Laundry

This is what happens when you do laundry in a dual-medic household.

Yes, it's true, She Who Must Be Obeyed works in The Business too.

Accessories

The scene: A house, at night. A fire engine and ambulance idle softly in the cool air. A patient has been loaded up, and now Yours Truly and a fire lieutenant wait for his wife to lock up the house. Yours Truly notes the fireman is holding some of the lady's belongings.

Me: "... That's a very nice purse you have."

Lt: "Do you like it? It's from my spring collection."

Me: "It matches the color of your eyes."

Lt: *blush*

Overtime

Eleven hours in to a shift in the city, my phone rings. I glance at the face. "SUPERVISOR JIM." Hmmm. They've been paging for a night shift, more and more frantically. I thumb the green key.

"No."

"Hear me out!"

"No. I'm not working a twenty-four."

"Dammit, just ... listen, okay? It's a sweet deal."

"... okay."

"There are two medics on the car already. The problem is, neither of them is a lead medic. But they're both checked off. And one is in the lead training program. You just need to be THERE, to keep an eye on things. They'll do all the work."

"... no charts?"

"You can sleep in back all night, and just wake up for calls! Come on, man."

I take a deep breath.

"Let me check to make sure the wife doesn't mind."

"You da MAN!"

"And I want movie tickets."

"Done."

* * * *

Three in the morning. I'm horizontal on the bench seat, strapped down against the bumps and turns of post moves. The radio is clipped to the stretcher next to me. I've just, finally dozed off when the tones blare. Damn Motorola. I swear, every time they go off, a year drops off my life.

I try and sit up. Too bad I'm still strapped in. Coughing, I pop the belts and make my way to the jumpseat. We're already moving.

I rub my eyes and address the cab of the ambulance as a whole. "What tomfoolery are we off to now?"

"A stabbing."

"... what?"

"See?" The MDC is turned to face me.

ENTRY: STARTING MED, SAYS SUBJ HERE IS STABBED IN BACK, REFUSING TO ANSWER OTHER QUESTIONS. POLICE ENRT. MED TO STG.

"Huh."

My partner scrolls down.

UPDATE: SOMEONE IN BACKGROUND YELLING, "THE COPS ARE COMING, HIDE THE WEED, HIDE THE WEED!" H/U ON ME. NO ANS ON CALLBACK.

I lean back against the airway seat. "Okay. This is probably BS. Don't stage too close."

We find a spot about ten blocks away and nose up to a curb, shutting the lights off. I close my eyes, and instantly start to drift aw--

*shwzooom!*

The whole ambulance rocks.

"What th' f-"

*shwmm!*
       *fwmmm!*
             *zmmmm!*

This time I can see the lights, as three more cops rocket past us, in full afterburner, doing somewhere upwards of Mach 2. I look out the back windows as five or six more police cruisers blow past, stacked up in a line, lit up like Christmas trees, and apparently headed for hyperspace.

"Hmmm. Guess they think it's real."

A few minutes later the tac channel crackles. "Per police onscene, medical is cleared to come in."

We zip around the corner, down the street, thread our way through shoals of white police cars, and pull up in front of a house surrounded by uniforms. A man is laying on the porch. I blink and rub my eyes again.

"Okay," I tell the front of the ambulance. "I'm just gonna walk up. If he's truly stabbed, we'll just put him on the gurney and bounce."

As I approach the porch, four cops enter the house with guns drawn. "Police!" they shout. Definitely a secure scene. The man is sprawled on the porch, moaning and holding his side.

"Well?" I ask one of the cops. "Stabbed?"

He nods. "In the back."

I fish my flashlight out, and roll the man slightly to his side. Sho' nuff, there's a neat 4cm puncture wound in his mid-back, thankfully well away from his spine.

I'm already stepping off the porch as my partners and the fire crew approach. "Put him on the gurney," I tell my crew. "No c-spine. I'll be in the bus."

As I climb back in the rig, I spin the dial on my radio all the way to the end, from FIRE DISPATCH, past TAC A and B and C, through EMS OPS, to TRAUMA.

I try to suppress a yawn and key the mike. "Trauma, Medic Six with a system entry..."

* * * *

At the hospital, as the trauma team pokes and prods and ultrasounds and ponders, I chat with a cop and a surgical resident.

"So," the doc asks, "any idea who did this?"

The cop shrugs. "Maybe a domestic. It's not really clear."

Chuckling, the resident suggests, "Was he Standing On A Corner, Minding His Own Business? Was it Sumdood? Or Those Three Guys?" Clearly he's not new to taking care of the Knife & Gun Club.

The cop snickers. "Yeah, probably Sumdood. That guy is always causing trouble."

I wave at the cop. "Well, what are you doing here? Get the f*ck out of here! Go catch him!"

* * * *

Later, in the ambulance, I compose a text message to my supervisor.

Stabbing interrupted my nap. Actually had to work. Damn you!

Parking

"Well," said the fire captain, "how are you going to get out? Do you want me to back you, or ... ?"

I looked up and down the four-lane highway. Between an engine, a rescue, our ambulance, and two cop cars, we'd completely blocked two lanes. I'd nosed the ambulance up close to a State Police car when we arrived. The trooper was still taking statements from witnesses.

I shrugged at the captain.

"I think I'll just push the state trooper's car into traffic, and then once it's been smashed out of the way by oncoming traffic I should have plenty of room."

"Hey!"

I turned. Oh yeah. The trooper was still taking statements -- five feet away.

"Oh, crap!" I grinned at the fireman. "They have ears!"

The trooper just looked at me and fired up his standard-issue Fifty Megawatt State Trooper Glare. I tried not to wilt.

"Well ... gotta go! You guys take care!"

"Soooo..." The captain was smirking. "I'll back you, then?"

Crosses

In this part of the country -- maybe everywhere -- when someone is killed in a car wreck, more often than not family or friends will put a cross up by the roadside where it happened. Sometimes there's a name, sometimes flowers, occasionally a photo. If you keep your eyes open, you'll see these little memorials here and there, scattered around, slowly fading and weathering.

I always, my whole life, drove by crosses on the roadside and wondered what happened. Was someone drunk? Just tired, or unlucky? Were they young or old? Just idle thoughts as I drive down highways and back roads.

The other day, as I was driving to work, I passed a roadside memorial I hasn't seem before. For some reason I pulled over to glance at it. The name sounded familiar, though I didn't recognize the photo tacked to the scarred tree.

But then I realized -- if I replaced the lazy afternoon sunlight with 3am mist and strobing LED lights, if I swapped the soft sounds of the breeze and quiet birds for the grumbling mutter of diesels and Hurst tools, if I put fifteen people on the roadway and one wrapped between the car and the tree -- then I knew the place well, because it was my call, and my patient, and we knew even as we struggled to tube her and cut her free that she would never live.

Rules

I recently got my yearly performance review. While it was generally positive, there was a small attached list of behaviors which are now forbidden to your truly. I thought I would share a few.

* * * *

Per dispatch center request, please do not respond to dispatch directions with "delightful," "by your command," or "pip, pip, righto, guv!" Additionally, please refrain from speaking on the radio in any foreign language.

* * * *

Per fire agency request, please do not provide an exterior building size-up on medical calls, request "the first-in engine company bring up my gurney on arrival," add your ambulance to box alarms, or assume Command on a chest pain.

* * * *

Per chart review committee request, please do not use the phrases "poor life choices," "pharmacologically assisted gravity attack," or "terminal deceleration syndrome" in your documentation. Additionally, we wish to remind you that "Funny Lookin' Beats" is not an acceptable description of ECG ectopy.

* * * *

Per fleet maintenance request, please refrain from turning in a vehicle failure report with reason listed as "PONTOONS DO NOT INFLATE FULLY WHEN ENTERING WATER." Additionally, please refrain from submitting requests for nitrous systems, afterburners, in-seat DVD players, or "bitchen' rims."

* * * *

Finally, per management request, please refrain from operating a lemonade stand, massage parlour, off-track betting establishment, or payday check loan business out of your station.

Moments (IV)

We drive east, in the darkness and rain, bluegrass and crackling radio traffic in our ears.

Thirty minutes ago, we were giving report to nurses and a doctor, swapping the O2 over, 1-2-3 lift, there we go, no allergies, had three neb treatments, what else can we tell you?

Forty minutes ago, I watch my partner rip out a BVM, in the rear view mirror, and my fingers are resting lightly on the EMERG MASTER switch before he even gives me the nod. Yeah. Blinkies and woo-woos now.

An hour ago, we load a little old lady in the back of the car. She doesn't look great, but her sats perked up nicely on the neb, and she doesn't look awful or anything.

Eighty minutes ago, a firefighter is telling my partner what he knows, as I try to tease information out of an anxious son, carefully as any detective handling a skittish murder witness, firm but kind.

One hundred minutes ago, I was on the phone with my wife. Wait a sec, I said, as tones started whistling on county dispatch. Whoops. That's us. Gotta go. See you in the morning.

Love you.


Twenty minutes ago, through the hospital curtain, I heard a son, talking to a mother who might not have even been able to hear him. I'm here. We're here. Be strong.

Love you.

Spine

In a quiet, unassuming way, the call is terrifying. In two ways, actually.

She's laying at the bottom of a half-staircase, surrounded by a fire crew. Nothing appears unremarkable. She's awake and talking. She's pink, warm, and dry. She isn't covered in blood. No bones project from her skin.

She isn't moving anything below her waist.

The fire paramedic looks up at me, and gives me a short report. It's all fine until he closes with, "We called medical control to ask about solumedrol -- they said no."

It's all I can do not to gape and shake my head. We move on with the call. Backboard, trauma entry, code 3 to the big hospital. She has true neuro and motor deficits below the level of her bellybutton.

I try to comfort her, reassure her, but she knows exactly what's going on and how ominous it is. I try so hard not to lie to my patients. It's a struggle not to tell her everything will be alright. I don't know that it will be. She's an avid cyclist. She talks about riding hundred-mile races.

After we leave her in the capable care of the trauma team, I ponder the fire medic's seemingly-innocuous words. Did he know anything about the solumedrol he'd asked for, or had he just heard somewhere that it could be used for spinal injury? Did he know about the plethora of studies that question it's effectiveness, or even the dose? I'm sure he didn't realize it would have taken 11 or 12 of the 125mg vials we carry to reach the 30mg/kg dose in this comparatively small patient.

I am forced by these circumstances to come back to my previous point, which is that we should all stick to our areas of expertise. I don't know step one about fighting a house fire. I know just enough about vehicle extrication to be dangerous. I know enough about HazMat to run the hell away. I leave those things to the fire department -- it's their expertise.

But I do know about prehospital medicine. I know the protocols, and the science and medicine behind the protocols, and when medication X or procedure Y is really necessary. I have an idea of when you can step outside the protocols, call medical control for permission to do something unusual.

I know enough to know that asking a doctor if you can give a patient steroids for a spinal injury, in the city, without knowing the dose, only makes you look a fool. That's my area of expertise.

Airway

In the prehospital setting, we are taught that airway comes first. A before everything else. And as paramedics, we're taught that the definitive airway, when we need to protect it, is a properly placed endotracheal tube.

But is this really the best for our patients? Certainly an ET tube is the right definitive airway for the hospital, but a plethora of recent studies suggest that paramedic intubation success rates are relatively poor. I'm not even talking about the effect on morbidity and mortality; it appears to be a fact that we're no good at getting the tube in the right hole on the first try.

A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.

"Nine hundred twenty-six patients had an attempted intubation. ... For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients)."

Review of endotracheal intubations by Ottawa advanced care paramedics in Canada.
Tam RK, Maloney J, Gaboury I, Verdon JM, Trickett J, Leduc SD, Poirier P.
Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):311-5.

"The study population comprised 1,029 intubated patients ... ETIs were successful for 64.6% (95% CI: 61.7, 67.5) of the first attempts; 79% of successful intubations were achieved within two attempts."

We get upset when we read these studies. What are they saying? We can intubate people! Our skills are solid! And yet, the numbers would seem to indicate this is not the case.

Many, many people have weighed in on this issue, and a few recent calls I've run have made me ponder these issues. I cannot argue that some of the data out there shows that paramedics are bad at intubating people, and there's no doubt that we're not doing our patients any favors by screwing around in the field.

The questions I want to ask are why are we bad at intubating people and how can we do better?

There are some of the local first responder agencies I work with that prefer alternative airways. The King Airway, in particular, has become popular lately. While I feel that the King is a great rescue device, I see red when I hear agencies espouse a culture of de-emphasizing ET intubation in favor of just "tossing in a King." Here's the facts in my experience: King airways allow you to ventilate and oxygenate a patient, so they're good for the purpose of a rescue device. They get the job done temporarily. They do NOT protect a patient's airway and lungs against vomit. If you bag too forcefully, you WILL end up with subcutaneous emphysema in your patient's neck. They do NOT always work, and if "Insert Tab A" is your ONLY plan, when that doesn't work you are hosed. (Yes, I'm looking at you, Mr. Non-Transporting Firefighter Paramedic.)

The three major reasons paramedics have issues intubating patients, in my opinion, are EXPERIENCE, VERIFICATION, and TOOLS AND TECHNIQUES.

Experience is the biggest factor. We don't perform enough intubations to be truly proficient. A physician will perform hundreds, if not thousands of intubations before they are even out of residency. A paramedic may perform ten, if they're lucky. Maybe more, in a good paramedic training program. This is not near enough. No wonder we're no good. If we expect to be good at intubation, we need to do a LOT more of them.

Verification is the second most important factor. I firmly believe that there is NO, zip, zero excuse for a misplaced ET tube in this day and age. If your agency isn't using continuous waveform capnography, you're behind the times. Visualization, lung sounds, tube misting, sure, but ETCO2 is the gold standard. You cannot have a misplaced tube with a good ETCO2 waveform on your monitor. If every patient you secure a tube in has that waveform, you won't misplace tubes. It's as simple as that.

Tools and techniques are the final factor in why we don't get our tubes in the right place. When's the last time you pulled out a bougie? Are you proficient using both Miller and Mac blades? Do you have a video laryngoscope? When's the last time you practiced -- let alone performed -- a NASCAR intubation, a digital intubation, or your surgical airway procedures? Do you know two-person intubation techniques to improve visualization? Do you know exactly how and when to use your rescue techniques and devices? If you answered NO to any of these questions, I don't think you should be intubating people in the field.

All of these ideas are nice, but how can we actually implement them, and do better at airway management? For the answer, I've got one more paper.

An analysis of advanced prehospital airway management.
Bulger EM, Copass MK, Maier RV, Larsen J, Knowles J, Jurkovich GJ.
Department of Surgery, Harborview Medical Center, Seattle, Washington 98104, USA.
J Emerg Med. 2002 Aug;23(2):183-9.

"The results showed there were 2700 patients intubated... The indications for intubation included medical emergency in 82% of patients and traumatic injury in 18%. Fifty percent of patients were intubated with the use of succinylcholine. The overall oral intubation success rate was 98.4% and definitive airway access was achieved in all but 12 patients (0.6%), with 30 patients receiving surgical airway access (1%). The successful intubation rate for patients receiving paralytic agents was 97.8%."

Wow! Look at that! Paramedics can intubate people! So what the heck is so difference about the system in Seattle, that they have such success rates?

The system in Seattle is tiered, with a small number of ALS ambulances backing up a larger system of BLS first responders and BLS ambulances. The initial training program for ALS providers in this system is extensive and stringent. While there are some unrelated issues with this system, the fact is that a SMALL number of HIGHLY TRAINED paramedics can and do intubate people effectively.

What's the implication? First off, I'm sorry, but paramedics need to get the hell off fire engines. We need to reduce the number of paramedics in almost every EMS system, and removing ALS first responders is the way to start. More and more studies are coming out which question the efficacy of ALS for critical patient (cardiac arrests and trauma patients in particular). First responders need to focus on solid BLS skills -- that's where the lives will be saved.

Second, every patient does not need an ALS ambulance. While systems need to have effective triage tools and constant, vigilant QA to make sure that the patients who need ALS get it, there's nothing wrong with BLS transport. Simple logic says that if you reduce the number of paramedics in a system, those paramedics who remain will see more critical patients and perform more procedures.

Finally, we need to change paramedic education. Three terms at a community college is ridiculous. Two years of full time college to be a paramedic. End of story. If that's too much time for you, if that's too hard, TOO BAD. We have too many medics, I said it above, and making the entrance and educational requirements tougher will only improve the quality of our providers.

We need to change our systems from paramedic-saturated over-ALS'd behemoths where each medic is maybe managing one or two airways a month, to lean, mean, highly-trained and highly-experienced systems with a small number of medics who can consistently, effectively manage airways the right way, the first time, definitively.

Tricks

I don't think I am alone among medics in that I have a small "dirty tricks" bag that I bring to work. I don't mean "dirty tricks" in the sense of pressure points or joint locks -- though those have their place -- but instead little items that are not standard issue which we have found to be useful.

I recently went through and organized my little black bag, and when I was done, here's what I had:

- O2 wrench
- Small zipties
- Needle-nose pliers
- A Code Strap
- InforMed Emergency & Critical Care Pocket Guide
- Tarascon Adult Emergency Pocketbook
- County Protocol Pocket Guide
- RSI Dosage card
- Booties
- Extra-large Tegaderm
- One each adult and pediatric single-use adhesive SpO2 sensors
- King Airway syringe
- A Zerowet Supershield

So, readers, I ask you -- what do YOU bring to work that isn't standard issue, but you've found to be useful, or want to have in case of that particular unusual situation coming up?