Order

Day off. Cleaned the house. I'm trying to go through all my stuff and throw out anything I don't need. I was going to work tomorrow, but my girlfriend backed into my car in the driveway and busted the door. Tomorrow I will have to get that taken care off. What time I'm not spending on that I will spend cleaning. Trying to get my life in order. Making lists.

Sound Sleeper

3 days, 40 hours, 3 transports, 2 refusals. Never had a week this slow before.

The one transport today was a nursing home pneumonia. The first refusal was a fall, the second came in as a baby unable to wake up. I thought it was going to be bad, but we got the update, baby awake and breathing. I guess she was just a sound sleeper.

I'm off tomorrow. Hopefully, this slow week will help me get rested and I'll be ready to go when the calls start coming in.

Transport

Second day in a row with only one call. It came in as a stroke at a doctor's office -- a pass from the commercial service. No way was it going to be a real stroke. The patient would have had to been driven to a doctor's office, and then the doctor would have had to made the decision to call for a commercial transport rather than dialing 911.

Its an old lady I've transported before. She has chronic pain. She is sitting in her wheelchair, moaning "I hurt, I hurt."

The doctor walks by and when I ask what's going on, he says, "She's in severe pain. I can't manage her, take her to the hospital. It's not life threatening." And he walks off.

This is probably about the fourth or fifth time I've taken her. Every bump we hit, she moans, "Help me, help me."

Back

Back to work, all excited to use why I learned down in Baltimore, but only did one call -- an old woman with altered mental status. I was tired from the trip so it was good I guess that the day was slow.

Changes

The last day of the conference featured a closing address by a guy who was president of a big hospital chain in the south. He talked about some of the changes coming to hospitals that might effect EMS someday. He had a neat demonstration of carotid artery stenting. Before he spoke they presented the man of the year to the men and women of Acadia Ambulance for their heroism in Louisiana during Hurricane Katrina, and they touted the ability of a private ambulance company to make a difference in an emergency. The president of the company asked everyone who went to Lousiiana to help to stand up.

The lectures didn't begin until 1:30 -- the time between ten and one-thirty was scheduled for Expo time, so I took a cab up to the Baltimore Museum of Art, and then took the bus back.

Baltimore Museum of Art

The afternoon lectures were very good. I went to a recap of the new AHA guidelines by Dr. Robert O'Conner. It was going over the same material, but since I am giving an CME on it next month, I wanted to know as much as I can. Here are some of his PEARLs:

Keep tidal volume to 400 on ventilations.

There are two ways to hyperventilate: Too many respirations and too much volume in a single respiration.

Most pulses that emerge after a shock don't show up for 60 seconds.

There are fewer v-fib codes today than several years ago because of the better cardiac care peopel recieve from their doctors. Most codes are sicker people.

Epi has a IIb rating because they cannot do a study where epi is used against a placebo. No ethics board would allow it. Without such a study, there can be no Level I rating. Its one of the quirks of the evidence rating system.

On cardioversion -- if the patient can remember what you look like after you have cardioverted them, don't cardiovert because they probably don't need it.

One of the reasons, cardiac arrest discharge from hospital rates are so low is because the post resuciation care at the hospital is so poor -- it often consists only of trying to make a person a DNR.

I asked him about the phrase Seek Expert Consultation in the Tachycardia algorithm, and he said, it means if you don't have to give a patient drugs, don't, wait for the hospital.

The last session was called Lightning Round #3 Ask to the Street Medicine Docs -- it was a round table session with five docs who used to be medics. They talked about the future of intubation and other issues.

On Intubation, they said, for people to keep intubating, their program needs a solid QI program and people need to go to the ER if they are not getting enough tubes. One doctor said, "a misplaced tube is a travesty. It means, your patient would have done better in a Yellow Cab."

I asked them about the issue of using morphine for abdominal pain. Studies have shown that it actually helps the surgeon to an abdominal evaluation. They cited that sturdy and said by all means, we should be giving morphine to patients with abdominal pain.

Instead of taking the train back, I got a ride with a friend from work who had driven down a day before me. He has been going to the conference every year for quite a number of years. On the ride back, we talked about all the changes we've seen over the years. He has to teach a Paramedic refrecher on Monday and says he now has to rewrite his lectures.

They will be holding the conference again in Baltimore next year. I think I'll get a better hotel this time.

Free Pens

The lectures today weren't as good as yesterday.

The first one was the best: The Science Behind EMS by Dr. Bryan Bledsoe. I am a big fan of this guy. He is a former medic, who is on the leading edge of dispelling EMS myths. He talked about permissive hypotension suggesting BP should be kept around 70 for trauma patients and fluid should only be administered if the pressure gets below 40.

The next class was called Clinical Controversies: Technology in Medicine -- Help or Hindrance? This was taught by two doctors, and their message was with each new toy, you have to ask: Does the equipment work? and Does it work for the physiology? Will it impact patient outcome? They also said what we are learning today will no doubt be different tomorrow.

The last class was called Daily Habits of the Clinical Masters. I was hoping for a class to really get me psyched up to be the best medic I can be, but it didn't.

Today was the first day of the EXPO where you could wander among the exhibits and see all the latest gadgets from . You couldn't walk ten feet without seeing another CPR machine. Johnny Gage was there signing photos for $20 a pop -- I believe the money went to a charity. The line was long. I didn't want an autograph, but I wouldn't have minded getting my picture taken with him, but it wasn't set up for that. I did get to play with the Vida-Care Easy IO -- that was very neat. I can see how you could get IV access in just about ten seconds. It can be a life saver in cardiac arrest, although I fear it will be overused in other instances, such as trauma because it is so cool to play with. It also costs about $80 a needle. Overall my impression of the EXPO was somewhat negative. Maybe it was because I was tired. Lots of people trying to make a buck. Everyone wanting to show you stuff. I did grab quite a number of free pens.

I went to a seafood buffet and then walked up that big old hill to the hotel.


Easy IO

Compressions

The first day of the conference. We all gather in a big ballroom.

I arrive just as they are doing a presentation about the EMS Memorial. They do a slide show of the 26 EMS people who lost their lives in 2005. It is very moving. You see these photos show the people smiling proudly in their uniforms(as music plays). They could be the person next to you. They clearly have no idea of what their fates would be, certainly not expecting to be a part of this slide show.

Here are their names:

Tommy Allen Allred of American Ambulance Service, Cullman, AL who died in the line of duty on August 18, 2005 of injuries received in a motor vehicle collision while on duty.

Bridgett Nicole Autry of Herring Volunteer Fire & Medic Department, Clinton, NC who died in the line of duty on June 13, 2002 of injuries received in a motor vehicle collision while on duty.

Heidi Jean Behr of Riverhead Volunteer Ambulance Corp Inc, Riverhead, NY who died in the line of duty on May 3, 2005 of injuries received in a motor vehicle collision while on duty.

Timothy Russell Benway of Yampa Valley Medical Center, Steamboat Springs, CO who died in the line of duty on January 11, 2005 of injuries received in an aeromedical aviation accident.

Christopher Dale Clingan of Pafford EMS, Hope, AR who died in the line of duty on February 19, 2005 of injuries received in a motor vehicle collision while on duty.

Gaylette Drummond of Midwood Ambulance, Brooklyn, NY who died in the line of duty on July 13, 2001 of injuries received in a motor vehicle collision while on duty.

Jeffery Scott Ferrand of Pafford EMS, Hope, AR who died in the line of duty on February 19, 2005 of injuries received in a motor vehicle collision while on duty.

Felix Hernandez Jr. of New York City Fire Department EMS, Brooklyn, NY who died in the line of duty on October 23, 2005 of complications from toxic exposure suffered while on duty at the scene of the 9/11 terrorist attacks.

Phillip H. Herring of LifeNet of the Heartland, Norfolk, NE who died in the line of duty on June 21, 2002 of injuries received in an aeromedical aviation accident.

Courtney Hilton of Highlands Ambulance Service, Lebanon, VA who died in the line of duty on June 4, 2005 of injuries received during an assault while on duty.

Scott David Hyslop of TriState CareFlight, Durango, CO who died in the line of duty on June 30, 2005 of injuries received in an aeromedical aviation accident.

Timothy Patrick Keller of New York City Fire Department EMS, Brooklyn, NY who died in the line of duty on June 23, 2005 of complications from toxic exposure suffered while on duty at the scene of the 9/11 terrorist attacks.

David B. Linner II of Yampa Valley Medical Center, Steamboat Springs, CO who died in the line of duty on January 11, 2005 of injuries received in an aeromedical aviation accident.

Chastity Hope Miller of American Ambulance Service, Cullman, AL who died in the line of duty on August 18, 2005 of injuries received in a motor vehicle collision while on duty.

Ryan P. Ostendorf of American Medical Response, Topeka, KS who died in the line of duty on December 5, 2005 of injuries received in a motor vehicle collision while en route to duty his duty station.

Brendon D. Pearson of New York City Fire Department EMS, Brooklyn, NY who died in the line of duty on April 23, 2005 of complications of surgery for an on-duty injury.

Terry Lee Pearson of Roseau Ambulance, Roseau, MN who died in the line of duty on January 4, 2005 of injuries received in a motor vehicle collision while on duty.

William "Pod" Podmayer Jr. of TriState CareFlight, Durango, CO who died in the line of duty on June 30, 2005 of injuries received in an aeromedical aviation accident.

John Jeffrey "Jay" Rook of Pafford EMS, Hope, AR who died in the line of duty on February 19, 2005 of injuries received in a motor vehicle collision while on duty.

James Philip Saler of TriState CareFlight, Durango, CO who died in the line of duty on June 30, 2005 of injuries received in an aeromedical aviation accident.

Lori Ann Schrempp of LifeNet of the Heartland, Norfolk, NE who died in the line of duty on June 21, 2002 of injuries received in an aeromedical aviation accident.

Heinz Schulz of Emergycare/LifeStar of Erie, Erie, PA who died in the line of duty on October 7, 2005 of injuries received in an aeromedical aviation accident.

Patrick W. "Pat" Scollard of LifeNet of the Heartland, Norfolk, NE who died in the line of duty on June 21, 2002 of injuries received in an aeromedical aviation accident.

Ricky Allen "Rick" Seiner of Citizens Memorial Hospital EMS, Boliver, MO who died in the line of duty on September 2, 2005 of injuries received when struck by a vehicle while operating on the scene of a call.

William Anthony Stone of Riverhead Volunteer Ambulance Corp Inc, Riverhead, NY who died in the line of duty on May 3, 2005 of injuries received in a motor vehicle collision while on duty.

Jennifer Theresa Wells of Yampa Valley Medical Center, Steamboat Springs, CO who died in the line of duty on January 11, 2005 of injuries received in an aeromedical aviation accident.

National EMS Memorial

***

The main speaker is Dr. Norman McSwain, an EMS pioneer who was also the chief surgeon at Tulane Hospital during Hurrican Katrina. He gave a talk about what it was like to work there with the place surrounded by 9 feet of water after the levees broke. He said 80% of the police, fire, EMS people in New Orleans were still homeless.

***

My first session is called Improving Hemodynamics During CPR taught by Tom Aufderheide, M.D. He is one of the world's top CPR researchers and very involved in the new AHA guidelines. The new guidelines absolutely dominate the conference. Nearly every session I will attend hammers it in. Compressions, compressions. Allow full chest recoil and no hyperventilation. Ventiltate your codes at 8-10 times a minute. In recent years EMS has moved towards evidenced based medicine, and as more studies are being done, what we have taken for granted has been challenged.

The crux of Aufderheide's talk is this:

Studies show half the time in CPR compressions don't get done.

When you stop compressions, all blood flow ceases.

Studies show paramedics, doctors and nurses all ventilate at rates from 30-40 a minutes.

High ventilation rates screw up the interthoracic pressure preventing effective blood flow.

Normal people breathe through negative pressure. We ventilate people with positive pressure.

Our ventilations should be fewer and less both in terms of volume and duration.


He talked about a study with a new devive called a ResQPOD, which enhances negative thoracic pressure. (The device attaches to the ET tube and also has timing lights on it to keep you ventilating at 10 a minute.) The study showed the new device more than doubled short-term survival rates in patients presenting with pulseless electrical activity.

The American Heart Association gave the device a IIa rating, which is a higher rating than any ACLS drug recieves.

Clinical evaluation of an inspiratory impedance threshold device during standard cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest

RESQPOD

The drawback is the device costs around $90.

***

The next session was called Managing the Wheezing Patient by Dr. Corey Slovis. Very good presentation. He focused on asthma, COPD, CHF, and anaphalaxis. Here are some of his pearls:

He was big on magnesium for asthma and COPD, advocating 2 grams in 100cc over 1-10 minutes.

He advocated instead of doing one treatment followed by another, do a continuous treatment, which is basically dumping two treatments in the neb to begin with.

He was a big proponent of CPAP for CHF.

He was very cautious on lasix. He said never start with Lasix and never give it unless you are also giving nitro because lasix's initial action is as a vasoconstrictor.

(On the lasix issue there is a new study coming out that will show how often it is mistakenly given both in the field and the ER for pneumonia.)

On anaphalaxis, he said give epi IM in the thigh

He also said fluid boluses do absolutely nothing for asthmatics, which was new information to me, as I have been giving fluid to asthmatics for years, thinking, as I was once taught, that it helped break up the mucas.

***
The last lecture of the day was Lethal Power of the ET Tube by Brent Myers, M.D. Also a very good presentation. He also hit on the new AHA guidelines.

He said with all the problems there have been with ET intubation in this country there was no way the FDA would approve the procedure today based on available studies.

He emphasized the A was for airway, not intubation, and pressed the imporatnce of circulatining the blood. He said studies showed uninterrupted compressions increased survival by 300%. Anything that interrupts compresions is bad. He said for patients in vfib, you should delay intubation. They should have a good supply of oxygenated blood in their body that will last for five minutes or so. You could monitor their status by using a nasal end tidal CO2 cannuala while using a bag mask. When you do intubate try to keep compressions going while you pass the tube. If you need to stop compressions, stop only for a brief moment. On number of ventilations, he cited a pig study where when pigs were put into arrest, 6 of 7 pigs survived when they were ventialted 6 times a minute, only 1 of 7 survived when they were ventilated at 30 times a minute.

He said everyone intubated should have end tidal Co2 monitoring.

***

When the conference let out I walked along the inner harbor and went to Mo's Seafood restaurant and ordered the Mo's Famous Crabcake's. They were $33. I didn't order anything else, and just drank water. The crab cakes were huge. I could only eat 1, and took the other one back to the hotel.

Again, it was cold and a long walk back uphill to the hotel. I admit the room really depressed me. It seemed like the kind of room, you could die in alone one day and no one would find you for a couple days. I had a nasty coughing fit, and it went on so long I though people in the hall would probably think I was an old alcoholic. Instead, I was in the dim room with my large bottle of water trying to wash away the dryiness in my throat. I lay back on the bed and thought my eyesight was growing dim and I was losing my sense of colors when I realized the color TV wasn't really very colorful.

Still the room was cheap.

JEMS CONFERENCE- Arrival

I took the 11:19 train to Baltimore and arrived a little before 5. I walked a mile or so down Charles Street to the hotel. All the high-end hotels on the inner harbor near the Convention Center were booked so I got a room in this place. It is semi-flea bag, but cheap. After I check in I walk down to the Inner Harbor. It is a cold evening and I don't hang out too long. I'm still fighting a cold and the mile long walk back uphill to the hotel wears me down. If I was feeling better and was at a nice hotel, I could see sitting at a bar having some cold ones, instead I go to bed early on a mattress that nearly swallows me up the springs are so bad.

Co2 retainer

Started off with a nursing home patient I had a week or so ago -- a C02 retainer, who was lethargic. Same deal again today. Her vitals were okay. I put her on the end tidal cannula to monitor her, which was interesting. Her number was 44-50. She had hypoventilation syndrome as well. A couple times the apnea alarm went off briefly. Then we did a lady who fell and bruised her knees, and a man from a diaylsis center having chest pain that was resolved by our arrival.

This afternoon we got called for a fall at a housing construction site. The worker fell through the first floor to the basement when the plywood gave way. He landed on his head, but was only knocked out for about thirty seconds. He had head, neck, back, chest and leg pain. He had some blood coming out of one ear and had a nasty lac on his femur about 3 inches right through the fatty tissue. We boarded him, and took him in of an easy priority because of the mechanism. He was Mexican and didn't speak an English. I ended up translating in the trauma room.

Later we went out for a dog bite.

Bun and Cheese

Day started out with an 11-year-old having chest pain. She had a cold. We took her to the hospital while her mother followed in her car. Not like it hasn't happened before.

Next stop the clinic of a retirement community for a woman with chest pain, a fever and a cough. We took her to the distant hospital where the retirement community's doctor is affiliated.

We were en route to a doctor's office for a thirty-year-old woman with plueritic chest pain, when we were diverted to an unconcious patient on a bus in front of a supermarket. Elderly Jamaican woman with a blood sugar of 30. When we brought her around with some D50, she had no idea how she got where she got. Seems she missed her stop. She didn't want to go to the hospital at all. She had some bun and cheese, a Jamaician specialty, and a banana with her so we had her eat the banana and have some bun and cheese. It was 2:30 in the afternoon and she hadn't eaten since breakfast. She said she'd just catch another bus back to where she lived, which was just across the town line into the city. We ended up just driving her home. We needed to monitor a little longer and recheck her sugar, so it wasn't like we were giving up any available time to drive her. It worked out well and she was very appreciative.

On the way back, we did a minor motor vehicle that ended up as a refusal.

Possibly Dead

Three calls today -- a woman with kidney pain, a woman with a UTI, and a call for an unresponsive person in a car, possibly dead. Before we got there, we got an update that the woman was now out of the car and walking into the supermarket. The officer who arrived first, canceled us after learning that the woman had merely closed her eyes for a few moments to think about what she needed to get at the store.

AHA Guidelines

Feeling a little bit better today.

The new 2006 American Heart Association Emergency Cardiovascular Care (ECC) Handbook/Guidelines Booklet arrived in the mail today along with 2005 American Heart Association Guidelines For CPR And ECC, which is a reprint the 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care that appeared in the December 13, 2005, print issue of Circulation.

You can order your own at the following link:

AHA Books

Winter Wind

This cold has got me beat down. Sometimes when you are sick, it seems like you just can't picture yourself ever being well again. I have generally been very healthy in my life. And I know that my current sickness is nothing more than my annual winter cold. I can't really imagine what my patients feel like -- people who are really sick.

It is nice outside today -- or at least it looks that way. When I went out the winter wind was bitter. Yesterday my partner told me he saw a robin. I can't wait for spring to be here again.

I signed up today to go to Baltimore next week for the EMS conference:

Conference Schedule.

I went several years ago when it was in Philidelphia and thought it was great. This year I've booked a room at a run-down motel eight blocks from the convention center. It is only $80 a night. They wanted over $300 for the Marriot. If I had booked in advance I could have gotten a conference rate.

I should be feeling better by then.

"Quick" Evaluation

Well I was feeling run down, but I went to work anyway. I was supposed to be precepting so I figured it would be an easy day. They were short people so they pulled our driver. It was just me and my preceptee. No heavy lifting though. Our first call was a transfer -- a little seventy pound lady. We worked eight hours. We did a sixty year old lady with plueritic chest pain, an 18 year who told his girlfriend he was going to jump off a building, another transfer, and an old guy in a nursing home who slapped a lady who ran over his foot with her wheelchair. They called the cops and per the nursing home policy, he had to go in for a "quick" psych evaluation at the ER. We were the transport. Not a hard day, but I was beat by the end.

I will stay home and rest tomorrow.

Bronchospasm

My cold has me really down today. I tried to go to bed early, but woke up in a coughing fit. I was in a severe bronchospasm. I could not get my breath. Each time I took a breath I had to breathe deeper. I couldn't get any air. I wasn't panicked, not yet. I have seen patients with the same problem. I tried to drink water in between gasps -- my throat was so dry, but I kept having to spit it out. I imagined me as a paramedic standing over myself, trying to calm me down. I also imagined myself as a medic finding me dead on the floor. Then I finally got it under control. Now I'm drinking as much water as I can to try to moisten the dried mucas in my lungs.

I don't think I'll work tomorrow.

Easy IO

I was up all night coughing. I went out to my regional EMS meetings. The Ed meeting was cancelled because we didn't have enough people there. At the med meeting we talked about when we were going to put the new AHA guidelines into effect. Probably July 1. I'm doing a CME in April on the changes. We saw a demonstration of all the new IO devices, which hopefully we will be getting out on the road. The new AHA guidelines call for IO access in cardiac arrests if you can't get a quick IV. Drugs down the tube are now a very last resort.

Easy IO

Came home, was feeling tired. I was going to take a nap, but ended up watching Sideways, which I really enjoyed. It was one of the nominees for Best Picture a year ago. I used to watch all the best Picture nominees before the Oscars were awarded, but last year and this year I just didn't get to the movies much, so I am trying to catch up on DVD. Nothing like a good movie. I'm doing some laundry now, and am looking forward to watching American Idol tonight. Enjoying the day off. I plan to sleep late because I'm off again tomorrow before I hit another stretch of working days.

Nursing Home "Strokes"

Two nursing home calls today -- both came in as "strokes." One had a blood sugar of 60, they gave her glucagon and put her back in bed. They told us she's been drooling and had slurred speech. We only found out that she'd had a low blood sugar and had gotten glucagon when we read the paperwork out in the car. She seemed fine to us and had no neuro deficits. The other one was responsive to pain only. he had a fever and no neuro deficits.

I've got a low grade fever myself and my annual winter cough. I'm off for the next two days thankfully.

Old Women

Three calls. An old woman with Alzheimer's and bad balance who fell and bruised her knee, an old woman with abdominal pain and another old woman from a nursing home with lethargy. All three frequent flyers.

I am feeling run down today. I hope I am not getting sick. There is a lot of it going around. When I get sick I feel like an old woman and I do not wish to feel that way.

Paramedic Workout

Working a Saturday 16 hour shift in the suburbs. The base is quiet today as the class is out helping with a practical exam before they take their state exam. We've been out three times. Started off at the nursing home for the trached patient in respiratory distress. By the time we had gotten there she was doing fine. I've taken her in many times. She gets a mucas plug, desats, they suction her, she's better, we still end up taking her in. Later we did two refusals -- a diabetic who was out of chemstrips and feeling a little woozy. We checked his sugar - 67 -- and had him eat a sandwich before he went out to dialysis. Last refusal was for a woman in a grocery store, who the manager said was short of breath. He called us, she heard that and bolted. The cops stopped her in the parking lot. She was already in the car. Great big woman on 02. I offered to take her in, she said her husband would take her there now, and then they took off.

***

Getting bored. I went out into the bay and came up with the following workout:

The Paramedic Workout

Walk Around Block/Light Stretch

Superset

A. Monitor Stepup/Monitor Upright Row 2 Sets of 12 Reps

Using the life pack 12, I stepped from the ground onto the back of the ambulance, then back down 12 times, followed immediately by 12 upright rows with right arm, 12 with left, then repeat.

B. Monitor Lunge 12 Steps holding in right arm, then 12 steps holding monitor in left

C. Monitor Bent over Row 2 Sets 10 reps each arm

D. Monitor Squat 2 Set 12 reps, switching arms

E. 02 Tank Curl to Shoulder Press 2 sets 12 reps 1 tank in each hand

F. 02 Tank Fly 1 set 12 reps 1 tank in each hand

G. 02 Tank Tricept Press 1 set 12 reps each arm

H. 02 Tank ABD Curl 2 set 12 reps

I. 12 pushups

Stretch/Walk Around Block

Not a bad workout. I have been feeling very weak and short of breath (on climbing four flights of stairs carrying my equipment)lately. I went to the gymn three times this week. This morning after doing cardio for the first time in forever yesterday I could hardly lift my legs to get out of the ambulance. It has gotten better as the day goes on.

Now I am ready for Saturday night pizza.

***

No sooner did I write the above, then we got dispatched to the pizza place in town for an ABD pain. On the way back from the hospital, I got Jerk Chicken instead of pizza. I ordered the medium size, thinking it would give me some extra for lunch tomorrow, but I ate evr last bit of it. Jerk chicken with stew chicken sauce, rice and peas and salad. It was good.

Poodle

Started the shift off with an unconcious at the senior center. It turned out to be a five year old who passed out briefly on stage while performing 60's songs with the kindergarten "poodles." She was very cute. She wore a pink skirt with a poodle on it like all the other kindergarten girls. The boys wore dark sunglasses. We waited for her mom to come get her. The flu has been going around their family.

Went to a doctor office for a woman complaining of bricks on her chest for ten days with a history of pnemonia. Her ECG showed a LBBB which she didn't have three years ago, so the coctor gave her a prescription for biaxin and called us to have her taken in for a cardiac evaluation.

We did an old woman from a nursing home with lab values that showed she was having renal failure, a minor accident where a man on a bike was grazed by a car, but never knocked off his bike, complaining of ankle pain, and a transfer.

And that took up eight hours.

Exxon Valdez

Spent the first three hours helping another car lift a heavy patient on a lengthy wait and return transport.

Then when we were coming back into the city we were stopped on Main Street when a pedestrian came up to us and said some fluid was pouring out of the bottom of our ambulance. We turned onto a side street and the engine died. We got out and it was like the Exxon Valdez -- we dumped all the oil in our engine, a huge black slick. While waiting for a tow, we went to a deli and got some excellent pasta with sausage and marinara sauce.

Switched into a new rig, we got a call for a chest pain. I thought it was a lady hyperventilating. She said she felt tingling in her arms. She had a seizure history, but nothing like this, she said. I was getting frustrated getting her to describe what exactly she meant when she said she had seizures, I'm talking to her and then we are in the ambulance, her left arm and left leg stiffen and start shaking more and more. I put in an IV and get the Ativan out, and ask my partner to get some quick demographics, but it is too late, her eyes deviate to the left and she starts really seizing, though only her left side. Her friends, who are meeting us at the hospital have her pocket book and we know nothing about her -- not even a name. The ativan stops the seizure, and fortunately just as we arrive at the hospital, she wakes up and is quite coherent, much more so then initially. She says she had a focal seizure five years ago.

Our last call is a transfer. My partner is only on the schedule for eight hours. I'm on for ten, but they let me go home because they have no one to work with me.

Johnny Gage

Eight hours in the city. Came into work, they had no ALS house bag for me, so they ended up giving me an empty old orange fishing tackle box and I stocked it with meds. I was hoping for a big scene call so I could pretend I was Johnny Gage on Emergency, but I never got the chance to really use it.

Started out with a round trip transfer. We initially took the patient to radiology, but they had no record of him. Well, it turns out he was supposed to go for radiation at the cancer center, and they had just booked it wrong, so we eventually got him there. Later did two calls, a woman who fell stepping off a bus and an Alzhiemer's patient with chest pain. Easy eight hour day.

HP Car

I worked the HP - high performance car today for the first time. The deal with the HP car is you do nothing but transfers. As soon as you have done eight, you can go home and still get paid for your 9-5 eight hours. If it is slow or you have to wait too long for a transfer to be ready, you still get credit for a call. I took the shift because an old partner of mine was working it. He recently came back to work for the company after being away for four years, working a variety of other jobs -- group home, security, research lab, er tech. He likes the HP shift. "I did all those calls with you, the shootings, stabbings, digging babies out of toilets, I don't need to do that anymore. I come in, I do my job, and most days get out early."

We had a good time, catching up on news and rehashing old times. We did our eight calls and were out an hour and a half early.

I can't say as I really enjoyed humping all those transfers -- we didn't have a break -- but I was impressed with my friend and with the idea of the HP car. The first four calls were all dialysis patients. He does the same patients every Tuesday and Thursday. One of the calls involved helping an amputee down some narrow stairs, using two of those stair escalators, and then an outside elevator. You could tell the patient was comfortable with him and he joked easily with her and her daughter. I knew the patients liked having the same guy come for them every time rather than an endless procession of new faces. At one diaylsis center, he helped dress an old woman the way she liked, putting her hood up and wrapping a scarf around her. On our next to last call, we took a woman home from the hospital to her daughter's house. We showed the daughter how to put a cannula on the mother, how her 02 machine worked, how a foley bag needed to be keep low so it would drain, and pointed out a sore on the woman's ankle. We gave her the company's number and told her to call us if she needed transportation and told her to call 911 if any emergencies developed. She thanked us as she let us out the front door.

Tomorrow I'm back in a regular car.

3 patients

3 patients, all 3 I have had before, one had recurrent pnemonia, one a recurrent rectal bleed, and the other a fever.

I gave the fever patient some fluid. We were driving down the highway and all of a sudden, she says, I'm getting wet. I look. The IV catheter has come completely out of her arm. The fluid is flowing out through the catheter spraying everywhere and blood is coming out of the hole in her arm. To make matters worse we are in our brand new ambulance. This is like the 5th call it has ever had. Blood on her gown, blood on the sheets, blood on the floor. Some on the cabinets. Not happy about it.

I played around some more today with the electronic data forms. They need work, but have potential. We got it to print at one hospital, but it wouldn't work on the other hospitals. What will be nice about these forms in the end is that everyone will be leaving a legible run form.

Six calls

Another busy day. Once we got started doing calls we didn't stop. Not a whole lot interesting. A motor vehicle, a man with gout in his toe, a man dizzy in slow afib on digoxin, a COPDer, a motor cycle accident with no injury to the driver, a two month old with pneumonia.

I did get a good period of time this morning to write, and I was grateful for that. I write best in the morning.

In the evening when I got back from our six calls, I worked on ordering supplies and cleaning the supply room.

Vent

Had a really bad sleep. I dreamed I was working for a rich man on a special assignment. I had been highly recommended to him, and for the most part he was pleased with my work, and wanted me to sign on for a longer term. I told him I wanted to go back to my job as a paramedic. He scoffed and asked me how much money I made working for the rotary( he meant the volunteer ambulance and I think he thought I made nothing). He said if that's how I felt, he wanted nothing more to do with me.

Work was busy.

We took care of a 82 year old priest who fell and badly bruised his knee. He said the pain was excruciting, but he he said he had major hallucinations when he took morphine. He said the lst time he had it, he wanted to fight the whole rectory.

We were called and then cancelled on a motor vehicle.

We went to the house of an 82 year old woman where we found her in bed with back pain. She was a pack rat. Every room piled high with junk. The house stunk. Insulation hang out of the cieling. She had some Alzheimers. It made me want to go home and bag up eveything I owned except for the bare essentials and cart it all to the dump.

Went to the nursing home for the dsypnea. Found a patient with fish out of water lying on its side, last gasping breathing. The nursing home couldn't get a SAT, they said her pressure was 80/50. She also had a bloodsugar of 55, then they gave her orange juice and took her sugar again and it was 50. She could still talk, but they said she was hallucinating, talking about not being able to hold on much longer. Her belly was all distended. She had everything in the world wrong with her -- IDDM, HTN, COPN, CAD, asthma, pnemonia, renal failure, CHF, etc. She was a full code. Out in the ambulance, our pressure was 70/?, no sat, no palpable pulse. I had her on a nonrebreather as she was still talking some. I missed my first IV, then got the second. I pushed an amp of D50, after having givin her some glucagon, after not getting the first IV as the blood sugar I had gotten was 39. It was too small of a line to run any meaningful fluid through. I called ahead to the hospital and told them I had a hypotensive, hypoglycemic, now hypoventilating patient. They got a pressure of 32/20. She took 3 amps of D50 and just barely got her sugar over 100. She also got at least three liters of fluid. Then she coded, but they got her back with some epi. She had blood in her stools, a low H and H, a sky high potassium, and other screwy labs. She was unresponsive and on a vent.

84 year old female had a syncopal episode but didn't want to go to the hospital despite our insistence.

A 74 year old female not feeling well. I had picked her up earlier in the week. She was belching. Same symptoms she had then. I asked her what the doctors had told her. She had had silent MI and had two stents placed. She just got out of the hospital. On the 12 lead, she had inverted ts in the septal leads which I know she didn't have earlier in the week.

Ten minutes before crew change, we get a call for chest pain. My relief is nowhere in sight. Sucks to be me. We get updated that it is a twenty year old male. I think it is bullshit, but then we get to the house I can see a hospital bed in the back bedroom. The patient is a quad on a ventilator. He had a fever and dark urine in his foley bag. As I get the medical history, I ask how he became a quad. Spinal injury, the mother says. I ask how again. Gunshot to the neck. I know the patient. I took care of him, I say. The mother says nothing. Today we are in a small apartment. Then, almost two years ago, the scene was a nice big house. We were called for a shooting to the head, updated as shooting to the neck. We pulled into the driveway and saw two teenagers wailing. Inside we expected a messy scene, but there was little blood. Kid lying on the carpet in the living room, not breathing. He still had a pulse. I intubated him, and we raced him to the hospital. I guess they were playing Russian Roulette. He missed the major vessels, missed any bones. Severed his spinal chord. We bag him en route to the hospital. He is wearing a skull cap, and watches me as I breathe for him. He mouths that he is cold. I pull the blankets up over him, and tuck them in. He says nothing else, but I find him watching me. I wonder what he is thinking. Going to the hospital again. Not feeling well, even if he gets better, he is still going to be a quad. Always will be on the ventilator or always have to have someone breathing for him. At the hospital, the mother signs the back of the run form, and then thanks me when I say good luck.

I don't punch out until an hour and a half past crew change. Back at work at six in the morning.

OT

Okay, so I didn't pick up a shift for today. I did stop by the office and sign up for three eight hour and one ten hour OT shifts for next week so I should have daily reports all next week.

Snow - Warm Inside

How great is it when you have a day off and it snows and you don't have to go to work? Stayed in (never even went out to shovel), cooked a pork shoulder, watched American Idol. All my favorites are still in. I'm rooting for Mandisa -- the big black girl who sang "Cry Just a Little" the other night (or whatever the name of the Faith Hill song is. There are lots of good singers this year, particuarly the women.

I am going to sleep until I wake up tomorrow, and then maybe go in to work if they have an open shift or maybe I'll just take easy.

Waiting Room

Three calls today. A woman with chest pain on movement, a man with pnemonia, and a man who fell and broke his hip. The man with pnemonia was in the waiting room of his doctor's office. He had a sat of 84, a respiratory rate of 40, a heart rate of 172, a BP of 88/40 and he was confused and too weak to stand. Only his wife sat with him. As we were getting him to a gown and on our stretcher, a doctor poked his head out and said, "He has a right lower lobe pnemonia, take him down to the hospital. They know he's coming." Okay, doc. I've had a similar experience at this same office before. He calls 911, then parks the patient out in the waiting room, and goes about his business.

I was without my preceptee today, and I enjoyed just doing the calls by myself. I need to write a longer account of my feeling about precepting and how they have changed over the years. I am definately becoming more hardnosed.