Truths (II)

EMS is not what they teach you in classes, in books, in school.

Or, rather, that is merely the surface of EMS, the way a history textbook's account of politics is merely the surface of the sweaty, ugly truth of marches and protests and speeches and backroom deals.

EMS is a journey, much like grief, with defined and common stages, and yet a differing experience for everyone.

EMS is opening a bar at 7am, rather than closing at at 2:30am, but getting just as drunk, stumbling tired into the daylight, cussing because now you'll sleep the entire day and get nothing done and you only have so many days off.

EMS is becoming comfortable with things than would have horrified you a few years ago, and finding wholly new things to horrify you.

EMS is an arranged marriage to a stranger who you will spend 48 hours a week with, locked in a box, in stressful situations, talking and eating and sleeping and laughing and fighting and working it out and fighting again and learning more about them and yourself than you ever wanted to know.

EMS is standing in the house of a stranger, telling his wife he's dead, and putting your hand on her shoulder or hugging her or making her a cup of tea, like you've been friends for years, because there's no one there but him, and he's three flat lines on a LifePak screen.

EMS is rolling into a trauma center with a critical shooting victim, more holes than you can count, walking right up to the senior attending trauma surgeon, and telling him, not asking but telling him that he needs to put this patient directly in an operating room, do not pass go, do not stop in the emergency department, and here's exactly why, do it now, sir.

EMS is pushing PLAY on the CD when the tones go off, cranking the rock up until it drowns out the siren, and cranking the radio up so you can hear Ops over the rock.

EMS is realizing that as much as you are there to help and care for your patients, you must help and care for yourself and your partner and everyone else in blue first, and learning that sometimes your "primary survey" will be their hands against the side of your bus as you search them for weapons.

EMS is walking into rooms or onto streets or into buses or onto planes with people who are dead, dying, bleeding, puking, crapping, coughing, and in many cases are just fine, and holding the same calm expression on your face.

And that's only the beginning.

Class

We're all in National Registry refresher class. A fellow medic is giving a pretty solid lecture on cardiac physiology, with plenty of audience participation.

This may or may not be a good idea.

* * * *

Instructor: "So, what causes cardiomyopathy in young, healthy adults?"

Medic In The Next-To-Back Row: "Cocaine!"

Instructor: "Yes, indeed, that's one cause ... What about our elderly population? What causes cardiomyopathy in old people?"

(pause)

Yours Truly, In The Very Last Row: "... Cocaine!"

Elevation

We've had a long night already, and we're not even half done. We finally got dinner, and we're eating on the move when the tones go off again. Male, 40s, chest pain, I read on the computer before I haul the ambulance around in a sweeping u-turn. We're maybe half a mile from the address, too.

My partner snorts, through a bite of tuna fish. She's tired and in no mood for the standard crap. "Unless it's a STEMI, I'm not interested," she chuckles.

* * *

The man lays on the bed, sweating and nervous. He was working out when his chest started hurting. He's never had heart problems before, but he did get checked out for chest pain recently. Everything was normal. He's got a history of anxiety, though. He's breathing fast. His fingers are tingling, and oh god the pain.

Hmmm, we say. Slow your breathing down. We'll take good care of you. My partner collects history while I get vitals. I slap the ten round stickers on arms and legs and chest, ask him to lie still, and thumb the 12 LEAD button. Glance down at the printout, expecting to see nothing remarkable.




* * *

Things move quickly then. I run to the ambulance and grab the phone, to send the EKG. My partner starts the workup - oxygen is already on, aspirin, nitro, and oral zofran follow. The firemen grab the stretcher. I've got the 12 sent and the hospital alerted before he's even on the stretcher. We load and roll. The strobes make flickering freeze frames of the snow that is falling lightly.

We get to the hospital, one of our favorites, and the doc (best in the city, in the opinion of most medics) all but meets us at the door. Nurses and techs and x-ray are all waiting. I ask if they've called the cath lab. "Of course," the doc replies. "They've been headed in for twenty minutes now."

When the patient thanks the doc, he points out the door to us - me making the gurney, my partner charting. "Thank them. They got you here fast."

By the time I come back in after cleaning up the rig, the patient is gone to the lab.

* * *

The standard of care for interventional cardiology, the benchmark everyone strives to make, is 90 minutes door to balloon. That is, 90 minutes between the time the patient rolls or walks into the ER until the time the interventional cardiologist inflates a tiny balloon to re-open an occluded artery.

Tonight, everything came together and the system worked perfectly. From the time our patient called 911 until the time the balloon went up in his occluded LAD, barely 78 minutes elapsed.

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."