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Dueling Coughs

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cough

“You sound worse than I do,” my patient said to me this morning.

“How about we draw straws to see who gets seen at the ED first,” I said.

My cough is actually improved from a week ago. My preceptee was treating a lady with chest pain who had a deep rattling cough. I was sitting in the captain’s chair and every time the lady coughed, I responded in an eerie EMS version of “Dueling Banjos.” I’d replicate her cough and then do a variation on it that she would try to match, but then I’d out cough her again.

I’m actually hoping I have turned the corner. A few days ago, after five weeks with the cough, I finally went to the doctor and was put on antibiotics and given some Tessalon Perles.

My room air SAT is back to 99% after a recent dip to 94-95% and not just 94-95% one time, but 94-95 % on our three pulse oximeters and on every oximeter at every hospital triage station I could test.

This cough is an annual winter passage for me, but it seems to be getting worse each year. It starts in my head, then descends to my chest and like a nasty tenant, is a bitch to evict. The weather this season hasn’t helped. I thought I was over it a week back when we had a rare balmy day, then the next day it was back to cold and wet and my cough was back with a vengeance.

After awhile the coughing wears you out, particularly when it wakes you up at night. I was hoping to keep my physical fitness up through the winter, but have given up now. I just need to rest this out – rest this out while still working, although I did take two sick days in the last two week period from my 70% desk job. I actually find I get the most rest at my paramedic job, because here at least if I am not doing a call, I can rest. The desk job has me on the go and home – with three girls 2 years, 9, and 14 with all their activities – there is no easy rest there.

Last night when the town was quiet, sitting alone in the back of the ambulance, watching my ETCO2 wave form roll across the screen, and trying to blow vapor rings with the nebulizer, I knew quite assuredly that I was not alone. I knew that in other ambulance stations and in ambulances on street corners in other towns and cities across this country and perhaps even the globe, other medics and EMTs were doing the same as I was, sucking in some Albuterol, getting the medicine down into our lungs so we could breathe a little easier, so we could, as Bob Dylan sang, “keep on keeping on.”

Ah, to see Spring.

***

Unfortunately, this had been an annual topic.

2008: Medicine For Paramedics

2007: Sick

2006: Hacking

Posted by on January 28, 2010 • Filed under: ems-topics • Tagged: ,

Bed Pan Brigade Recruit

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bed pan

Both Rescue 999 and Too Old To Work, Too Young To Die posted recently about what they considered essential ambulance equipment. Very thoughtful posts that sparked me to consider offering my own take on the subject (and I expect I will), but first I have been diverted due to a new post by CKEMTP of Life Under the Lights raising the spector of the dreaded bedpan.

Somewhere Around Here

I have to confess in my twenty-one years in EMS, I have only gotten the bed pan out less than a dozen times. I also admit there were occasions when the bed pan was not always in the first place in the ambulance I looked (this was at a time when I was in a different ambulance every shift — “I know it is in one of these cabinets. Somewhere.” I either didn’t know where it was or perhaps, I was stalling for time.

Now please don’t think I am heartless. I write this as someone who just a few moments ago assisted a very obese supine man with a urinal. Assisting a morbidly obese supine man with a urinal basically means I do all the work (scooping the end of his penis into the urinal) while he merely relaxes when I give him the all set equipment in position update.

I should mention this episode did not occur in the ambulance, but in the hospital ED where our patient was assigned to a crowded hallway. When I was able to corral a passing nurse, she needed my help pushing the stretcher into a temporarily vacant room where the patient could have some equally temporary privacy.

It was then that the question of his being able to use the urinal by himself or needing help came up. Since the nurse was a female, and it wasn’t her patient, and she had at least responded to my request only because she has a perpetual smile and is a good-hearted care-giver — unlike the other nurse who, perhaps a waiter in a previous job, walked straight past my wavying arms without making eye contact (No tip for you) — well, I ended up volunteering to put the gloves on.

We’re Almost There

This is not to say I haven’t pulled out my share of urinals in the ambulance. I will get a urinal or a bed pan if I must. However, my first response to a request for a urinal or a bed pan is “Can you hold it?” (Followed by “We’re almost there. Just a couple more blocks.”)

They usually can hold it. But not always. When they insist that they cannot, I get the urinal out. When I do get it out, I have found a great many men suffer from performance anxiety trying to stuff their male IDs into urinals while riding down the road despite the attendant’s elsewhere gaze. The only patients peeing is easy for are the drunks. Considering they grab the urinal as if it were another frosty beer, as well as the orgasms of relief they emit when they tap their bladders, I can understand why.

On the Move

But back to the bed pan. Here’s the problem with the bed pan. It’s hard enough pooping in a hospital bed, but when you are bouncing down the road, strapped onto a stretcher, and still wearing your pants or nylons or whatever, and you need to get them pulled down, it is a production, particuarly if you are 300 plus pounds, and overflowing the stretcher to begin with. And then there is the TP part. I have never mastered the skill of giving a good wipe on the move.

So I avoid bed pans if I can.

What I do not avoid, and I will brag here (which I shouldn’t because I am just doing my job) is if I am in a patient’s house and they are covered in shit, I do not wrap them up and toss them on the stretcher with an extra blanket on top to contain the order and leave the dirty work to the ED techs. Male or female, I wipe them clean, get them in the shower if I have to (condition permitting) get them in some nice clean, cotton pajamas or just the hospital johnny I carry on my stretcher.

Impression

A police officer came up to me one day and said, “You really impressed me on that call yesterday.” I said, “huh?” trying to recall a cardiac arrest where I sunk the tube as soon as I walked in the door, used a blow dart gun to catheterize the jugular vein and then caused the person to rise up and do a just resucitated happy to be alive jig where she had previously lain quite dead.

“I’m talking about you got right into it and wiped that old lady’s ass. That was some nasty shit. That was above and beyond.”

Not really.

The Job

I love intubating. I love recognizing a STEMI. I love giving people morphine to take their pain away. And while I may not like many of the components of it, I love helping a patient in their lowest moment feel as if they are blessed members of the human community, which they all are.

I love doing these things because I love being a paramedic.

Under the Bench

Props to CKEMTP for honoring the lowly bed pan. I just rechecked my rig. Under the bench seat, you can find a pink bed pan, a pink female urinal, and two male urinals. True the bed pan is a little dusty, but maybe I’m just having a dry spell on bed pan calls. I will try to be better about getting it out. Maybe one less, “We’re almost there.”

Writing this I realized that the arguement I often use to give a patient another dose of morphine in the parking lot is that time to the hospital doesn’t always equate to time to medical care in the hospital. Studies have shown hospitals can have a median time of 149 minutes to medication after triage. I wonder what the numbers are with regards to time to the hospital versus time to the bedpan in the hospital.

Posted by on January 26, 2010 • Filed under: ems-topics • Tagged: , ,

Arthur

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As my entry to this month’s The Handover blog carnival (publication date January 29), hosted by Gomerville, I am submitting the following entry for the topic “EMS Profile.”

I worked with Arthur as a regular partner for a couple of years in the late 1990′s, and then periodically worked overtime shifts with him for many years after that until he moved to Florida five years ago. I wrote about him quite a bit in my second book, Rescue 471: A Paramedic’s Stories. (Clicking on the proceeding link and you can read The “Arthur” section through Amazon’s “What’s Inside” technology.)

Rescue 471

It seems like the first thing anyone who has read the book asks me is “How is Arthur doing?” The answer is well. I saw him in March in Atlanta. He is still living in Florida, driving his Cammaro, and enjoying retirement at his nudist campground.

The entry below I wrote in October of 2005, commemorating our last shift together and his last shift with the company.

Farewell Tour

My old partner Arthur has finally gotten his transfer to Florida. He moved to this area from New York fifteen years ago when he first met the woman who would become his wife. Now that they have divorced, he says he has no reason to stay up here. He loves Florida and the sun – he is a nudist, and has always hoped to live out his golden years in the Sunshine state. He’s a few years short of Medicare eligibility, so his plan is to work for our company’s Florida division for a few years until he is eligible for insurance, then he can stop punching the clock and hauling stretchers.

We were regular partners for several years – and had many an adventure together — and have often found many occasions to work overtime together. Since he doesn’t have a regular partner in his current shift, I have been filling it in recent weeks.

He tells one of the triage nurses today he is going to Florida, and I crack that he’s finally gotten into the Golden Acres Manor. “A Bed, a roof over my head and three squares a day,” he says.

From the look on her face, for a moment the nurse seems to think he is serious – that maybe he really is ready for the Manor. My partner picks up on her reaction and disturbed, says, “I’m only kidding.”

***

We are sent to a nursing home to pick up a dialysis patient. They dispatch another unit to give us a lift assist. It’s a big patient. We get there first. “Let’s go in and do it,” I say. “We don’t need any help.”

I’ve picked this guy up before, but that was when I was working with a smaller partner. Arthur and I can handle it. In the old days we never needed a lift assist and we don’t need one now. We walk down the hall to the guy’s room. We look in. Arthur looks at me. “He’s as big as a house,” he says.

I’m looking at the patient now too. Damn, he looks bigger than I remember. He looks to be about 500 pounds. “Yeah, maybe we should wait,” I say.

“In our younger days we would have done him,” he says.

“No doubt,” I say.

“No sense in getting hurt.”

***

His last day arrives. I’m glad we are working together, but I admit I am depressed. These last two weeks have been sort of a farewell tour. People who see him and know he is going, give him hugs or handshakes and wish him well. He says he has no reason to stay, but he is an institution around here. Nearly everyone knows him — in the hospitals, the ambulance companies, police and fire. He has a large extended family here, even if it is only a family when he is at work.

“I’ll be losing a lot of great friends,” he says.

“We’ll all be here. You know you can come back anytime.”

“I hope I’m doing the right thing.”

“You’ll do fine.”

In a week he’ll be unhitching his trailer and setting it to stay at his campground. The monthly park fee is reasonable and clothes, of course, are optional. Even though he will be making four or five dollars less an hour, his expenses shouldn’t be too bad, he says.

I do worry about him. He is very set in his ways, and it may be hard at sixty-two to fit in with a different way. He will be the new kid at the ambulance company down there and have to be on best behavior.

Last night we were driving down a dark street. A car was parked to the side of the road and a man leaned into the window. He was hard to see, and while my partner didn’t come close to hitting him, he was a little startled, so he jammed on the air horn and swore at the man. As we continued down the street, I prayed a bullet wouldn’t zip through the ambulance and go through my back, then out my chest, leaving me a few moments to realize I had been shot and was about to die because my partner had finally pissed off the wrong pedestrian. But the bullet did not come.

***

Today there is a young EMT at one of the hospitals — a cute girl maybe 21, who has heard about Arthur and me, but has never met us. When she hears Arthur has been working in the city fifteen years, she tells him she was in kindergarten when he started.

Later outside in the ambulance, one of Arthur’s first partners sees him and comes over. He is a cop now — ten years on the force and now a detective. They commiserate about ex-wives, and then the cop says he has remarried, has two kids, owns his home outright along with both his cars, and is looking forward to retiring with a big pension in ten years when he is 47.

Waiting in triage, Arthur and I were fooling around with the automatic blood pressure cuffs. My reading was 114/74. Arthur’s was 177/98. He was bothered by that. Later back at the same hospital, we take our pressures again. I am 112/70. He is down to 138/92. I can see the relief in his face.

***

After work tonight, he brings all his uniforms in to operations and hands them to the guy who checks the run forms to see if we have filled out the billing properly and gotten all the necessary signatures. That guy was on the road for years himself, until he hurt his hip too badly to work. They shake hands and wish each other well. Arthur also hands in his vehicle fob and ID. There is no supervisor there to say goodbye. We shake hands and I wish him well, and we say what a great time it has been, and what a good man you are. We hold the handshake longer than normal. Then he punches out and leaves.

***

Every morning we worked together, Arthur would insist on checking the oil, then grumble about how many quarts the car was down.

“Guess what?” he said on the last morning. “It’s my last day. I’m not checking the fucking oil.”

***

Here are some other old posts about Arthur.

Old Partners

Modern Medicine

The Stretcher

Posted by on January 22, 2010 • Filed under: ems-topics

AHA Guidelines 2010 — Coming Oct.

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16580-inter-logo[1]

When I was a kid, I couldn’t wait for the Street and Smith’s Annual Baseball issue to hit the newsstand so I could check out how their experts thought the Red Sox would be in that coming spring — what was the projected lineup? Who were the hot rookies? Who would win the pennant?

Now I wait every five years for the American Heart Association’s ECC Guidelines. What kind of CPR will we be doing? Any changes in ALS drugs? What about airway — delayed or immediate intubation? Any new interventions or devices?

I particularly look forward to the AHA ECC science book which goes into detail about all their recommendations in far more depth than the student handbook for the ACLS class. This material is what I believe will be published on-line in October, and later made available in print.

Here is the 2005 version:

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The time for the 2010 edition is rapidly approaching,

Check out the video below from the EMS1 network, which says the guidelines will be out on October of this year.


ParamedicTV is powered by EMS1.com

After watching, you can go to this web site, International Liaison Committee on Resuscitation (ILCOR)
and read some of the 100s of worksheets which give some hint of the areas they are looking at, including the following:

In patients with suspected ACS and normal oxygen saturations, does the use of supplemental oxygen, compared with room air, improve outcomes?

In adult cardiac arrest, does the use of a supraglottic airway device vs an endotracheal tube, improve any outcomes.”

In adult cardiac arrest, does the use of the Autopulse compared with manual CPR, improve any outcomes?

In adult patients in monomorphic (wide complex) tachycardia, does the use of any drug or combination of drugs compared with not using drugs (or a standard drug regimen), improve outcomes?

“In adult patients with ROSC after cardiac arrest who have cardiovascular dysfunction, does the use of any specific cardio-active drugs or other intervention as opposed to standard care (or different cardio active drugs), improve outcome?”

In adult and pediatric patients in cardiac arrest, does the use of passive oxygen delivery during CPR compared with oxygen delivery by positive pressure ventilation improve outcome?

“In adult patients suffering from a cardiac arrest does calling of EMS and starting chest compressions (without ventilation) by trained laypersons or professionals compared with calling EMS and starting chest compressions plus rescue breathing improve survival to hospital discharge?”

In victims with suspected cervical spinal injury does spinal immobilization benefit the patient over doing nothing in outcome?

These worksheets will serve as the basis for discussion for a panel of experts who will decide on final recommendations that will eventually make their way the street.

Stay tuned…

Posted by on January 18, 2010 • Filed under: ems-topics • Tagged: , ,

Where Am I?

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sleepI set my alarm each night for 5:00 A.M. Some mornings I can anticipate the alarm, and so I shut it off a minute or so early. Shower, shave, dress, look in on my sleeping daughter, and hit the road. I’m in at work by 5:45. I’m not due until 6:00, but I hate being late, and I don’t like to jam up the night medic with a late call any more than I like being jammed up with a late call at the back end of my shift.

At work, after checking my gear and the ambulance, I usually head down to the bunk room to catch a little more sleep (We’re allowed to sleep until 8:00 A.M.). On a quiet morning I awake when my body is ready to wake rather than being jarred awake by the tones going off. It’s a great feeling to wake slowly and wonder where I am and slowly open my eyes and realize my surroundings. “Hey, I’m already at work. How great is this!” Two hours down, ten to go.

This morning I had that same feeling — the slow waking, wondering where I was, opening my eyes, looking around…

I was still at home. I swung my head violently to look at the clock.

5:45

Oh S—-!

I hate being late.

Posted by on January 17, 2010 • Filed under: ems-topics

Death By Detergent

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toxic

The call comes in for a body in a car. No lights and sirens.

The address is at the end of a long dead end road. We go as far as the ambulance will take us, then get out behind the two police cars, and trudge though the snow. A hundred yards ahead, we can see the officer standing by the snow-covered car, but then he turns and waves his arms to get our attention. “Stay there!” he shouts.

He says something to the second officer who has just reached the car, and then the second cops starts walking back towards us.

“Been dead awhile,” the officer says. “There are placards in the windows saying there are hazardous chemicals inside. (The other officer) got of whiff of ammonia. We’re going to call a HazMat team in. It looks like its one of those internet death by chemical cases. We just had training on it. Someone wants to off themselves, they mix some chemicals in a bowl. It makes hydrogen sulfide and poof they’re dead. They put placards in the windows to alert rescuers.”

I have never heard of this, but my partner says he has. We get in the ambulance and back down the road aways to the turnabout, and stage there.

More cops and firefighters arrive. And the official call goes out for the full Haz Mat team. After an hour we are relieved by a commercial ambulance so we can go back to covering the town.

It is many hours until the scene and body are decontaminated enough for the medic to run his strip and call the time.

Here’s some information on this increasingly common type of suicide in case you find yourself outside a car with a body inside and placards in the windows.

Ada County Sherriff;s Office Emergency Responder Safety Bulletin

Suicide Fits Disturbing Trend

Dangerous “Detergent Suicide” Technique Creeps into the United States

Suicide2

Posted by on January 14, 2010 • Filed under: ems-topics, hazmat • Tagged: , ,

ACLS Drugs: The Verdict

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New Picture (7)

Do ACLS medications make any difference in cardiac arrest?

The American Heart Association rates drugs and interventions according to the following scheme:

Class I
Benefit>>>Risk.
Procedure/treatment or diagnostic test/assessment should be performed/administered.

Class IIa
Benefit>>Risk.
It is reasonable to perform procedure/administer treatment or perform diagnostic test/ assessment.

Class IIb
Benefit >Risk.
Procedure/treatment or diagnostic test/assessment may be considered

Class III
Risk> Benefit.
Procedure/treatment or diagnostic test/assessment should not be performed/administered. It is not helpful and may be harmful.

Class Indeterminate
• Research just getting started• Continuing area of research• No recommendations until further research (e.g. cannot recommend for or against).

According to the 2005 AHA Guidelines for managing cardiac arrest:

Magnesium is IIa for Torsades.

Epinephrine and Amiodarone are class IIb.

Vasopressin, Atropine and Lidocaine are class Indeterminate.

In other words, according to the AHA, we have no idea if vasopressin, atropine and Lidocaine work, epi and amiodarone might work, and magnesium likely works. Not the best endorsement.

New Study

Now a new study has come out that makes the best attempt yet to answer this crucial question of whether or not ACLS cardiac arrest drugs work, as well as another question: “If the drugs aren’t doing any good, is it the drugs’ fault or perhaps the fault of poor CPR?”

Here’s the study:

Intravenous Drug Administration During Out-of-Hospital Cardiac Arrest: A Randomized Trial

It appeared is the November 25, 2009 issue of the Journal of the American Medical Association.

This was a prospective, randomized trial that took place in Oslo, Norway between May 1, 2003 and April 28, 2008. It involved patients 18 and over who suffered out-of-hospital nontraumatic cardiac arrest.

When medics arrived on scene and they opened a sealed envelope that instructed them to either start IV access and proceed with ACLS drugs or do ACLS without drugs and IV access. If ROSC (return of spontaneous circulation) occurred in the non-IV group, they were instructed to wait five minutes before starting an IV and proceeding with post-arrest care.

Medics did 3 minutes of CPR before shocking v-fib and 3 minutes between unsuccessful shocks per European guidelines.

Endotracheal intubation was the prefered airway method.

851 Patients

418 patients received IV meds, 433 did not. The primary outcome was survival to hospital discharge, while secondary outcomes such as hospital admission were also studied.

Patients were excluded if they arrested in the presence of EMS crews.

Personnel carried LifePak 12s capable of recording the quality and quantity of CPR.

Both groups had “adequate CPR” with compression and ventilation rates within the AHA guidelines. All resuscitated patient received therapeutic hypothermia.

Survival to Hospital Discharge

In the IV group 10.5% survived to hospital discharge versus 9.2% in the non-IV group.

Survival with favorable neurologic outcome was 9.8% versus 8.1% in favor of the IV patients.

ROSC was 40% in the IV group, 25% in the non-IV group.

43% IV group to 29% non-IV group in hospital admission

In patients with VT/VF as the presenting rhythm there was no difference between the groups.

In nonVF/VT, ROSC was 3 times higher in the IV group, but there was no difference in the survival rate because patients without the IV did 3 times better in the ICU than those who received the IV and ACLS drugs.

Other Results

Patients with VF/VT had 10 fold likelihood of survival.

Patients with witnessed arrest had a two fold increase in survival.

Long-terms survival odds decreased by 17% for every minute without CPR

While the IV group did slightly better than the non-IV group, statistically, it was deemed insignificant due to the sample size. The trial would have had to have included 1400 for such a difference to be considered significant.

Bottom line

ACLS drugs make no difference in long-term survival.

IV meds do not delay or affect the quality of CPR.

Patients in VFib/VT may do better without ACLS drugs.

While ACLS drugs can help return circulation to patients in PEA and asystole, they may ultimately be toxic to these patients.

Thought for the Future

Either cardiac arrests patients outside of VF/VT are gennerally not saveable or we need better ACLS drugs.

Personal Comment:

This study squares with my observations. I have gotten ROSC many times in nonVF/VT patients, and that ROSC almost always comes shortly after I have given them IV epi. (Thus the phrase “That’s the epi talking.” )

Many times (in the old days) when I started working a patient in the house and gave epi down the tube, I would get nothing, but then once removed to the ambulance for transport (as everyone was transported then), I would get a peripheral IV, and give epi and suddenly have ROSC.

Earlier this week I had my first cardiac arrest of the new year, 80-year old man collapses in front of his wife. First responders start CPR. Patient is apneic with no pulse on my arrival. But the monitor shows a sinus brady at 40. I intubate the patient with an initial ETCO2 of 20. With IV epi, the ETCO2 almost immediately goes up to 70 — an indication of ROSC. It then stabilizes in the 35-40 range. We get a bounding pulse with a BP of 110/60. We start the hypothermia protocol. 10 minutes later, I see the ETCO2 start to steadily drop — all the way down to 20. BP is 58/30. Start the dopamine, right away the ETCO2 goes back to 40.* Bounding pulses again. We arrive at the ED with a BP of 120/70. I’m feeling that this could be a save.

An hour later, they are doing CPR on the patient again. When I check back, they tell me he is up in the ICU. He is septic and they have been having a hard time maintaining his BP, giving him 5 liters of saline and using multiple pressors.

Two days later he is in the obits.

Another one bites the dust.

With the exception of patients suspected to be victims of respiratory arrest, all my asystole/PEA ROSC patients have died in the ED or ICU.

The few true cardiac arrest survivors (nonrespiratory induced) I have had in my career have almost all been patients in their 50s and 60s who collapsed in a public place and recieved early CPR, and who (finding them to be in VFIB) I shocked on arrival.

* For an explanation of ETC02 in cardiac arrest see:

10 Things Every Paramedic Should Know About Capnography

New Picture

Posted by on January 11, 2010 • Filed under: ems-topics • Tagged: , , , ,

Glimpse of the End

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house

Let me say right from the outset that I love being a paramedic and dread that day that I can no longer do this work. That said I have had two moments in my career where I have glimpsed that day.

These moments are not moments that you would expect. It was not a bloody, gory call or a tragic death of a child or even the more typical getting splattered with poop and vomit.

Approaching Sirens

The first moment was actually many years ago. I had probably been a medic five or six years. We were called for a multi-car motor vehicle involving a semi-truck. I was the first responding ambulance, but two others were within siren range. I stepped out and got the quick run down from a first responder. There were four patients. The sixty-year-old driver of the truck who had a head laceration and no recollection of the crash, although now he was fully alert and oriented, a thirty-year-old hysterical woman in a car that was pinned between the semi-truck and the bridge abutment who had neck, back and leg pain, and two men in their forties in the pickup that had rolled over, one had neck pain and the other had an obvious broken shoulder. The first responder said a fellow firefighter had crawled under the semi truck and been able to access the woman by entering through the hatchback of her car.

As I listened to the sirens of the other ambulances get closer, I thought how when I was first a medic I would have quickly scooted underneath the semi-truck and gotten into the back of the pinned car to assess the patient for myself. But now the thought of stooping down low and maneuvering myself into position just didn’t seem like something I wanted to do. i thought about the choise between crawling on my hands and knees or staying on my feet and scrapping my back on the underside of the truck. Niether choice appealed to me.

To the first medic I said, “Your patient is pinned in the car. You can get to her by going under the truck.” To the second medic, I said, “You have the truck driver.” And I took the two patients from the rolled-over pickup.

My triage wasn’t inappropriate. You might argue that the first medic on the scene should be the last off, therefore I should have stayed with the one who needed the extrication. But that’s really neither here nor there. I took two patients, one who I gave ALS care. Everyone was treated. No one complained. The crew that got the trapped lady was thrilled by the call and got to tell their extrication tale many times over that day.

The point was I stood there and thought I really don’t want to have to go under that truck unless I have to. Maybe it’s because I am six-foot-eight (I was likely six-foot-nine then as this job has knocked me down at least an inch over the years). Or maybe it was because I was on that line between not being nimble enough and not being excited enough to call on my nimble reserves and so I punted to the other crew.

I thought that day – I may not do this job forever.

This Morning

The second occasion was this morning. After checking my gear, I got in the bed in the bunk room and took a little nap. I’ve had my annual bad winter cold, aggravated by the dry cold air of late and have been hacking up a storm, enough to disrupt my sleep at night as the phlegm rolls down my throat and sets off a violent coughing attack. I managed an hour or so of sleep when the tones went off – man with abdominal pain.

We pulled up to the house and I got out. It iwas really cold. The thermometer on my car said 6 degrees as I drove in this morning. I would guess it was still not much more than ten, which is cold for these parts, and colder still because it has been so dam cold every day for the last several weeks that it makes me wonder if it will ever be warm again.

A Small House

I looked to the house and saw a handicapped ramp and then saw a very large man walk out of the front door, and motion to us. It wasn’t the motioning of a frantic man, just a motion to say this is the house that called not the neighbor’s. But the size of the man – I pegged him at 400 pounds — made me think for some reason that an even larger man lay within the house, and on this cold morning, we were going to find a very large patient in a very small house and we would face difficulty.

I have been in the houses on this block many times before and the rooms are small and the halls are narrow and in most cases, you can’t get your stretcher into the bedrooms. And taking this all in, all of a sudden I just knew I did not want to be there. I didn’t want to be there in deep-rooted way. As I walked up the driveway, I thought is this really what I want to be doing with my life? Is this what I will be doing for the rest of my working life?

I was right about the patient being large. The two first responders stood inside the door and said the patient was stable, but he was big. How big? They did not know. They pulled back the covers and saw only enough to confirm the patient was large. They chose not to uncover much more. They had the basic truth of the patient’s size and that was enough for them. They said they were glad we had a three person all-male crew. They were waiting there by the door in case we needed their help, but they were hoping we would not need them.

This Time

The hallway and bedrooms were as narrow as I had guessed. The stretcher clearly would have to stay in the living room, but this time the call itself went fine.

The patient had a Hoyer lift and the family was more than willing enough to operate it for us. They lifted the patient up, wheeled him out of the bedroom, down the hall and into the living room and set him down on the stretcher easy as pie. We then raised the stretcher up by pushing the (+) button at the foot of our power stretcher and not a muscle was strained.

The Thought

Still, it was that thought on this cold morning staring at the house that made me take notice –that thought that inside could be the end of my trail –that something small but telling might happen, and that something will happen someday. And when it does, I will say – that’s it. I’ve had enough. It’s time to do something else. And I will finally walk away.

Hopefully that day is still far off.

Posted by on January 10, 2010 • Filed under: ems-topics • Tagged:

Paramedicine 1995-1997

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In my previous post 2009 A Year of Paramedicine I gave a breakdown of the medicine I gave over the course of 12 months.

Below are my medicine stats from my first three years as a full-time medic in the 1990′s, working in a one medic per ambulance urban system with some responses to suburban towns. (Also at that time, there were fewer medic ambulances than there are today). The numbers includes only calls where I was the primary medic and wrote a run form. Does not include calls where I backed up another medic on cardiac arrests or respiratory distress. Each number represents a unique patient. A patient receiving 3 doses of NTG counts as 1 NTG. Does not include ALS transfers. ALS calls were any call that I either put the patient on a monitor and/or put in an IV and or gave medicine, and of course, saved the run form.

I had been meaning to get rid of these old run forms for years, but quite enjoyed going through them and revisiting old calls. My memory of the old days and the actual facts of them were interesting. I recalled having more intubations and having done more traumatic arrests than I actually did. I thought I had given narcan far more than I did.

When asked by newer medics to talk about the city “back in the day,” my tales would always begin: “There I was in bullet proof vest, largynescope in one hand, narcan syringe in the other, two bags of fluid ready to run wide open, hanging from my teeth…” (For the record, I have never worn a bullet-proof vest).

My memory of more traumatic arrests (besides the exaggeration of years) was likely more a case of the number of times I would have jumped in the back of another medic’s ambulance to do CPR on the fly than actual calls I was directly dispatched to as the primary medic, as well as the number of calls where the patient did not arrest until the hospital or was simply presumed at the scene (after the PD let us through the yellow tape).

Some of the drugs I have given are remarkably consistent between the decades such as ASA and NTG. Even the number of cardiac arrests is fairly constant. The biggest discrepancies are where the medicine has changed. Compare my use of Lasix between the 1990’s and the present day. I gave it 21 times in 1996, 0 last year. I cringe on reading my clinical impressions on calls where I gave Lasix, ?CHF/?pneumonia, ?CHF/?sepsis. It was still before our protocols contained the caution:

CHF vs. Pneumonia: If the clinical impression is unclear and transport time is not prolonged, consider using
Nitroglycerin and withholding Lasix or Bumex or contact medical control.

Even my narcan usage seems excessive in light of today’s protocols, which call for its use only in patients with hypoventilation/ depressed respirations related to likely opiate overdose.

The most shocking to me is how little I used morphine. At the time it required on-line medical control. When I did use it, it was more likely for CHF than for trauma. And when I did use it for trauma, I never gave more than 2 mg. Ouch! I read through all these old run forms documenting trauma and I did nothing for them. Worse, most of the fractures I likely encountered I BLSed, thus no run form was saved. In my first three years doing a much higher volume of calls than I do today, I gave morphine for trauma twice. Last year alone, I gave morphine 37 times.

Other observations:

1. As a new medic most of my intubations were on dead people. (We have never had RSI). A few years ago and before we had CPAP, half my intubations were on living people. Last year, I only intubated 1 living patient. I think that was a bit of an abberation.
2. For all I sweated learning about lidocaine and dopamine in medic school, I really didn’t use them very much.
3. The popular image of medics putting paddles on the chest and shocking isn’t much of a reality, although, I did use the gel and paddles in those days when I could, even though we had the option of hands off patches.
4. There was nothing I could give to all the patients I had in rapid afib. Today I can give them Cardizem or Metoprolol.
5. The higher rates of breathing treatments would have been a function of the high rates of asthma in the city, as the higher rate of D50 today is a function of an extremely high obese diabetic problem among the elderly population in our town.
6. I don’t see as much serious trauma in the town I work in as when I was in the city full-time.
7. I wish I knew how many BLS calls I did in the 90’s. Even though medics were reserved for the “better” calls, I am sure I still BLSed a higher portion of my calls then than I do today.
8. My traumas from the 1990′s almost all have IVs wide open despite normotensive blood pressures.
9. All Cardiac Arrests that were worked then were transported, whereas today we have the ability to work and then presume on scene if the rescusitation is unsuccessful.

***

1997

376 ALS Calls

12 Cardiac Arrests (10 Medical, 2 Trauma)
14 Intubations (1 Nasal)
2 Defibrillations
1 ROSC
?0 Survival to Hospital Discharge

NTG – 38
ASA – 37
Ventolin – 37
Atropine – 18
Lasix – 17
Epi 1:10,000 – 12
Dextrose – 11
Narcan – 10
Benadryl – 4
Adenosine – 4
Epi 1:1000 – 3
Glucagon – 3
Lidocaine – 2
Morphine – 2 (1 for chest pain, 1 for ankle fracture)
Valium – 1

1996

512 ALS calls

12 Cardiac Arrests (11 Medical, 1 Trauma)
11 Intubations
1 Defibrillation
1 ROSC
0 Survival to Hospital Discharge

NTG-45
Aspirin-44
Ventolin – 42
D50-21
Lasix-21
Atropine – 12
Epi – 1:10,000 – 10
Benadryl- 6
Adenosine-5
Morphine-4 (3X for CHF, 1X for burns, gave 2 mg with permission of med control)
Narcan-4
Epi 1:1000 – 2
Valium-2
Lidocaine-1
Glucagon-1

1995

361 ALS calls

9 Cardiac Arrests (8-Medical, 1 Trauma)
7 Intubations
2 Defibrillations
2 ROSC
1 Survival to Hospital Discharge

Ventolin – 36
ASA – 32
NTG – 27
Lasix – 11
Benadryl – 10
D50- 8
Atropine – 9
Epi 1:10,000 – 8
Epi 1:1000 – 7
Narcan – 5
Adenosine – 4
Lidocaine – 2
Valium – 1
Glucagon – 1
Dopamine – 1
Morphine – 0

Other drugs we carried for all or part of these years: Bretilyium, Procainimide, Pitocin, Sodium Bicarb, Calcium, Isuprel, Thiamine, Dramamine, Allupent, Verapamil

Results are limited by run forms saved.

Posted by on January 7, 2010 • Filed under: ems-topics

2009: A Year of Paramedicine

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Our service went to electronic run forms late in 2008. I was able to go through the data bank for the full year 2009 and select out my calls to get some quantitative idea of what I do as a paramedic in a one year period. I am sure there are more sophisticated ways to data mine, here is what I did. Ran total number of calls. Ran calls where IV was listed as intervention, which I than called ALS calls. Ran total number of calls where medication was given. I then reviewed each medication call and tallied the meds I gave. The results below represent meds per unique patient. I may have given a patient three squirts of Nitro, but I tallied it as 1. As tallied below I gave Nitro to 27 different patients. I did not count oxygen or saline as drugs.

Every medic’s experience is going to be different based on the type of service they operate in, their medical control, the hours they work and the population served.

I work in a one-medic system in a urban/suburban town (bordering the city) 26 square miles with a resident population of 20,000 according to the 2000 census. 54% African-American, 40% white, 6% other. 1 out of five people are over 65. (A few years ago when we were only inputting demographic and dispatch time information into a computer, I ran a query that showed the average age of our patients was 69). There are five convalescent homes, several retirement communities, many doctor’s offices, and good amount of industry, ranging from insurance companies to a helicopter plant. The population is a mix of lower middle class and middle class, although there are a few upper middle class and wealthy neighborhoods. I worked 40 hours a week Sunday 6-18, Monday 6-18, Tuesday, 6-22 (sometimes Saturday 6-22 instead of Tuesday). Week days are much busier than weekends. I worked no overtime. No transfers (although many of the calls I did we call “emergi-fers” calls from nursing homes going to the ED for non-life-threatening reasons where 911 was called) .

466 Calls
312 ALS Calls
9 “workable” cardiac arrests (all medical)
3 ROSC
0 Survivors to Hospital Discharge
8 intubations
2 LMAs
2 Defibrillations

Drugs
Zofran – 41
Morphine – 37
ASA – 36
NTG – 27
D50 – 19
Duoneb – 11
Albuterol – 10
Atropine – 11
Epi 1: 10,000 – 9
Solumedrol – 7
Benadryl – 4
Ativan – 3
Cardizem – 3
Adenosine – 2
Amiodarone – 2
Epi 1:1000 – 1
Narcan – 1
Torodol – 1
Sodium Bicarb – 1
Dopamine – 1

Did not use: Calcium, Magnesium, Metoprolol, Tetracaine, Haldol, Versed, Vasopressin, Lidocaine, Lasix

Some drugs are very situation dependent. We can’t give amiodarone unless we have a patient with V-fib or VT. Others are more a matter of choice. Morphine for instance. (I hope to soon sort out the morphine calls and breakdown what I gave the drug for such as hip fractures, abdominal pain, etc.).

I have at home copies of paper run forms from my first three years (1995, 1996, 1997) as a full-time medic (although working mostly in the city with some suburban response). I am going through them now, and will soon post the comparison results, which so far are very telling in how paramedicine and my practice has changed over the years.

Posted by on January 4, 2010 • Filed under: ems-topics • Tagged: ,