It Depends

 An emergency doctor friend of mine has a great lecture called “It Depends…” He says that for many EMS patient care questions he is asked, the answer is “It depends…:” But there are other questions where it does not depend, he points out. For instance, when your patient suddenly goes into v-fib. There is no "It depends." You defibrillate. Your patient is in severe anaphylaxis. It does not depend, you give them epinephrine.

When I analyze a call now, I try to follow the decision making. Did it depend or did it not depend? and if it did depend, what did it depend on?

Here is a question that I recently considered. If you have a critical patient who you are worried may crash, when do you do the IV? At the patient’s side, on scene in the ambulance, or en route to the hospital? The key is that you need to have the IV when you need it. What is my thinking as I consider this question?

Well, it depends on whether or not I am going to be able to do anything for the patient and can the hospital do something that I can’t that will make a different in outcome. For instance, a gunshot to the torso. The patient needs a surgeon. My IV is not going to offer me much avenue to help. I would elect to do the IV en route once I have taken care of other priorities.

Now how about a pale, diaphoretic patient in ventricular tachycardia with a pulse? This of course raises the question of shocking or giving meds. Another it depends question. Let's say I choose to shock first and it is unsuccessful. Back to the IV question. For me there is no more it depends. It doesn't depend, I need the IV right then. I will go for the IV right at the bedside because I will be able to deliver amiodarone and if the patient codes, other ACLS drugs (for what they are worth). Bottom line, I won’t wait till the ambulance to get my IV.

Now let’s say the patient has sepsis and hypotension. Here my IV can be an avenue to give this patient needed fluid. While fluids may be life-saving the IV is less moment dependent than in the previous case, so depending on the surroundings in the home (lighting, space, etc), I may wait to the ambulance, and then depending on whether or not I think I can get the IV easily (or who is driving) I may elect to do the IV enroute or try first in the parked ambulance if the patient has poor vasculature and my partner is a rough driver.

Most every EMS call has many “it depends” moments. Here is one I am thinking about now. You are alone in back and your patient goes into sudden cardiac arrest. Ventricular fibrillation. You shock once with no success. What do you do? Do you have your partner continue to drive to the hospital while you try to manage the code or do you have him pull over and help you out in back?

What does your decision depend on? How far are you from the hospital? Can you effectively deliever quality compressions, manage the airway, and deliever quality care by yourself? How far away is help? Is it safe to pull over where you are? Does the screaming family member in the front seat affect your decision? I would lean strongly to pulling over at the first safe spot and getting assistance to work the code right there.

Tough calls. Tough questions.

And the answer? I think when deciding if it depends or does not depend, the answer must always be -- When it comes to what is best for the patient, it never depends.

Christian Smeck

 Christian Schmeck passed away a few days ago at 59. I saw his obituary posted in the EMS room at a local hospital. I suspect most of the newer EMTs who saw it didn’t know who he was.

I first met Chris over twenty years ago when I worked at the state health department. He was a service chief for a local volunteer ambulance and we had invited him to an EMS Summit to discuss ways the health department could improve the EMS system. He wore his white chief’s shirt with the gold badge on it, but he came across as an unassuming man who was happy to be invited, glad that someone wanted to listen to him. I remember sitting next to him at lunch and having a long talk with him about a call he did where he came upon a family found dead in their beds from carbon monoxide poisoning and I saw how deeply it affected him.

A few years later when I left the health department and started full-time as a paramedic, he was a training officer at the service where I was hired. He gave us all our orientation on our first day, and he was reassuring in providing guidance to the group of us new hires. Over the years I worked with him a few times. He was a good solid partner. Never a know-it-all, but not afraid to direct me if I started down a wrong track. And he was kind to patients – always. He never spoke a harsh word or showed a lack of patience.  He was an EMT you wanted taking care of one of your family members if they ever needed help.

Like many in EMS, he was often tired, working commercially during the day to support his family and then spending long hours as a volunteer at night, teaching classes and doing calls. As the years went by, he divorced, moved to a new town, joined another volunteer service, and suffered a slow decline in his health. Eventually, he gave up the road, and went into dispatch, and then just teaching. I saw him a few times in hospital rooms in the ED and did a double talk on seeing him on the other side of the stretcher.  I'd always stop and talk and wish him well.  He would tell me he was doing better, just waiting to be discharged or possibly just admitted for the night.

The last I saw him was in the aftermath of big storm we had last October. He was walking out of an emergency shelter. He wore a nasal cannula and carried a small O2 tank on his shoulder. I didn’t have time to talk, but we said hello.

For those EMTs who read his obituary, but who never knew the man, Christian Schmeck was one of us.

The Wheelchair

 The call is for an unresponsive in a wheelchair on a street corner in front of a social services agency.

A woman who works at the agency flags us down. She says she has a man in a wheelchair who is unresponsive. She does not know him. He is not a client there. She says a stranger wheeled him up in the chair, said he was on some heavy duty drugs, and then bolted.

The man in the wheelchair’s eyes are closed, his head is tilted all the way back and his mouth is wide open. He is about forty years old with long dirty hair to his shoulders. He is wearing an army jacket. He is breathing, but you have to watch him for several moments to see that he is his rate is so slow. His pupils are pinpoint. I give him a shake. He opens his eyes, mutters, and then he falls back asleep.

This appears to be a narcotic overdose. We lift him out of the wheelchair and place him on our stretcher, and then get him in the back of the ambulance. While I assess him further, my partner opens the ambulance's side door, and puts his wheelchair in.

When I started in EMS we always gave narcan to heroin overdoses. You had pinpoint pupils, you got narcan. Nowadays narcan is limited to suspected opiate overdoses who are hypoventilating -- low respiratory rate and/or high ETCO2.

I debate what to do about this guy. If I stimulate him enough I can keep his respiratory rate up, but he can’t talk to me. I don’t know his name or anything about him. And I have to keep stimulating him or else he'll drop back off to hardly breathing at all. I put him on the capnography and I get an ETCO2 of 57, which is high, and suggests he is not effectively ventilating. If I stimulate him, I can get him to breathe more and the number drops down. I leave him alone, and it goes back up. His respiratory rate is 4. The end tidal climbs back up into the 50s. I finally decide to just give him a tiny dose of Narcan -- 0.4 mg to wake him up just enough that I won’t have to keep shaking him every two minutes.

No sooner do I give the 0.4 mg, then he opens his eyes, looks right at me and curses. “Shit, you just gave me that narcan shit, motherfucker.” He tries to undo his straps. “Now I have to go out and start all the fuck over again.”

“Whoa, Whoa,” I say. “You were barely breathing. I had to give it to you.”

“No, if you left me alone, I would have been fine.”

“Left you alone? I didn’t go looking for you. You want to get high and not have anyone bother you, lock yourself in a room and put a do not disturb sign on your door. You OD in public, someone is bound to call us, and if you are not breathing effectively, I hate to break it to you, but you will get narcan.”

“Where am I?”

“You were out and barely breathing. So you are in the ambulance now, headed to the hospital.”

“Where’s my money? Did you take my money?”

He frantically reaches for his pockets and is relieved when he pulls out some crumpled bills including at least a twenty.

“And we have your wheelchair with us, so don’t worry about that.”

“Wheelchair?” he says.

“Yeah, your wheelchair. Your buddy wheeled you over to the agency and they called 911. We put your wheelchair in the side. It’s right here, behind you. Safe and sound.”

“I don’t have a wheelchair.”

“Huh?”

“I don’t have a wheelchair.”

“You can walk?”

“Fuck, yeah.”

“Well, you were in a wheelchair.”

He looks puzzled, and then he says, “Wait a minute, does it say, "Property of Sam Thorpe' on it?”

“I don’t know. Maybe.”

“My roommate has a wheelchair.”

I slide over and look at the wheelchair. “Property of Sam Thorpe,” I say.

“That’s it. It’s my roommate’s wheelchair.”

“What’s wrong with your roommate?”

“He doesn’t have any legs.”

***

At the hospital, the patient continues to bitch that I gave him narcan. We put him on a bed in the hallway and tuck the wheelchair in next to the bed. No sooner have I started down the hall when a nurse takes the wheelchair and starts wheeling it away.

“Whooa, whoa,” I say. “That’s his roommate’s wheelchair?”

“Where’s his roommate?” she says.

I hold my hands out. “If only I had a crystal ball.”

How EMS is Like Baseball (But With Better Food)

 I think EMS is a lot like baseball. It can be fairly slow-paced (boring, if you prefer), but it has its moments of excitement. You have your days when you don't even remember the calls you did they were so routine. Like in baseball, you can stand around all game in the outfield waiting for them to hit you a ball, and maybe on a typical day, you get a couple easy flys you can catch, or maybe a couple singles come out your way that you retrieve, and return to the infield with a crisp throw. Every so often you get a chance to make a spectacular play, and even rarer, you get a chance to make a spectacular play with the game and the season on the line. Same with at the plate, you bat your average for the season, and every now and then you get a chance to win the game in the last of the ninth, but that chance is rare. It’s a long season, and, just like in EMS, the trick is to stay ready on every play, never knowing when you will be truly tested.

The above, translated, means, its been pretty slow and non-exiting lately at the ambulance ballpark. Some days it is more like a six year old girl’s softball game than the major leagues. (In girl’s youth softball everyone bats and there are a lot of walks). (Today I’ve transported three kids from a school bus accident who had no injuries, a two day old fall and I did a dialysis transfer). The highlight of my days has been finding good things to eat. While I love a Fenway Frank as well as the next guy, after awhile regular ballpark food can taste pretty bland. One good thing about the city I work in is the food is varied, multiethnic and generally awesome. Instead of writing about calls, I have been collecting notes on restaurants. I found an excellent plantain porridge at Mr. Snapper’s on Albany Avenue last week for $2.50, some great crispy roast duck from the A Dong Supermarket on Shield Street, and later had the best jerk pork I’ve had outside of Jamaica at the Jerk Pit Café out north on Main Street just past where Windsor Street hooks back up with Main. Today, I ate the Bem Brasil Buffett on South Whitney for lunch where you pay $4.99 a pound for food. I had chicken simmered with potatoes, short ribs, rice with vegetables, and a fried stuffed green pepper. It was great. As soon as I’d finished, I wanted to go back for me, but by then we had been moved to area 16. I’m hoping later to get posted to area 10 where on the way there I can get a pizza empanada at Aqui Me Quedo on Park Street.

Oh, yeah, and I’m listening to the Red Sox on the radio right now. Unfortunately, they are down 4-1 early in the game and unless they get their act together in the next couple games, they are in jeopardy of missing the playoffs.

Heroics may be needed.

***

Postscript: The Sox lost the first game of their double-header 6-5. They rallied to win the nightcap 18-9, and they remain two games in the wildcard lead. I did another transfer, a crash with leg deformity, and a shooting to the arm. The MVA and the GSW were stable enough to get pain management (Fentanyl) from me. I didn’t get to Aqui Me Quedo, but did get a most excellent Jamaican chicken patty (chicken in a light pastry) for $1.80 at the Golden Crust Bakery at the corner of Woodland and Albany.

What I Carry

 A reader (Lucus) queried me about what I carry on my when I am on duty:

I have a stethoscope around my neck. In my right shirt pocket, I have four small blank index cards. In my left pocket I have a pen, a pack of gum, and my I-phone.

I have trauma shears on my right side leg pocket. In that pocket I have my sealed controlled substances kit (fentanyl, morphine, ativan and versed), an IV lock, an IV flush, a 5 cc syringe and a 1 cc syringe. In my right small pocket, I have a needle, two alcohol wipes, and a nasal atomizer. I have my narc keys in the left small pocket; in the regular pocket I have a pair of exam gloves. I usually put the patient’s paperwork (W-10s, etc, med lists) in the left leg side pocket when they are handed to me on scene.

Surprisingly(Perhaps), I do not wear a watch. I stopped wearing a watch years ago because I could not afford to keep replacing my watches as I was always misplacing them. How can I work without a watch? When I feel a pulse, I feel for speed. Slow, normal, fast. Regular or irregular. I get a ballpark estimate that once I put them on the monitor is usually confirmed. There is a clock on the monitor. I also have my i-phone as a backup. All of my truly sick patients end up on the monitor.

I wish I carried a pen light more regularly, but those are hard to keep in stock. In the ambulance I have a flashlight, and someone on scene usually has a penlight if I need one.

I used to carry an EMS field guide, but now I use my i-phone to look up anything I need to check.

I am in a fly car mostly these days, so sometimes when I intercept, there are no locks or flushes on the shelves of the transporting ambulance. I find it is easiest for me if I just pull one out of my pocket. The syringes, needle and atomizer are all so I can deliver quick pain relief (IN Fentanyl) or to stop a status seizure (IM Versed). I like to have my kit at the ready to use. I don't like fumbling with the keys to open the lock box or being surprised on a call and not having my kit handy. I use my controlled substances kit, mostly for the Fentanyl fairly often -- at least every other shift, and not infrequently, two times a shift.

On my belt I have my company issued pager and when I am in the fly car, I have a portable radio.

When I enter a house, I always carry my Thomas pack and monitor. If I am the first one arriving, I bring in my oxygen bottle. If I am working the ambulance and it is for a fall, I always bring in the board and collar bag just in case. If it is for a cardiac arrest, I try to remember to bring in the suction.

I am not saying mine is the perfect set up or the recommended set up (I am not going to tell you not to wear a watch), but, based on twenty-plus years or responding, it works for me.

Note: Once upon a time, I did carry a window-punch. I only used it once, and I had a good time using it, but now I leave that to the fire department or other responders, now that we have so many others responding with us these days.