLS to transfer or priority 2), and the documentation people who want to have the run forms fully documented, and all the billing collected and signatures obtained. The road people do their best to walk the line to please everyone, while not forgetting about the patients needs, not just the patient they have, but the holding 911s who don't yet have car assigned to respond to them.

I do not mean to point the finger at anyone here, just to say, not that everyone hasn't already noticed, but the health care dollar is getting stretched thin these days. ED staffs are overworked too. There is a huge turnover in our EDs due to burnout as nurses cat handle the loads they are being asked to shoulder.  And for EMS, while I love my job, I come home after 12 hours of nonstop calls and driving and want nothing more than to get in bed so I will at least be partially rested for the next days work. Even when I was a young man three 12-14 hour shifts on consecutive days wore me down and it is much busier now and I am much older.

I was listening to a medical podcast the other day, and I heard a doctor tell a group of younger doctors that while she recognized the need to face the computer and input everything the patient was saying, it was particularly important -- at least on the first patient visit -- to observe the person as they spoke to get a sense of their body language, and to better understand the meaning of their responses.  At least on the first visit!

I start writing my run forms on the way to the call.  I can fill in a lot, but  often when I am working with a new person (I have partner du jour these days as one of my regular partners has been out hurt), I can look up and see we have gone past our turn.  I screw up often in this manner, forgetting they do not all know the streets as I do.  I continue writing the form on the way to the hospital, hopefully finishing in triage so I can quickly print it, and be available for the next call. I find I chat less with the patients than I used to in the days when I could scrawl out a paper run form in a few minutes.  I am just like the doctor sometimes, looking at the computer and missing the body language.

Let me tell you a story.  I tech most every call because I cant stand to wait at the hospital while my new partners take an hour to write their run forms. But on this call, we are driving by a homeless shelter and notorious intersection for drunks. We are hailed down by a cop. She's been drinking, the cop says, and points to a twenty-five year old or so woman with dirty blonde hair, torn jeans and a scowl on her face who is motherfucking him and us both. Such a stream of cuss words. My poor ears. We finally talk her into getting on our stretcher on the enticement she can get something good to eat at the hospital.  The diced peaches are particularly good!

l do this one, my partner says.  I have already done seven calls, and it is after all just a drunk and we are a half mile from the hospital, so I let him tech.  I get in the front, and hand him back the computer, and then in the rear view mirror I see him open it up and start typing away.  I drive to the hospital and when we pull the patient out, she appears to not only be unconscious, but have agonal respirations.  I see the fresh needle marks on her arm now, and note the pinpoint pupils.  I look at my partner and am thinking “Dude, did you not noticethe change in her condition?

Hmm, he said.I bet shes on heroin.

I stimulate her with a light medium punch in the arm She opens her eyes, and motherfucks me again.  She is breathing well enough now that narcan is not indicated. I had for a moment thought of putting her and the stretcher back in the ambulance and giving her some of the intranasal stuff.  Instead we wheel her in, and oh, look, there is a line at triage. We do some vitals in there, and she is Sating at 95%. Every now and then, her respiratory rate drops and I have to nudge her again. he wait continues. More and harder nudging are required.  Eventually, not even the nudging works.  Her SAT is in the 80s now and her respiratory rate is less than 6 even with sternal runs.  She is no longer arousable.  I have to get the triage nurses attention, and borrow an ambu bag.  I should have just had my partner go back out to the truck and get my gear.

Anyway, bottom line -- no harm was done with this call, but it shows what can happen when you are looking at the keyboard and not the patient. I like to think I do a good job of typing, chatting and looking back and forth between the patient and my keyboard. I like to think I am a good employee and can find the proper balance between getting my forms done quickly and clearing the hospital and giving the patients what they need.  But I do lament that it is not like it was when I started, when I had long conversations with patients on each transport, when all my assessments were thorough, when I saw more than I do now.

I would like more of an acknowledgement from our health care leaders of the stresses the new systems place on individual practitioners who must balance the need for high volume, high-level care, full documentation and patient-provider rapport (the heart of the best health care,) while often reporting to different taskmasters for each.

I recognize if the assembly line of health care goes too slowly, it is costly and unproductive. I also recognize if it goes too fast, it all falls apart.  I will do my best to continue to try to keep pace, but the entire system bears watching. When in doubt, the only boss to listen to is yourself, doing what is right for that patient right in front of you. We can blame, often with good cause, the system, but an imperfect system does not relieve of us individual responsibility. If asked to choose between the timekeeper and the quality guy, go with the quality guy.

Paramedic Students

 I remember when I was an EMT student doing my hospital observation time and watching the paramedics come into the hospital with their patients.  How confident they seemed.  I marveled at the ease with which they moved through this strange new world.  I held them in awe as I did the paramedics I later rode with during my paramedic ride time.  They knew the secrets I wanted to know, they had succeeded in the world to which I aspired.  I wanted to see what they had seen, to be able to able to handle what they could handle, to stand ten feet tall in the midst of the shit, to have my own swager.  They were mythic characters to me, and I wanted to be worthy of them.

I write this now after rereading Lights and Sirens, Kevin Grange’s new memoir about going through UCLA’s paramedic school and doing his ride time on the streets of Los Angeles.  It has been so long that I was in EMT class, and then several years later paramedic school that I have forgotten the stress, and forgotten the perspective of the new man trying to be worthy.

Grange’s book, which should be essential reading not just for those new to the field and those going through the unique experience of paramedic school, but for people like me and those I have worked with for years to help us remember not only what it was like to be new, but to recognize the ability we have to shape and help those who will soon to be riding alongside us, and for some, riding the streets after we have done our time and faded away.

Some of the people I rode with were real dickheads.  I remember one guy gave me one try at an IV, and when I missed, condemned me to observing for the rest of the shift.  I watched him do IVs and then jam the needles in the bench seat.  I remember he chased a “seizure” patient right off a scene, yelling at him to never fucking call an ambulance again.  “You again?” were his first words to the guy.  Another young woman kept syncopizing, and when I insisted we do a 12-lead ECG, he told me not to speak if I couldn’t recognize bullshit for what it was.  Halfway though the shift, a supervisor came out and told him a hospital had complained about his attitude, to which he swore at the supervisor, who told him to just play nice.  I hadn’t yet understood that sometimes ambulance services needed paramedics in their ambulances more than they needed good ones.  I hadn’t yet heard the term “meat in the seat.”   At the end of the shift, he wrote a short (two words) negative comment on my evaluation sheet.  Rather than turn it in, I threw it away and lost credit for those 12 hours.

Other paramedics I rode with were great.  They coached me through intubations, explained the difference between asthma wheezes and cardiac wheezes, and showed me the value of holding a patient’s hand, and attending to loneliness with the same commitment as I should attend someone with a gunshot wound.  To this day, they shaped the way i view this job, and I am forever grateful to them.

More than twenty years later, I know now that paramedics aren’t special.  We are just people like anyone else.  We have good ones and bad ones, gifted ones and others who just never stop working hard to be better.  No matter what profession or line of work you enter, there are people who will be dickheads, others who will be kind, and others who will be a mixture of both.  Angels and psychopaths can be found on the paramedic streets.  There are more of the former than the later, but neither is an oddity.

I have had a lot of new partners lately.  Between my two jobs -- as a paramedic and a hospital coordinator, I work 70 hours a week, and it leaves me perpetually worn out when I add on top of that being a father to three girls and trying to keep in shape at the pool.  I like nothing more than to come into work and see my regular partner Jerry, so I can go through a day not having to worry about anything.  But two months ago when we had a precepting paramedic with us, we were short cars so they pulled Jerry to work with a new guy in another ambulance who didn’t have a partner and they let my preceptee and I work alone together.  Jerry and the new guy were doing a carry down and the new guy didn’t know what he was doing and Jerry, in compensating for his partner’s mishandle, ended up with an arm injury that has kept him on light duty.

I have found myself being very grumpy to some of the new folk.  I don’t say much, and don’t like being asked if I have any hobbies or what my plans are for after work if I have already answered the first fifty attempts at conversation with monosyllables.  I feel bad sometimes that I am not always gregarious.  Jerry gives my new partners for the day a talk about what to do to get along with me.  Don’t worry if he doesn’t talk to you,” he says.  “Only worry if he says ‘What are you doing?’” That is as close to a swear as I will come to.

I clearly have forgotten what it was like to not know the streets or where I was going, or not know how to get a stretcher in and out of a room, or how unimportant it is to ask someone who is having trouble breathing when they last ate as a lead-off to your questioning.

Once many years ago someone said to me when I was riding:  “Don’t bother to tell me your name because I have seen so many people come and go, I don’t have the energy anymore, you are just today’s rider. There will be someone else here tomorrow.“  I swore I would never be that guy.

Jerry told me some people are afraid to work with me.  I did not understand this.  I tell them you are just a regular guy, he says, but you intimidate them.  Do I really?  Have I become like the old bear in the zoo who the zookeeper has to give special treatment to, and who no longer has to perform for the visitors? I hope not.

I will say, while I may not always be overly sociable to my new partner for the day, who after all signed up to work with me and is getting paid, whenever I have a paramedic student, I do always go out of my way to be hospitable and show them the way.  Even if I am beat and tired to the bone.  I will never write “Clueless Fuck” on any one's evaluation.

All of this is an extended way of saying reading Grange’s book helped me remember what it was like to be new at this work that become my life, and the next time a student rides with me, I won’t forget that I should be a guide and a role model, and that being a good role model to an aspiring medic student is as important a part of the work as giving the patient the proper care.  I should probably also try to extend this to all new partners, even if they are only riding with me for a day.

Check out Grange’s book and remember what it was like in the beginning.

Mirrors

 In the late 1970s and 1980s, the G------Motor Lodge out on the Turnpike was the place to take your girl for a swinging good time.  Mirrored ceilings and heart shaped Love-Tubs.    The brochure featured a hairy-chested mustachioed man in a velvet bathroom holding a bottle of champagne in one hand and a filled glass of the same in the other.  Need I say more.

Whenever I returned to Connecticut with a new friend from a different part of the country, my New England tour for her included three stops -- Fenway Park to see the Red Sox,  Cape Cod to see the Atlantic Ocean and the G--  to see the Love Tub and mirrored ceilings.  All three were big hits.

Times change, years pass, we grow old, and so did the G---.  It’s still open, and while it looks the same form the outside, the clientele has changed.  It is a welfare hotel now.  We get called there periodically for several day old dead bodies, drunks, psychs, and assaults.  The last time I went there was for a lift assist.  A man of my age who life has treated much worse than it has me.  He was morbidly obese with a foley bag dangling from him and smelled like he hadn’t bathed in days.  The room was layered in dirt, an old style 24 inch TV sputtered on a cable-less channel.  Empty liquor and beer bottles were lined up on the dresser like a dusty trophy rack.  (Alas, none were champagne.)  A home health aide was there to check on him and was unable to lift him back into bed, which is all he wanted as he said he was not hurt.

We donned our gloves, and lifted him back to the edge of the large wooden canopied bed.  Not an easy task.  While my partner checked him out just to make certain he was not hurt and to again offer him transport, I saw still there, albeit with some cracks, was a large mirror lining the ceiling of the canopy.

I wondered then what the man saw there now when he lay alone in his bed at night.  Did he see what he had become?  Or did the mirror still hold some magic?  Did he see his old mustachioed self?  And perhaps in the mirror, he was no longer alone.

Intranasal Narcan for All

 I was on Park Street last week headed into El Mercado to get some pernil (roast pork), yucca and tostones for lunch when a gentleman came up to me and showed me his overdose kit.  He said he'd gotten it at the local needle exchange program.  He said he had already used it once when one of his buddies ODed and it worked great (though his friend was initially a little pissed at him, but later came to understand when the friend smacked him and said, "But you weren't breathing, bro!".  The kit contained two 2 mg prefilled Narcan syringes and one atomizer.

 

My EMT partner Jerry just stood there shaking his head.  He didn't understand how some dude on Park Street could give Narcan to his overdosed buddy, but as an EMT Jerry couldn't give it.  In Connecticut basic EMTs can give intranasal Narcan, but only if their service is approved for BLS Narcan by their sponsor hospital.  That hasn't happened yet for our service so no Narcan for Jerry.

And I stood there shaking my head because while as a paramedic I can clearly give Narcan, we are having a severe Narcan shortage at work.  Our supply shelves are bare.  I, at that time, had only 4 mgs of Narcan in my bag, and that was only because I was able to get the second 2 mg dose by raiding another car that had a spare Narcan on the shelves.  I had none on my shelves.

I have been working the streets for 20 years and other than a few brief periods when a particularly strong heroin hit the city, causing seasoned addicts to overdose, I have rarely seen as much heroin on the streets as there is today.  Rarely a week goes by that I don't do at least one overdose.

I am all for everyone being able to give Narcan (when appropriate).  I think it is great that the street dude was able to save his friend.  I would like to see the police be able to give Narcan instead of directing traffic around the car with the blue driver passed out at the wheel at the stoplight.  I would like to  see fire be able to give it instead of having to bag the patient until we show up or perhaps to stand around while the unresponsive patient's respirations decline to near zero  (I have seen both excellent airway management by the fire department and less excellent airway management). And I would like my partner Jerry to be able to give Narcan on the days when he works with a BLS partner and instead of giving Narcan has to bag the patient all the way to the hospital because there are no medics available.

But to be able to give it, we have to have it.  Which brings me back to the guy with the overdose kit.  The reason he stopped me in the first place was he was curious how much each vial of narcan was worth.  I told him I thought it was about sixty dollars a syringe.  "Yeah?" he said, "That's what somebody else told me.  That's a lot."

I wondered why he was so curious.  Was he pleased that the state not only was willing to trust him with life-saving medicine, but with valuable life-saving medicine?  Or was he maybe looking to sell it?

I had a vision then of ambulances lined up outside the needle exchange center where another type of exchange took place.  "I'll give you forty bucks for your kit."  "Throw in your roast pork and a pack of smokes and it's a deal."