Holidays

He's messed up on something, messed up badly. Christmas Eve morning and he's broken into a swanky condo building downtown and started trashing the place. The police were called by the neighbors, and soon after their arrival asked for medical to respond, lights and sirens.

* * * *

My partner and I are standing in the elevator, all burnished steel and soft lighting, with four firemen and a cop, who's come down to lead us up to the patient. We've got a monitor and airway kit and medical kit, probably fifty pounds of gear.

The elevator doors open. Shattered glass covers the floor, a giant wall display of art pulled down and shattered. We gingerly step over it. The cop explains, apologetically, that he's all the way around the back and there's only one elevator bank.

We walk down twists and turns to the back side of the complex. We turn a corner, and here a fire extinguisher lies on the floor, ripped off the wall. Another corner, and a single shoe sits in the middle of the hallway. A quick zig-zag turn and a shattered 2x6 sits next to another fire extinguisher. We turn down the penultimate hallway, and for a second I think there is a fine filligree of string across the floor, with small black boxes scattered here and there.

Then I realize the boxes are spent Taser cartridges, and the string is the spaghetti tangle of probe wires. There must be four or five spent cartridges along the hallway. Bad news.

The patient is a little further on, handcuffed and hobbled, bloody, spitting, cussing, but not actually fighting. The police tell us he was on a violent rampage, that he made no sense, was chewing on glass, took threats and force and multiple taserings to subdue.

Faced with this, my partner -- for it's her call -- takes no chances, and we give him the full work-up. Backboard, restraints, oxygen, IV, 12 lead, the works. His mouth is swollen from the glass, and he responds poorly. He hasn't fought us at all. His blood pressure and heart rate are high. I press her to run him in code 3, lights and sirens, as something is saying "not right!" at the back of my head. She agrees, and halfway to the hospital we both realize that he's too subdued, he's too obtunded, something has changed.

* * * *

We pull into the hospital, and as we take the stretcher out I'm thinking about the cleanup we'll have to do, the low county levels, the chance that we'll get off on time, so that I can get my stuff together and load up the car and head south for Christmas with the family. And what the hell is going on with our patient. I ask my partner as I punch in the door code. Nothing has changed.

We slide him into one of the trauma bays, and as the staff gathers I catch a glimpse out of the corner of my eye, and there she is, standing back quietly, black fleece over blue scrubs. My heart lifts, a bit. We haven't made it here yet tonight, and I didn't know if I'd get to see her. It's a little spot of light in a generally grumpy morning (sometime around five am).

Maybe, I think, maybe I'll even find an excuse, a chance, to talk to her. I wonder if she has noticed me. How could she not have?

We move the patient to the bed, and I slide the stretcher out of the room, then scoot back in. I listen, and try not to interject too much, as my partner gives report. The doctor comes in, looks the patient over, and decides he needs to be evaluated by the trauma team.

"Okay, folks," the MD says tersely, "this is now a Level 2. Clothes come off, now."

I see her go for one pants leg, pulling trauma shears out of her scrubs pocket, and I pop the trauma shears off my leg, going for the other pants leg.

The patient groans unintelligibly, splattering the doc's faceshield with specks of blood. On one side, a nurse is drawing labs from a hastily-inserted second line; spots of red drip onto the floor from where he didn't occlude the vein quite enough. The speaker overhead is blaring, "Trauma activation, level 2, in department now. Trauma activation..."

She looks up as we both start cutting the man's jeans. Soft brown hair frames startlingly blue eyes. She smiles, shyly, with just a hint of a twinkle in her eyes. Oh, they seem to say, I didn't expect to see you here.

I smile back, and lean in to say something, just to her, under the growing bustle in the room.

"Merry Christmas, baby."

Wisdom

"First Rule Of Streets: In any given city, there will be a Main Street and a Martin Luther King Boulevard.

"And, even though Martin Luther King preached peace and acceptance, in any given city, if you are on Martin Luther King Boulevard, you are in a violent part of town."

Manifesto

I just read the final version of the National EMS Scope of Practice Model, a document intended to provide a unified guideline for the scope of prehospital providers in the coming years. While I like the idea of cleaning up the fragmentary levels of training and scopes of practice across the nation, I cannot help but be frustrated when I read this document. It doesn't really change anything, it makes the system as confusing as ever, and it doesn't really work to bring the profession forward.

Therefore, I'd like to present my own scope of practice model -- okay, more of a manifesto -- for where EMS should be in 10 years.

Providers

Emergency Medical Technician - Essentially unchanged from the scope they retain today, the EMT should be able to provide life-saving care for critical patients until more advanced providers arrive, and transport patients who do not require advanced care.

Specific EMT skills: OPA/NPA, BVM, King Airway/Combitube, AED, oxygen, spinal immobilization, ASA for chest pain, SQ epi for anaphylaxis.


[ EMT-Rural - An optional intermediate life support module only for rural areas where there is no availability of paramedics. Adds basic 4-lead ECG monitoring, peripheral IV access, fluid administration, first-line code drugs (epi, atropine, amio, lido), and a few other basic medications (albuterol/atrovent nebs, NTG for chest pain, pain medication if transporting provider). ]


Paramedic - An improved version of the current paramedic standard, with a two-year schooling program and increased clinical/internship time. An Associate's degree and state licensure (NOT certification) are mandatory.

Specific Paramedic Skills: Endotracheal intubation, Rapid Sequence Intubation (with paralytics), surgical cricothyrotomy, nasogatric tubes, adult and pediatric IV and IO access, 12-lead ECG monitoring, interpretation, and transmission, cardioversion and pacing, IV fluid, expander, and blood administration, needle chest decompression, CPAP/BiPAP, and administration of a wide variety of medications with few, if any, mandatory OLMC consults.


Prehospital Physician Assistant - The PPA is an experienced paramedic who has gone to a fully-accredited PA school. They are deployed in small numbers throughout the system to address two populations of patients: first, the patients that require simple procedures or care which can be accomplished in the field and eliminate their need for transport; and secondly, the patients who require more advanced critical care interventions which are out of the paramedic scope of practice.

Specific PPA Skills - Critical care: Additional advanced airway options (retrograde intubation, LMA/ILMA, fiberoptic intubation), chest tubes, certain central lines (IJ/femoral), advanced medications (additional pressors, beta-blockers, mannitol, and others), Foley catheterization, pericardiocentesis, and more. Primary care: Wound cleaning and suturing, Foley/G-tube replacement, trach tube replacement, point-of-care lab testing, evaluation/referral option for non-emergent patients.


System Model

Prehospital emergency care in the urban area should consist of a tiered system of BLS, ALS, and advanced providers. A system should deploy a mix of EMT and paramedic ambulances, with a small number of single-PPA "fly cars" in the system.

Calls should be triaged according to an evidence-based model; for most calls both an EMT and paramedic ambulance should be dispatched. 4 providers onscene is an optimal number for managing both patients, and except in the simplest cases there will always be a paramedic evaluation of the patient. Patients will be transported by the appropriate ambulance, and if the patient is critical the EMT crew will assist the paramedic crew with transport (allowing both paramedics and one EMT to function smoothly in the back of the ambulance). On certain critical calls (cardiac arrests) a PPA unit will be dispatched as well, but in most cases they will be requested by providers onscene for either critical or simple patients. In the event of a critical patient the PPA will assume patient care and work with the paramedics during transport; on a simple patient the PPA will be able to free the ambulance and remain onscene to resolve the issue.

Fire department personnel will retain CPR/AED or First Responder certification, and will respond on traffic accidents, EMS requests for lift assists, and cardiac arrests, and other specific calls as needed. EMS systems will be encouraged to develop in-house tactical, extrication, and technical rescue teams.

Medical directors will provide primarily offline protocols with a high amount of ongoing education, case review, and training, particularly in high-risk/low-frequency skills. Wireless communications technology will be in place to allow providers fast access to physician consults if needed, with easy transmission of monitoring data.



That's my pipe dream...

Responsibility

Things change, as they always do. With my promotion to senior medic comes (along with other things) my own shift, my own car -- and a junior partner.

You never know who you will get, and it's the topic of discussion among the senior medics when the junior spot on your car is open.

"You'll get someone who's brand-new."

"They won't even know their way around."

"You'll have to babysit them, all night."

"I had a junior once, new guy, and you won't believe what he did..."

So with all this in my head, it was with no small trepidation that I waited to hear who my permanent partner would be. It could be someone experienced, I told myself. There are a few people who might want on my shift ... my night shift ...

Crap.

And then the phone call, giving me the heads up and a name I didn't recogize. "Did she come from B shift?"

"Nope," said the voice on the other end of the phone. "She's brand new."

Perfect.

* * * *

So she came on the car. Young but sharp was my first impression, with a good attitude and a willingness to learn. But short on experience, she freely admitted, short on codes and tubes and all that fun. A white cloud, a medic who doesn't ever seem to get the critical calls.

Great. Just like me. We'll never have anything.

In the first week we had a truly critical call every single day.

And by the end of the week, I knew she was, indeed, solid; already a good medic despite her lack of experience, and with the potential to be a great medic.

* * * *

Of course, that's not all the responsibility I have to bear now. There's the narcotics, and making sure everything is in order, and doing little bits of paperwork for this and that.

And I guess there is one other thing.

* * * *

"Etomidate is in!" the fire medic announces, and swaps syringes. "Sux going in."

I look down at the patient. Sick, bad sick. Head injured. Unconscious. Jaw clenched. He needs an airway, needs PVC down his windpipe, and there's only one way to do that.

When you can't be trusted to breathe for yourself any more, we take over.

The drugs take hold, and he stops breathing.

"Okay," I say, softly, to myself, twisting my cap backwards and out of the way, clicking the laryngoscope open with a soft snick, taking a deep breath.

"Here we go."

Snippets

"... all units, stand by for dispatch."

* * *

"Man, I don't, I mean, you don't, I mean, I don't have to have this collar on my neck and be on this board!"

"Well, sir, I respect your feelings, but seeing as how I'm the paramedic and you're drunk, I'm going to go with my first instinct."

* * *

"... Trauma communications, got an entry for you, bicyclist crashed, no helmet, confirmed loss of consciousness ..."

* * *

"... Big poke in your arm here, sir. "

* * *

"Well, yeah, it hurts worse when I take a deep breath, and when I cough -- see, I've had this cold for a few days..."

* * *

"Medic 38, in service ... Ready for more."

Test Post

This is a test of blog posting from my phone...

Memories

We do a transport from a group home, an uncomplicated chronic problem. The patient is friendly and cooperative, but as a matter of policy the group home sends a staff member to escort him. The staff member is only a few years older than me or my partner (we're a "young" car) and he laughs when he gets in the front seat of the rig.

"Yeah, man, last time I was in one of these I don't remember it!"

Of course I am curious.

"I was shot, man! Two times, I was fightin' for my life."

Wow, we say. Crazy. He laughs again, and agrees, and we go off to the hospital.

* * * *

We're sitting in the bay, doing paperwork, just about ready to go back in service, when the staff member comes out to smoke a cigarette. As he walks by he stops for a second.

"I know I don't remember when y'all took care of me, but I know I was in good hands, man. Y'all are heroes."

Thanks, we say. Thanks very much, and we hope not to ever have to help him again.

"Yeah, man, I hope I don't ever have to see y'all either. Hey, you know what they call you guys in the hood, right?"

Uh. No?

"Ghetto angels, man."

(Mis)information

I've said a few times before that all I really want to know before I go to a call is where I'm going. Every call we go on, we get a typecode (breathing problem, chest pain, bleeding problem, trauma, etc), and then whatever information they have recieved from the caller about what is going on. This should allow us to prepare for the call in terms of equipment, resources, protocols, and so on.

Unfortunately, they're often dead wrong.

It's not the fault of the calltakers; they can only go on what they are told by upset, untrained, concerned, and often confused callers. That they get as much information as they do is, quite frankly, amazing to me.

Even so, it's often a better idea to not even read the call on the computer.

* * * *

There are the tapouts that make the hair on your neck stand up.

ENTRY: M, 18MOS, UNC, NOT BR

ENTRY: 1 Y/O FEM, NO BR, BLU

ENTRY: BABY NOT BREATHING, LANG BARRIER

All of these will be febrile seizures, with updates saying the baby is breathing and crying, and a hale and hearty baby with a fever who needs some Tylenol.

* * * *

There are the ones that make you think you're in for some serious work.

ENTRY: 2 CAR ACC, ONE VEH ON ITS TOP, INJS

ENTRY: SINGLE CAR INTO POLE, OCC PINNED INSIDE

ENTRY: M, 20S, ARM CAUGHT IN MACHINERY

All of these people will be out, relatively unscathed, and all the resources that have gone screaming out from stations and posts will be recalled, Hurst tools and prybars and plasma torches left in trucks.

* * * *

And then there are the ones that make you cuss, because it's the end of your shift and you can't believe they are calling for this.

ENTRY: M, 30, ABD PAIN, VOMITING

"Really?" I shout at the computer. "Seriously?!" My partner doesn't rise to the bait, just swings the car around and lights it up, headed way up north, twenty minutes before logoff. I keep my rant going, because it's Friday and I'm tired and seriously.

"Come on, dude. You're sick! You've got the flu! Drink fluids! Suck it up! You don't even need to see a doctor, let alone go to an ER, let alone take an ambulance!!"

The fire truck arrives well before us. Of course they keep us coming lights and sirens, because their shift change is soon, and they want to be off on time too. I punch the REFRESH button on the computer, but there are no updates from dispatch.

We finally pull up to the apartment complex. The open door is way in the back, a decent walk from the closest place we can park, on the second floor, up a rickety-looking staircase.

I sigh, and shrug at my partner. "Tell you what, just get the gurney to the bottom of the stairs. I'll go up and see if he can walk down, so we can get this show on the road."

He nods assent, and I trudge over to the stairs, up and around the turns, and into the apartment.

A man in his 30s is sprawled in the middle of the living room floor, on his back. He's blue, covered in vomit, and maybe breathing six times a minute. Fast patches are stuck on his bare chest, and beside him the Lifepak calmly announces in glowing yellow numerals a heart rate of 38 and an oxygen saturation of 79%. The fire crew is ripping out airway and IV access gear. Their medic is at the man's head, bagging him. He looks up at me.

I gape, wondering if somehow I'm in the wrong house.

"We gotta sux this guy," the firemedic says, and I nod. Yeah. Duh. Crap.

I step out the front door, look down to where my partner is leisurely working the cot between cars.

"Hey!" I shout. "Forget the bed, get up here!"

Uprooted

I am sorry, dear readers (all three of you) for the absence. There have been some drastic changes in my life in the past few months -- all of them good. In brief, I have more responsibility at work now, more space at home now (and a different address), and someone who I am spending a lot of time with.

So, while I have not had the time to really write up any good stories recently, I do have a tidbit of wisdom to share.


You see, I left my old partner, albeit not very willingly. Promotion, in my agency, is almost forced, and of dubious value; I accepted nevertheless, and am left wondering if I lost more than I gained. No doubt I am simply unsettled by the transition, shifted from comfortable tracks to uncharted territory, but just so, I am unsettled and find myself missing the comfortable partnership I had for such a large chunk of my (relatively short) career. I feel a bit uprooted, and I fear it will be some time before I relax again.

That aside, on our last night I asked him what the secret wisdom to being a truly excellent paramedic was.


He thought long and hard, and finally told me he had no clue what the secret to being a truly great paramedic was.

"Here's what I do know," he told me. "Here's what I have learned:

Go to work.

Don't get in trouble.

Go home.

Forget about it."


Words, I feel, to live by.

Crunch

Sometimes, in EMS, particularly in the jaded urban world, we get a tendency to discount the opinions of bystanders -- or anyone except us and our partner (nursing home staff, fire dept, etc). How many times, either through intent or stupidity, have they told us something completely wrong?

"She's having a seizure!" the man shouts, as his wife screams and beats her fists on the floor. No, she's throwing a tantrum -- at fifty years old.

"He's having difficulty breathing," the CNA tells me, holding out a packet of paperwork. On the bed behind her, the man is pale and still. His chest does not move at all, I feel nothing on either side of his throat when I dig for a pulse. "Medic 38," I snarl into the radio, as I help my partner yard him onto the floor, "with patient, working code."

"She's having an asthma attack, it's her asthma, you've got to give her the medicine!" But sixty seconds of assessment show me clear lung sounds, perfect saturations -- and a CO2 of 15 with a respiratory rate of fifty. "No, ma'am, ma'am -- ma'am, listen to me -- ma'am, look at me, right here -- you are breathing just fine. You are hyperventilating. Listen to me, we're going to slow your breathing down, okay?"

So with all these -- with all these tales, and a million more that could keep me and my coworkers telling stories for an entire night, laughing over beers at the poor diagnostic skills of laypeople with no medical training, clearing the inevitable ring of tables around us -- with all these, can you accept our inclination to be disbelieving? Or, if not accept, can you at least understand?


* * * *


Last week we were first onscene of a motorcycle vs. car wreck. The motorcycle rider crouches, holding the shoulders of a child sitting on the ground next to the bike. The rider -- the father -- looks up at me. "His femur is broken."

I couldn't help thinking, Yeah, okay, sure thing, buddy. I think I simply told him "Okay, let us check him out," and moved in on the kid. We cut his pants leg open and see a nasty open tib-fib fracture. I do a half-assed palp of his upper leg and glance at it, keeping half an eye on the firemedic doing bleeding control and stabilization on the lower leg, and half a mind on managing the rest of the scene. Ask the kid where it hurts, and he says his ankle.

Two minutes later, we're getting a vacuum splint in place around the kid's leg, and we cut his pants leg a bit more. The lieutenant from the engine abruptly says, "Whoa, what about that femur?"

And indeed, the deformity that wasn't obvious from my viewpoint with the pants half-cut is now very obvious. Totally fractured. Balls. We can't do a traction split because of the ankle fracture, our treatment won't change, but balls on missing that first go around. And a big pat on the back to the knuckle-dragging clipboard-holding EMT-Basic lieutenant. They say basics save medics, and I'm here to tell you it's the truth, more times than I can recall even in my short career.

As we're loading the kid up, I talk to the dad briefly, tell him what's up, what we're doing, where we're going. "And," I finish, "good call on that femur; you were spot on."

"Hey, man," he shrugs, "I was a field medic," and by this and his age and bearing I can only guess military.

"Besides," he says, "I felt that shit move."