Paramedic Journal : A Year on the Streets

Notice

2006-08-16T20:10:00.000-04:00

I am suspending this blog indefinately as I am becomming burned out from trying to keep it up everyday in addition to all my other projects.

I direct readers to the following blog, where I will try to post once or twice a week on the life of a paramedic and topics of interest.

Street Watch: Notes of a Paramedic

Thanks you all for reading.

Cold

2006-08-14T21:16:00.000-04:00

Driving into work I had my portable on. The medic I switch with at the beginning of the week always comes in a little early in the evening so I don't get slammed with a last minute call so I try to return the favor for him. I'm crossing the town line when I hear them paged out for a mother who's son is cold. Okay, I'm thinking code, but I'm also thinking presumption. I start that way -- it is on the other side of town. They get updated that CPR is in progress. They are already out when I arrive. I find them in the bedroom doing CPR on a middle-aged man. He is in asystole. The night medic is going for the line while the cops do CPR, compressions and bagging. I go to the head and put in the tube. His jaw is not limber -- there is a slight amount of stiffness there, but I am able to get the tube in. We work him for twenty minutes, and then call the hospital to gert permission to presume. We don't have to call, but since he is in his forties, we do. The night medic tells the mother that her soon is gone, and she starts crying, and comes over to the body and gets down on her knees and throws her arms over him and starts crying out to Jesus. (Often I give the family a chance to say good bye before we stop CPR, telling them that while we are breathing for them and pumping their heart, they might be able to carry their family's voices off with them when we let them go. I didn't even think of it this morning. Maybe because I wasn't the one running the code or maybe it was still so early in the morning. I wish that I had.) It was a very emotional scene. The night medic's partner was in tears. It was sad, but it was also one of those times when you feel good about the world because you see so clearly the love that people have for each other. The guy died young, but he was surely loved by his mother.

Later in the day we were sent for a seizure possibly not breathing. It was out a house I hadn't been too for several years, but I remembered as a psych's place. We found a semi-naked fourty year old woman in the back seizing, well, she was shaking. I wasn't convinced it was a seizure. She was hot and diaphoretic. I put her on the capnography and saw she was breathing fine and had good cardiac out. In the ambulance she admitted she had been drinking and hadn't had a drink for three years. Then she started shaking again, her whole body. On the capnography she was apneic while she shook, but it never lasted more than thirty seconds. I thought maybe she was holding her breath. My preceptee tried to line and she jerked it out. When she stopped seizing, we tried a sternal rub, but she didn't respond, but then she was awake with no postictal period. The ride in was a bit of a fiasco with us yelling at her to knock it off, her alternately seizing and swearing at us. When I told her I had to stick her to get a line, she said it had hurt the last time. My preceptee had stuck her when she was suppossedly unresponsive. We ended up giving her 1 mg of Ativan just to chill her out some. At the hospital she did her seizure routine for them, and ended up getting strapped down after she started screaming she wanted oxycodone.

Then we got sent priority one for a "severe hemmorage" at the diaylsis center on a commercial pass -- it turned out to be guy walking around with a clamp on his arm. The place was closing and after two hours he still hadn't stopped bleeding whenever they removed the clamp, so because they had to go they couldn't observe him anymore so we had to take him to the hospital.

Sammy

2006-08-13T21:14:00.000-04:00

Three calls: 1) the old lady from last week with dementia who was disorientated. Today her problem was she couldn't sleep -- she needed sleep. She slept only an hour. She had to sleep. We hoped when we brought her in might finally get some social service help, but they said she couldn't get her on Medicaid because she still owned her house. Her daughters live far away and she is losing her mind. The neighbor said she called her 22 times the day before. They put her in the waiting room.

The other two calls were for a nursing home man with sepsis and man with abdominal pain.

We spent the afternoon doing mock codes with my preceptee, using an airway maniquin and a CPR manequin. I taped a sponge in a plastic baggy to the manequin's neck to serve as a jugular vein so he could inject drugs. We used our expired epi, atropine, etc. I played "Sammy's friend," and succeeded in pulling the tube out while assaulting the crew. I had them load the mannequins and drive around the block doing CPR. Good times.

My Birthday

2006-08-12T21:06:00.000-04:00

Day off.

Beam

2006-08-11T21:44:00.000-04:00

Precepting again today. 12 hours in the city. Again, it was nice all 911s.

We did a seizure, a dsypnea, a patinet who was peppersprayed by police, an emaciated patient who we had to talk into going to the hospital, and another call I don't remember.

We were in the apartment of this old man with dreadlocks, emaciated as a Biafrin. he did not want to go to the hospital. Two big guys from some social organization had called us. My preceptee was doing a really good job talking to the guy, convincing him to go to the hospital, to get a meal, get cleaned up, and have the doctor check him out, and then helping dress him and manuever him into the stair chair, all the while the guy is going slow because I sense he worries he won't be coming back to his clutterd little apartment, where I notice two books a paperback -- "The Keys to Success" and a hardcover library book by the same author "How to make a Million Dollars.'

"Too bad, you can't just beam him to the hospital," one of the big guys said. "Just hit a button and he's there."

"Well that would be nice," my partner says, "But that would sort of put us out of business."

"No, no, it wouldn't. You'd still need someone to come and check the person out -- someone to make the decision to beam them -- someone to push the button on the beamer. They couldn't have just anybody do it."

"Well, I guess if you put it that way," my partner said.

Fast

2006-08-10T20:11:00.000-04:00

12 hours precepting. We were busy, but only one ALS call for a chest pain. The other calls were for an OD/psych, a back pain, two falls, hip, and a psych. At least the day went by fast.

Cleaned Out

2006-08-09T21:15:00.000-04:00

First patient today was a woman who I've taken care of several times over the years. She has a history of seizures. She's had them ever since she was born. Her mother had gone to, in her words, "have her womb cleaned out," and the doctor somehow missed the fetus. The fetus was wacked in the head repeatedly with the vaccum, and surprise of surprises lived through the episode, and has seizures as a result. Talk about a survivor. Poor girl works for an insurance company and has for almost a decade, but gets no benefits because she is actually employed by a temp agency.

Last call was an asthmatic, who got two treatments and was still working a little hard.

Tomorrow I am in the city to precept another medic for a few days.

Great Interest

2006-08-08T23:46:00.000-04:00

I had a vicious headache today. I don't normally eat Burger King, but I have always found it to be great anti-headache food, so on the way to work this afternoon, I stopped and got a combo whopper meal, and just as I was pulling into work, just as I opened the door to get out, my radio went off -- a call. I hate that. I had to eat my hamburger going down a bumpy road with the lights and sirens on. That takes away all anti-headache properties. The call was for an old woman and increasing regular customer, who lives alone, and whose complaint today was she just felt "all disorientated." On the drive in she told me several times about how she'd had a big supper. Meal and wheels had brought her meatballs. We had the same conversation five times. My guess was she had some dementia coming on.

Later we did a two patient MVA and a morbidly obese woman who was spitting up blood. We went to the same hospital. The disorientated woman was sitting in the hallway reading the HIPPA form I'd left her. She'd pick it up, read it with great interest for a minute, set it down, and then pick up again and read it with great interest again. She was the only person in the hallway who didn't seemed agonized about the wait.

Congested

2006-08-07T21:31:00.000-04:00

An unresponsive at a nursing home, who on inspection seemed only to be feigning. Then we were called out for an MVA only because the uninjured driver was pregnant. Just before crew change we got a call for baby not breathing, but it turned out to be either a febrile seizure or the two year old with a fever who choked temporarily on a mucus plug. He was fine, just a little congested.

Steri-Strip

2006-08-06T11:00:00.000-04:00

One thirty in the morning, patient in a nursing home threw up some coffee grounds emesis. Patient has a big psychiatric history and has some gender issues. He tries to engage me in a conversation about gender, but I chose to focus on the emesis issue.

Four twenty in the morning, patient with ABD pain and dsypnea with a COPD history. Her lungs are clear and the capnography shows a good wave form. Touch her side and it hurts.

I get back at five and sleep until nine when we get a call for a man in a nursing home who has fallen and has a cut on the bridge of his nose. The nurse has put a steri-strip there and thinks he needs a stitch. Dial 911.

A daughter finds her diabetic mother asleep on a bench in the lobby of her retirement community home while she waits for a ride. She is a diabetic. Her sugar is 343. The mother has no complaints. She says she just fell asleep. The daughter calls 911. We get there and inspect the patient's blood sugar log. Not a day goes by that she isn't up in the 300 or 400's. I have taken care of her before when it was in the 20s. I suggest we call her doctor. We sit there for almost an hour waiting for the doctor to call back. The mother is walking around the apartment telling jokes. Finally its time for her to take her insulin. the daughter is finally convinced to just make an appointment with the doctor's office for tomorrow and to call us if anything changes.

Then its three more nursing home calls -- a seizure, a CHF, and a chest pain. Nitro takes care of both patient's problems.

And now I'm home finally.

A Supplement

2006-08-05T23:49:00.000-04:00

Three-forty in the morning. Man with Alzheimer's can't pee. We take the man to the most distant hospital. History of urinary retention, can't pee, I say in my radio patch. The man is a bit of a kick. He talks about the place where he is staying: "A good place, you get three squares a day and they look after you when you are under the weather. Breakfast, scrambled, eggs, toast, some sausage, orange juice. I have major medical. People think you can rely on Social Security. You can't its only meant to be a supplement. I have a good pension."

I ask him if I could get into this place with just Social Security. "No, its only meant to be a supplement. Its a good place here. Three squares a day and they look after you when you are under the weather. Breakfast, scrambled, eggs, toast, some sausage, orange juice. I have major medical. People think you can rely on Social Security. You can't its only meant to be a supplement."

We have the same pleasant conversation about five times before we reach the hospital. I finally ask, "Well ,what do I do if I only have Social Security."

"Maybe find a dice game," he says. "Social Security is only meant to be a supplement. I'm lucky. Its a good place here. Three squares a day and they look after you when you are under the weather. Breakfast, scrambled, eggs, toast, some sausage, orange juice. I have major medical. People think you can rely on Social Security. You can't its only meant to be a supplement."

Depressed for lack of a good dice game, I don't get back to sleep until 5:15. My shift is over at six. I get up, give the narc keys to my relief, punch out, and then get back in bed and sleep until 8:30, before heading home.

This afternoon I am going to a reunion picnic for my Dominican trip, and then back to work at two for eight more hours.

***

Quiet afternoon and evening. Only did one call -- at a nursing home for high white blood count.

They were extremely short people this weekend, so since I slept most of the afternoon, I am doing the overnight again.

No Way

2006-08-04T23:59:00.000-04:00

Working the overnight in the suburbs -- always a calculated risk -- will I be able to sleep or will I do calls and be sleep-deprived for a week after? I've done three calls on the first leg -- a medical alarm, a man having cluster headaches, and an apparent miscarriage. The miscarriage came in as vaginal bleeding a couple days before the woman's period is due, no possibility that she is pregnant. We get there there is blood all over the floor, and a clotty sack that looks like it might be the beginnings of a fetus. She claims she has been having regular periods and that she isn't pregnant. I explain to her in the ambulance that from everything I have seen she is having a miscarriage. She nodds and seems to understand. At the hospital, her mother is there and the nurse tells me she keeps claiming there is no way she is pregnant.

The eleven o'clock crew comes in and not two minutes later we get called for a fall with hip pain. Its in the alzheimer's unit of a retirement community. The leg appears slightly shortened and rotated, but the man has no pain when I palpate his hips. We lift him up and gently and give him an easy ride in.

I get back just before midnight.

Now if only I can sleep the rest of the shift.

Hot Dog Eating Contest

2006-08-03T23:35:00.000-04:00

Went in for a rare six hour evening shift in the city. I was with another medic, and he said they wanted us to sign on as soon as we could because we were going to be posted down at the city park to do some kind of a standby at a hot dog eating contest. As soon as we signed on, they sent us instead on a transfer, but then a couple minutes later they took us off the transfer and assigned us to the park for hot dog eating contest. The larger event was a Battle of the Bands contest, but before that got underway there was the hot dog eating contest, and when we got there, they explained they couldn't start until we showed up. They needed us standing by in case someone choked. They wanted us on stage with our gear at the ready. I made certain we had our crick kit with us. My partner and I joked about marking everyone's crickothyroid membrane in advance and measuring them all for tube sizes.

It turned out they only had four contestants, and the contest was only going to be for 12 minutes. The champion ate all 16 on his tray and stopped with minutes to spare, although he did get a brief scare when someone told him the old guy on the end was on his second tray of hot dogs. The old guy on the end I think was in fact a homeless man who had either volunteered or been recruited to fill out the table. He only ate three hot dogs and ate them rather leisurely. We were supposed to stay around for a half hour afterwards in case any of them got sick, but all of the entrants left. We ended up staying until the end of our shift just doing a routine standbye for the concert. We sat in the air conditioned ambulance behind the stage -- the AC up so loud you couldn't even tell there was a concert going on -- reading magazines, talking about how screwed up EMS was and how we should distribute money in our 401Ks, and then at the end of the night this incredibly beautiful girl comes up and knocks on the window and asks for some band-aids. I point to my partner ans say, "Here's the band-aid man, right here. He'll take care of you," and then she asks me if we caught her set. And I said,"Yeah, you guys were smoking!" She seemed pleased with that, and my partner got her some band-aids, and I went back to reading my magazine.

Hot Again

2006-08-02T23:12:00.000-04:00

Worked from two in the afternoon until ten at night in the suburbs. It was over 100 degrees with high humidity. Only went out once -- for a child punched in the eye. Why the recreation people called an ambulance, I don't know. We couldn't tell which eye he'd been punched in. We had to wait around for forty-five minutes to get hold of a family member. He didn't want to leave his house to get the boy so we took a refusal over the phone. The cops gave the boy a ride home.

8

2006-08-01T23:03:00.000-04:00

Another hot humid energy sucking day. Started off with four straight calls.

A nursing home DNR, dialysis renal failure, MI, CHF, COPD, IDDM, etc, 80 something year old female who they found this morning with facial drop, slurred speech and a BP of 63/30.

Then a 84 year old woman who slipped in the bathroom and broke her hip. You didn't need an x-ray machine know. Unable to move leg, leg shortened and rotated, extremely painful at rest and more so on palpation of the hip. I gave her seven of morphine -- she weighed 70 kg -- before I even moved her in small increments - 2, 3, and 2, then I waited about five more minutes. We put her on the scoop stetcher with about five pillows for padding. She was still in a fair amount of pain so I called in to get permission to give her 3 more mg. I got permission for 5 more. Hooray for the doctor. She was almost pain-free when we came through the door. I was monitoring her on capnography. Her respirations which were almost 30 a minute were now to down to 8. She was still alert. She and her son, who had questioned me rather rudely when I first said my plan was to medicate her, were both very happy and thankful to us, which was nice.

Did a 24 year old pregant girl with vomiting and "seizure" activity. I had her friend describe the seizure and it didn't sound like a seizure. We got out in the ambulance and all of a sudden she started this arms and legs out straight, shaking like she was at a zombie dance party. I told her to cut it out and she stopped cold. No postictal state, no incontinence, no tongue biting. She said she was aware of the shaking, didn't know why she did it, and she thought it was strange because she was shaking, but she wasn't cold. I have a small digital camera I keep in my pocket to sometimes take pictures of accidents to be able to show the trauma team the mechanism of injury. It has a motion camera feature on it. I thought about getting it out to be ready in case she had another one of her fits -- I thought her doctors would like to see it seeing as they have been unable to make a diagnosis -- but I wasn't certain about how they fit into the privacy laws. It is an interesting question. I suppose it you had a blank disc and left it at the hospital with the patient as part of their record it would be okay.

The other calls were all at nursing homes -- some sick, some not so sick. Falls, pneumonia, etc. Total of seven calls today. Now I am home, sticky hot, sucking down a Corona and about to shower before getting in bed and turning the fan directly on me. It is supposed to be worse tomorrow. I don't go into work until two.

hot

2006-07-31T16:44:00.000-04:00

Started the day off with three calls -- a man with abdominal pain, a man in DTs, and a woman with a headache since a fall a week ago who a scan done today that showed a subdural bleed. Then we got a little bit of a break, and then responded to the town pool for a little girl with head and neck pain after someone jumped into the water on her.

It is hot out.

DVT

2006-07-30T17:49:00.000-04:00

12 hours. One call at a nursing home for a possible DVT. Spent the rest of the shift working on projects. No complaints.

Standing By the Car

2006-07-29T21:19:00.000-04:00

Worked eight hours with another medic. I thought maybe that would get me out of the transfer runaround -- that and it being a Saturday. Still ended up with three transfers, although one was ALS. I don't understand the posting and assigning of calls sometimes. We're a double medic car in an area covering two 911 towns, a car gets sent from the city to our post and we're sent into the city to do a dialysis transfer.

The other three calls were decent. A 23 year old with kidney disease, HTN and IDDM, feeling weak. She had a BP of 220/110 and a blood glucose of 390. She got admitted.

We had another diabetic not taking her meds with a high blood sugar.

The last call was for a rollover in the north end of the city. We were quite aways away when they gave it to us because we were the only car free. I have probably done 10 rollovers in this park of town. I told my partner it was probably a stolen car and there would be no patients. That's how it always is. But I was partially wrong this time. The fire department was reporting downed wires and a patient under them. Another car cleared up and was sent because they were reporting multiple patients. We got there just after they did. I went to the EMT and asked for a report as he was helping board a patient -- an older woman who was bleeding from the mouth. He said she was the worst -- the other two were minor. I said I'd take her then. I came back with the strethcer and got her on it, only then did I realize the EMT was a medic. He was wearing his baseball cap backwards like another guy at the company and when I was talking to him, I'd hadn't seen his face clearly. I apologized then for stealing his patient. He was cool about it.

The story I got at the scene showed I was partially right in my impression. The car that rolled was a new car and its occupants had fled the scene. Same as always -- they steal a car in one town, then come barrelling down a residential street into the city, roll it, and then flee. The fire fighters told me the woman was standing by the car. I thought it meant she had been standing by her car that was hit by the other car when they got there, but as we were en route to the hospital and I was interviewing her, I finally figured out she was standing by her car when she saw the car speeding down the street out of control, and the car had struck her car and rolled over it, striking her. She had a smashed up face, broken teeth, and was somewhat confused. She ended up in the trauma room.

I got off an hour late.

Two Minutes

2006-07-28T23:20:00.000-04:00

Did a bunch of transfers to start the day including a wait and return at a doctor's office. The poor woman we brought in barely fit on our stretcher. Her right side was flaccid from a stroke and we had a hard toime keeping her straight. At the doctor's office, a nurse took her BP and her pulse and listened to her heart. Fifteen minutes later the doctor came in and talked to her for about two minutes. he asked her is she had any chest pain or any trouble breathing, and then he listened to her lungs in two places while she lay on the stretcher. I offered to help him sit her up, but he said that was allright, and then he left. He wrote some notes for her, and then we left.

Other calls included a chest pain that was just hyperventilation, a motor vehicle accident and a drunk who fell down.

Tomorrow I'm only working eight.

Expired 2000

2006-07-27T19:41:00.000-04:00

Hot, sticky day. Started off with a long transfer. We drove about forty minutes to pick up a lady at a distant nursing home to take her another thirty miles to a dialysis center. I guess they closed down the dialysis center near her. I was a little annoyed when I heard a basic car calling for a medic shortly after we got the call, but I didn't mind the air-conditioned drive. My car had just been filled with freon the day before.

On the way back we were sent to a chest pain. The pain came on at work for a fifty- four year old man unrelieved by his nitro. I gave him two nitro and the pain cleared up. I looked at his nitro -- it had expired six years ago.

Later did another dialysis transfer and an old woman with a UTI.

Back tomorrow for 12.

No Complaints

2006-07-26T21:14:00.000-04:00

Worked 12 in the city. Only had to take one call -- a woman who had a syncopal episode. She was undergoing radiation and hadn't been eating. She was way orthostatic. Her pulse went from 76 supine to 92 sitting to 120 standing. I gave her some fluid and she felt better.

Other calls were for a psych off his meds with suicidal ideations, an MVA refusal, a couple transfers, a difficulty breathing that turned out to be a homeless man sleeping.

We started the day off with three hours of sitting in a suburban town. I read quite a lot of my book today.

No complaints.

Back tomorrow for 8.

Code

2006-07-25T13:14:00.000-04:00

6:03. Person not breathing. The night medic hasn't left yet so he offers to come along. I'm thinking its going to be a stiff. We get updated. "The person has a pulse, we're about to use the AED." Okay. We enter the house walk through a narrow hallway,and then down a narrow staircase, and then around some big furniture to a basement bedroom where they are doing CPR.

We enter the room at 6:10. Man in his late fifties with a diaylsis port hanging out of his chest. He's warm. Family says he was talking to them shortly beforehand. A witnessed address. He's asystole now. I intubate him. End Tidal CO2 shows a good wave form with a reading between 17 and 23. We work him hard. Doing the new CPR. I get an EJ and in go the drugs. Epi and Atropine. (Later the night medic asked me why I didn't use Vasopressin. Vasopressin! Do'oh. I never remember we carry it now. It is zipped up in a small pouch. Over a decade of this, I am programmed -- epi, atropine. I give him some Calcium. Next thing I know the ET CO2 is up to 35. We stop compressions. He's got an organized rythmn and a pulse. BP is 124/80. It is now 6:30 -- a half hour into the call. We have to package him. Fortunately we can go out through a backdoor, but there will be a hill to push him up. As soon as we get him outside, the capnography drops down to 18. Back to CPR. More epi/atropine. Capnography gets him back up. We lose him again as we push up the hill, but regain ROSC as we near the hospital at 7:00.

Going down the hall, he starts to fade out again, and even though his ETCO2 is 32, we start CPR. The rythmn looks idioventricular. They work him awhile longer at the hospital, but he doesn't make it.

The capnography was very instructive. It did the following:

1) Confirmed placement of the tube.
2) Alerted us to ROSC three times.
3) Whenever we were doing CPR and the number started to fall, we switched compressors and the number came back up. At one point, I told my partner if he could get the ETCO2 up from 16 to 20, I'd buy at Dunk'n Doughnuts. He started pounding the CPR and the number slowly climbed all the way up to 28. Stopped compressions, the number fell off the cliff almost right away.
4) Confirmed continuously placement of tube. Pulling him out of the ambulance, the wheels didn't drop properly and we almost lost him. There was a lot of jarring, but when I looked at the monitor, the wave form was textbook. Tube still in place.

Here's the capnography trend summary showing Return of Spontaneous Circulation (ROSC).

***

Just when I start to feel like a paramedic again, my next two calls are for blood oozing from a catheter in a nursing home patient and a direct admit from an endoscopy center, both of whom called 911 instead of the commercial ambulance.

Later I did a dsypnea/chest pain with an MI/COPD history that felt better with a breathing treatment and two nitro.

No Bone Scans Today

2006-07-24T21:41:00.000-04:00

Three calls. All old patients, a tough old man with chest pain and two old women who were drama queens. One complained of weakness and did a phony vertigo slow motion spin with knees buckling, all while maintaining her balance when we tried to do orthostatics. The other lady grimaced in pain when we said we were going to move her even though we hadn't moved her. She had fallen three days before and still had hip pain. The portable x-ray at the nursing home was negative, so the doctor wanted a bone scan, so they called 911 and sent us to the farthest hospital, which told us they didn't do bone scans.

Back for more tomorrow.

Cleaning

2006-07-23T19:02:00.000-04:00

The internet was down at work and the computer I use was down, leaving only one older computer with not too much on it. So I spent the day cleaning out the storeroom, cleaning the ambulance, neating the quarters. Only did one call - a man with a fever coughing up blood.

Rotten Meat

2006-07-22T18:29:00.000-04:00

First call was for a rotten smell. I was thinking dead body, but as we go there the police and fire were walking out saying it was just rotten meat, no body.

We did three calls -- a man in a nursing home with rib pain, a man status post shoulder surgery with an infection and a nursing home dementia patient who hadn't peed in 24 hours.

A rainy, drizzly day.

Mesmerized

2006-07-21T20:52:00.000-04:00

10 hour shift. The day started out very muggy. Started out with a woman who fell and banged her knee a block from the hospital and wanted a ride in. We transfered a man from a VA with dsypnea to a local ER, took a patient from another ER to another hospital where his kidney specialists were, took a patient from a nursing home to an ER because her fever just wouldn't come down with antibiotics, did a hypoglycemic refusal and ended the day with a woman with a bleeding bed sore. At one point there was a torrential downpour, but fortunately we were doing a half hour transport so didn't get wet. I was in the back with the patient and was so mesmerized by the rain I forgot to call the hospital to let them know we were bringing in the lady with the fever. It was no big deal.

Back for another eight tomorrow.

Back Yard

2006-07-20T21:18:00.000-04:00

Had the day off. Went swimming, and then had a back yard barbeque -- chicken, corn, pork chops, shrimp and a couple beers. Back in the city for 10 tomorrow.

A Good Partner

2006-07-19T20:31:00.000-04:00

12 hours in the city. I got to work today with a woman I used to work with regularly on overtime many years ago. Her regular partner was on extended leave so I worked with her most everyday as she worked on my days off, so it was great overtime for me. What I like about working with her is she is so pleasant. She never rags about the company or about any other employee. She is nice to the patients and when we aren't on a call, she parks the ambulance in a quiet location, turns the engine off and reads a book. What a difference it makes in stress levels.

Day started off with a chest pain that turned out to be a ten year old boy who's chest hurt when he moved his arms. His mother was crying. "You hear about these young children having heart attacks." We reassured her and then transported him to the hospital where he was sent to the waiting room.

We then did a mild chest pain in a 91 and 1/2 year old who did nothing but crack jokes the whole time. He was Jewish and I asked him where he was born, thinking there might be a story about fleeing Eastern Europe(its amazing the number of patients you get in a year who are holocaust survivors), his answer was "I don't quite remember, but I believe I was born in a bed." He was hard to actually get a history from because he turned everything into a joke. My partner drove the long way to the hospital -- I asked her why later and she said it was because she was so enjoying listening to our conversation.

We were sent on a "sick call" in the city and when we got there there was no fire engine outside. The fire are selective first responders. They go to what sounds like a good call. They probably have protocols they follow. They usually don't go to the sick call. It was the top floor of a three story triple decked with a narrow stairwell. The husband showed up his wife in bed. She was in her late fourties. Her skin was like ice and very clammy. I couldn't feel a pulse or hear a BP. I had to use the automatic cuff and that said 90/50 with a heart rate of 92. Her husband said she had had a near syncopal episode and complained of not being able to see. We stood her up and did orthostatics. 80/40 with heart rate of 104. Again, she had trouble seeing. I was interviwewing her and she admitted sever bleeding from her fibroid. Then she puked all over the place. My partner went to get the stair chair. I told her to leave the equipment with me. I had a bad feeling. I have in the past had a partner bring the equipment back to the ambulance when they went to get the stair chair, only to have the patient suddenly code while we were getting them on the stair chair. Anyway, she didn't code. But in the ambulance, the machine said her BP was 64/38. Again, I could get on myself, and the machine is not very reliable. I gave her 500 cc of saline by the time we hit the hospital and she was looking and feeling much better although the machine was still reading a low pressure. The people were I believe Iranian, and were very reluctant to give me her social security number so I hadn't pushed it. She hadn't seen a doctor even though she had been having periodic spotting.

We were sent to intercept with a basic car on a cardiac arrest and got there as they were loading the patient. She was a cancer patient with a DNR but no paperwork. She wasn't in arrest, but she was out of it. En route she went apneic several times. I had her on the capnography and it caputured it. All we had to do was arouse her. My plan was to just deliver her to the hospital alive so they could call her doctor and verify the DNR. That's what happened. Turned out she didn't die, but they got all the paperwork together, transported her home and called in hospice care to help the family.

We did an 80 year old with kidney stones. I gave her 2 of morphine and it made the pain go away. I also used the capnography to monitor her ventilation. When I was in Ohio a medic from Texas showed me their pain protocol where they were required to do a pre and post sedation capnography strip. Her respirations stayed the same.

It was a good day. Some medic calls and no transfers. A good partner.

I knew as soon as I walked in the door...Plantar Fascitis

2006-07-18T23:15:00.000-04:00

Get called for left foot pain. We find a three hundred pound man who says his whole left foot hurts -- so bad he can't walk on it. No trauma that he can think of. The foot is tender to touch and he can't really move it without pain, but the skin temp is good and he has distal pulses. Never happened before. He says he is on his feet all the time. I'm thinking a stress fracture or maybe some gout. At the hospital the triage nurse says, "I bet it's plantar fasciitis. She says she had it oonce and it comes from being on your feet all the time, walking on hard floors. "How about that," I say, "You learn something new everyday."

Two calls later, it's a five hundred pound woman with left foot pain. Hurts all over. No trauma. Tender to touch. "Ever had plantar fasciitis?" I ask. "No," she says. "I'm betting that's what you have," I say. "Its got to be plantar fasciitis." The cop on scene is looking at me like I am a medical wonderkund. My partner looks like he is about to pee his pants he is trying to keep from laughing.

We go to the same hospital. Same tirage nurse. I describe the symptoms. "No doubt plantar fasciitis," I say. She hits me with her clipboard.

Other than that. An uneventful day. Two nursing home pneumonias, a teenager vomiting, and two plantar fasciitises.

Air-Conditioned

2006-07-17T19:35:00.000-04:00

At the risk of jinxing myself, it has been a slow stretch in a rather slow year for me, despite working as often as I do. I've had some challenging calls, but not many. I've only done two codes in six months. That's the fewest I've ever had in such a stretch. I've had many days in the past where I have done two in a day.

Its not that I am necessarily complaining. It was hot today 102 degrees. I spent most of it in the air-conditioned base.

Today I did two calls -- an abdominal pain and a man living in filth who was alert and oriented and did not want to go to the hospital. His daughter, who hadn't seen him in four years was the one who called for the ambulance. The police ended up calling in the health department and social services.

Three Calls

2006-07-16T22:21:00.000-04:00

Three calls -- an intercept into another town where we were cancelled before we got there, an abdominal pain, and an old woman feeling faint in the heat. She was wearing a heavy coat and hat while waiting for her family to pick her up. Once inside the air-conditioning of the super market, she felt better and a relative sat with her while she waited for her daughter to get out of church and pick her up.

I spent much of the day working on my Capnography blog.

Good At the Bank

2006-07-14T19:34:00.000-04:00

Spent the first half of the day posting in very quiet locations. I got a lot of underlining done in the Capnography textbook I have been slowly going through. Some of it is very heavy reading, but still some interesting concepts.

I did four calls -- a dialysis transfer, a fall refusal, a pregnant woman who had a syncopal episode, and a motor vehicle. It was hot and there were some testy people on the job today. Its going to be very hot for the next several days so I hope people can manage.

I got out an hour and twenty minutes late, but I didn't mind. As long as my check is good at the bank.

Registry Day Two

2006-07-12T22:33:00.000-04:00

Back to work in the morning. We moved a little quicker, completing the task lists, and then compiling lists of general knowledge and skills needed for the job, worker behaviors, tools, equipment, supplies and materials, and future trends and concerns. In the end, the faciltator said he was very impressed by the array of work we did. We had 169 seperate identified tasks. He said generally each task equates to $1,000 of income, so we should be making $169,000 a year based on our responsibilities.

All and all it was an interesting process. I tried to emphasize pain management, research, and "people care" as important or needed aspects of our job. As I said before, I don't know how this will all turn out -- our role was just getting the process started.

I flew home, landed safely and after a day off tomorrow, I will be back at work.

Registry Day One

2006-07-11T23:16:00.000-04:00

Okay, here's the deal on this committee. They have selected nine field medics from across the country with various experiences and from various types of services to spend two days with a facilitator from Ohio State to do a duty/task analysis of what paramedics do to help develop a curriculm and tests based on the real world. I am the representative from the Northeast region. There are people from Georgia, Missouri, Pennsylvania, North Dakota, Idaho, Texas, New Mexico and California ranging from one year experience to fourteen -- all of them have been nominated either by a state director, company president, EMS panel or medical control authority.

Our work will just be the begining of a long process that will eventually create a definition of what paramedics do, what our core competencies are, and what should be taught and tested to produce competent medics who the public can trust.

We are to complete a breakdown of duties and tasks that will later be further broken down into job steps. Our work will be reviewed by 1000 other paramedics selected from the registry's lists, and then gone over by a panel of EMS experts from the registry's board.

A Duty is a cluster of related ideas. A Task is specific units of work. Steps are what enable you to perform the task. An example of a job, duty, task, step would be as follows:

Job: Homeowner
Duty: Maintain the yard
Task: Mow the lawn
Step: Start the Mower.

Anyway, we start out by making a comprehensive list of things we do, going around the table until we are exhausted -- everything from check the oil on the truck to defibrillate to provide grief counseling. The lists are then hung on the wall and left there. Next we try to come up with the Duty List. I think we end up with 12 or 14. I didn't write them down by they were something like this: Maintain Response Readiness, Access the Incident, Scene Management, Perform Assesment, Provide Emotional Support, Manage Cardiac Care, Respiratory care, etc, Resolve the Incident, Legal Documentation, Operations Support, Community Relations, Professional Development. Then we had to take each duty and break it down into tasks. We got through two of the duties, and then called it a day.

They took us on a tour of the National Registry Building, which was quite nice, and gave us a little talk on what the Registry was up to as far as moving to online application and renewals, as well as some of their research projects, including one almost finished that shows EMS professionals suffer from sleep deprivation to a degree unlike any other recorded profession. One of the questions was something like "Have you ever gone to a friend's house to visit and fallen asleep on the couch?"

At night we went out to a great steak restaurant and had a wonderful dinner with cold beers and got to know each other better. I was very impressed with the other medics, as well as the people at the Registry.

Back at the hotel, I turned on the wanning minutes of the All-Star game and like a typical sleep deprived EMS professional fell asleep with the TV on in the middle of the American League's rally.

Unconcious

2006-07-10T23:45:00.000-04:00

Just one call today. It comes in as a man unconcious in the driveway. My partner recognizes it as an address he responded to a couple weeks before. "He's a drunk," he says.

We find the man laying on his side a few feet away from the car. He has a suturable lac above his right eye. He is as my partner guessed -- drunk. His wife says he drove home, got out of the car and fell down -- same thing as happened two weeks before. He has no idea where he is or how he got there. He admits to having a few beers. As we c-spine him I think about the call the previous day where the bystander appeared upset that I hadn't c-spined the boy at the country club and here I am now c-spining this drunk in a poorer section of town. Why? Well, it is indicated for him. He is impaired, the boy wasn't.

We have a nice chat on the way to the hospital. He is angry at his wife because she called 911 and the police came and took his licence away(He isn't arrested -- he just will have to go to the motor vehicles department and get re-tested). I tell him she saved him from being arrested for drunk driving. He agrees she might not be too bad after all. he says he has to pee. I ask him to wait. He managed to hold it until we got to the hospital, but then when I bring the run form back to the place in the hall where they have him on a cot, I see he has already gone. He is still asking to pee, unaware that he has already gone now at least once. After calls I often debvate what i should and shouldn't have done. How is this for a dilemna -- should I have helped him with a urinal? Yeah, maybe I should have, but while I resolve to try to be a more humane medic the next time, and while it does trouble me slightly, I soon forget about it.

My relief comes in two hours early so i can get to the airport -- I am headed the Ohio to serve on a committee for the National registry looking into paramedics competencies -- whatever that means. I will soon find out.

The flight is on time, but the plane is small and rattles when the landing gear drops. I catch the shuttle to a Marriot Hotel and have a steak dinner and two beers and then head back to my room to watch SAVED. (More about the show in a later post).

I'm supposed to meet someone from the registry in the lobby at 8:30 the next morning.

The Diabetic City/ Class

2006-07-09T21:59:00.000-04:00

Walter Payton, the great Chicago Bears running back, was known as "Sweetness." I think the medics in this town deserve the same name. While we're giving out new names, I think the town should be called "-------, the Diabetic City." We have a huge population of older black people, many to most of whom are diabetic.

It seems like everyday I am doing another hypoglycemic patient. Started today off with another one. 80 year old woman blood sugar of 48. She didn't eat. Lives at home with her husband, both on the verge of dementia. I gave her some D50, she woke up. Her daughter, who was there now after being called to come over, agreed to feed her and watch her through the day, and follow up with her MD. I also talked to the visiting nurse who was showing up as we left. She said the woman needed to be in a nursing home.

I do the ordering for our service and I order cases of D50 and we just go right through them. Same with glucometer strips. This is "The Diabetic City."

***

More calls.

A woman with pain in her right leg. A woman in a nursing home with a low blood pressure accoring to the staff, who said her pressure was 88/60 and she is normally in the 130's. We took it. It was in the 130's. The woman who was blind said she felt fine.

A woman who choked twice and had to have her family perform the Heimlick manuever. The only thing was she wasn't eating and hadn't coughed up any phlegm. She said she just couldn't breath or make a sound or get any air in. Odd.

Then we got called for a child who had passed out. It was at a country club. We found the young teenage girl sitting in a chair on the ground, feet up in the air with a man holding c-spine and a crowd of people standing around. They said she had been playing golf in the heat and humidity, and then wasn't feeling well after her tournament. She laid her head in her lap, then sat up and passed out and fell over backwards. They said you could hear her head crack from across the room. The only thing was she had no complaint of pain, no bump on her head. She was a little pale. I explained to the man that I was going to follow a protocol to determine whether or not I needed to c-spine her. He seemed sort of perturbed when I asked him to release cspine so I could have the girl move her head from side to side, and he stalked off. Everything was clear -- no neuro deficits, no pain on palpation, no limit of movement. Nothing. I did orthostatics. A stepping stone change from laying to sitting to standing. I asked the family what hospital they wanted to go to and they told me. I asked if they meant the affiliated kid's hospital across the street, but they said no, they would never go there. A doctor on scene had told them this was a trauma and they had to go to the trauma hospital. A couple years ago there was a big to-do when a child in a bad MVA was diverted by the trauma hospital to the kid's hospital where the child later died in the ER. I try to explain that this is a different degree of trauma. This is actually more a dehydrated related syncope than a trauma. But they insist, which is fine. I don't argue. If the hospital, which generally only takes patients 18 and over unless it is a serious trauma gets angry at me, I will just shrug and say, family insistence.

The family is very nice, but there is a little bit of the what took you so long to get here? are you sure he doesn't have a serious head injury? -- they said they could hear her head hit from across the room. No, I can't say 100 percent, but she has no signs of one. She doesn't even have a headache or a bump on her head. She is fully alert. She isn't nauseaous, she has no vision problems. When she closes her eyes briefly, the mother urges her to stay awake. I tell her if her daughter wants to rest, that's okay, she doesn't need to keep her eyes open if she is tired. I try to reassure her. I do give the child some fluid and some D50 as her sugar is in the 70's. I also put her on the monitor.

At the hospital I give the triage nurse the story and she scribbles some notes, then calls down to a nurse in the non-trauma wing we are going to and relays my story. My partner tells me later the mother is very upset with what the nurse wrote on the notes that it doesn't reflect what happened. She evidently read the nurse's notes while I was off writing my report, which I confess I put extra effort into to make certain I left nothing out.

I understand that every patient should be treated as if they are your child and that every parent has great concern for their own child and want the best, but I am a little uneasy when I feel there are two standards of care, where when you take care of a privledged child with connected parents, you feel as though you have to be more careful, more on the safe than sorry side. I suspect that at the hospital there may be the same pressures -- the family may insist the child may get a CAT scan and more tests than say an underprivledged child would get. I feel that I gave the child top flight, appropriate care. But I am left uneasy. Maybe it is because I felt the family viewed us as ambulance drivers and attendents and not as worthy as "The Doctor" at the club or their neighbor who was once a nurse before she married.

A part of me wanted to say look, I have assessed you child from head to toe, I have taken a full history. Your child is anorexic and didn't hydrate herself and she passed out and banged her head. It happens. She needs some gatorade and something to eat, and some rest in the airconditioning in front of the TV at home. But we are happy, more than willing to take her to the hospital of your choice becaue I understand she is a child and you want to be certain everything is okay. But she doesn't need a trauma center activation. But I didn't say that. I made her comfortable, explained everything I was doing, gave her IV fluid and some sugar, and transported her to the hospital of their choice.

I shouldn't feel uneasy, but I do.

I think it is the class difference in America that bothers me.

I need to ponder more.

Back

2006-07-08T14:48:00.000-04:00

Back at work. Not in the door four minutes when we get our first call. An old man who fell and was dizzy and not feeling well. I worked him up from head to toe, put him in a hospital johnny, did a 12 lead, drew blood, etc, even filled out a blank copy of triage demographics. I got him to the hospital before the seven AM nurses came in. The night nurses don't deal with me that much, except for the ones who remember me from when I worked nights. They were all impressed that I had the patient in a johnny and the labs all drawn. They asked me to hook him up to their monitors and do the rest of their routine while they went for coffee. They asked where I was going when I didn't do that. I told them I was writing up the discharge instructions. Good to be back at work.

Next call was for a diabetic. Blood sugar of 44. I gave her an amp of D50, and while she came part of the way around, she didn't come all the way around. her sugar went up to 140. I gave her another half an amp. Still she was having trouble remembering her birth date and her social and other numbers. She said she hadn't eaten that morning or the night before, but she didn't know why she didn't eat. She had a headache and was very hypertensive. I think maybe she had a small stroke the night before, and her muddled thinking caused her not to eat that caused her sugar to go down. I took her in and thety worked her up as a medic alert. Even a hour later, she still wasn't right.

Then we did another old woman -- this time in an MVA. It was a minor low speed MVA frontal impact, and while she claimed to have had her seat belt on, she had a busted nose and massive skin tears on both arms -- she was on prednisone. En route she complained of some chest pain on breathing. She had osteoporosis. She got a trauma workup at the hospital.

Last call was for an old woman with leg pain.

Rastafari

2006-07-07T11:32:00.000-04:00

Spent a week in Jamaica. It was my third time there, but the first time I stayed outside of an all-Inclusive resort. This time I really got to see the country and to "eat the fruit off the tree." I grew grey-whiskered stubble on my face, listened to reggae music, swam in the ocean and spent a couple days in the hills. I drank Red Stripe beer, ate akee with saltfish, pineapple, lots of mango, plaintain, gnip, Jamaican pears, and lots of jerk pork and chicken, along with curry goat. By the end of the week I could actually understand the local patois.

I had this conversation with a man on the roadside while my friend's brodda was in a small market looking for dinner.

Stranger: Wa-gwan-mon?
Me: Nothing wa-gwon.

What's going on man?
Nothing's going on.

My friend's brother came out empty handed. He said. "No fish today, sea ruff."

He is a Rasta and only eats fish, no pork. Not me.

So, anyway, I'm back, rested, and as soon as I shave, I'm ready for work at 6:00 A.M. tomorrow.

Off

2006-06-28T22:46:00.000-04:00

No posts for a week. I'm off.

Croup

2006-06-27T23:28:00.000-04:00

I'm tired. Fortunately, it's been another slow day. 1 call in thirteen and a half hours. An old man with dementia feeling weak. Another hour and a half to go. Watched both World Cup games today.

If I don't work in the city tomorrow, which is unlikely, I will be off for a week as I am taking a vacation. Hooray!

Tomorrow I plan to sleep late, then do some cleaning, mowing the lawn, doing errands, maybe even going to the gymn and hitting the weights. Get to bed early, then I am off.

Get a call fifteen minutes before crew change. A five year old asthmatic, except his lungs are clear and he is satting at 100%. He has a barking cough and his throat hurts. I'm guessing its croup. I give him some humidified oxygen and he seems to be doing fine. En route to the hospital, we get diverted because our origional hospital has just gone on diversion. I end up punching out almost an hour and a half late.

Stop Grimacing

2006-06-26T22:44:00.000-04:00

Took a nurse from a nursing home to the hospital for an infected dog bite. She was feeling a little woozy, so her boss ordered her to go to the hospital by ambulance. She had a little banadage on her arm. The bite occured two weeks ago, and she had been taking antibiotics, but the arm still seemed infected. She was embarassed to go by ambulance. My general attitude is you want to go to the hospital, I'll take you to the hospital. Fly the friendly skies. Then she pulled off the bandage and showed me the bite. It was nasty. Big punture wound, all white and red and ulcerous. She was afraid she might have gotten some nursing home germs in it. Like MRSA.

We did a routine kid choking, okay, he's not choking anymore, and when we get there, he is smiling and giggling. Nothing wrong with that.

Went to a business for a man who'd had a stent put in a week ago after a stress test revealed ST elevation on exertion. Healthy young guy, younger than me. No prior problems. He said he had a 95% blockage in his LAD becfore he got the stent. The LAD. Left Anterior Descending artery. The Widowmaker. Anyway, he hadn't been feeling well for a couple days with occasional chest tightness so the nurse at his job said they had talked to his cardiologist and he might have to be recathed so they could check the stent to see if it was working properly.

Last call was for a guy with a hernia that had popped out and he wasn't able to reduce it as he sometimes could. He said it would have to be resewn -- he knew the jargon. He was in a fair mount of pain. I thought this would be a great test case for me to call to ask for morphine, but he said he would wait until the hospital. He wasn't that bad. I felt like saying, then don't tell me you're in pain, and stop grimacing if you don't want me to help you.

I taped the World Cup today and instead of missing it while out on calls, I was able to watch both games, which were very exciting.

MORPHINE

2006-06-25T20:47:00.000-04:00

Walked in the door and the buzzer went off. 100 year old lady tripped in the dark during the night and broker her arm. She said her pain wasn't bad as long as she wasn't moving her arm. I asked her if she wanted any morphine and she said no. She was a very proper old woman who had spent her life at an upper class country club and who had quite high social standing.

I have been doing a lot of thinking about pain relief. There are two groups of patients I would like to help tht I feel are being neglected. The group that says that are allergic to morphine and the group that on hearing the word morphine, immediately says no. The first group is broken down into those truly allergic and those who just get nauseous. The second group thinks either they are not hurt enough to have to get MORPHINE or that Morphine will turn them into skanked out junkies. I think the 100 year old lady was in this group. Proper ladies do not partake of morphine under any situation.

I am working with the head of medical advisory committee to try to get us to carry another drug -- either tramadol or possibly nubain that would enable some relief to these people. What I did do the other day with someone who said they were nauseous whenever they got morphine was to pretreat them with phenergan and that worked really well. I'd just like to be able to provide relief to everyone. I suppose I could have just told this old lady I was going to give her something for her pain and gone ahead and given her a little morphine without naming it.

Other two calls were for a woman with a fever and a chest pain and a woman who took twice the dose of a diet pill and felt her heart racing. I thought it was a bit of a BS call, but when I did a monitor, she had flipped T's in the inferior leads. How that compared with her old ECG, I don't know.

On Time

2006-06-24T19:57:00.000-04:00

Eleven hours fifty-five minutes and no calls, and then the buzzer rings.

Fortunately, as we're pulling out, my relief is pulling in and I punch out on time.

Of Course

2006-06-23T22:17:00.000-04:00

Old lady with Alzheimer's fell and sliced the back of her head on a door. She denied she had fallen. Her husband told her she had to go to the hospital. You're not coming with me? she asked. No, I think I'll go to a tag sale by myself, he said. What? And leave me? No, he said, of course I'm going. He smiled at me and shook his head.

We went to the health center and I ran down to the library there to see if I could find a research article. I swear librarians are the nicest people in the world. You can't find a more helpful person. The health center is near my house and I think I will just drive there whenever I want to read any research articles. They have everything. If not in the stacks, then they have it online. It only costs 7 cents a page to print out. Sometimes I've paid up to $30 for an article I desperately wanted to read.

Last call was for an eight-year old girl who ran out in front of a car and got hit. She was sitting up by the side of the road when we got there. Her sister said there was no loss of conciousness, but the girl didn't remember what happened. She had road rash on her right side and looked like a broken arm. We took her in on a priority.

We had a cookout afterwork with about fifty members, including family coming. Good food. Pork tenderloin, beef tenderloin, barbecued chicken and hamburgers and hot dogs for the kids. Then the police chief talked about how they planned to fill the EMS chief for the town position. I have mixed feelings about the job. On one hand I would love to be the EMS chief for this town. I get along with everyone well. I have lots of ideas I would like to try out, it would be a big challenge. Plus there is the town pension. But it would mean less to no time on the road as a medic. And much less money, as while the salary may be more than I make in 40 hours, it would mean no overtime pay, and there have been years when I make more in overtime than I do in straight time. Everyone got in a big discussion then about pagers, and the discussion went on and on about the right kind of pagers to get and all the problems with each kind. I guess I would rather spend my time learning about capnography than pagers. I don't know. I love being a field medic.

Who Let the Dogs Out?

2006-06-22T22:38:00.000-04:00

Began the first of what will be six days in a row in the suburbs. Started the day with the same woman from the group home I brought in on Tuesday with the abdominal pain/knee pain complaint. The people at the group home were angry tht the hospital hadn't given them a diagnosis. She was sitting in her chair, feigning unresponsiveness when we got there. On Tuesday she and I had sung "Country Roads" together, so I sat next to her and started whispering in her ear the lyrics to the song, and wouldn't you know, she starts singing: "Country roads, take me home, West Virginia!" and then she ad libbed "Who Let the dogs out!"

She stood, got on our stretcher, and we took her in. The hospital said it was the third day in a row she had been there.

Then I did a 77-year old female with increasing respiratory distress. Only respiratory history was COPD, but she sounded like she had rales. Pale diaphoretic, warm, some pedal edema. Heart rate 108. Respirations in the high 30's. Sats in the 80's. She had a nice straight up wave form. I held off on a treatment and held off on Lasix and just went with 02 by nonrebreather and nitro, and she started breathing much better. Heart rate and respiratory rate improved steadily. Sat came up to mid 90's. Did capnography change the way I practiced? No, but it gave me more confidence in not giving a treatment, which I am always leary of doing when I sense CHF. At the hospital she had a temp of 100.7. I listened to her lungs with the respiratory therapist and she said she heard crackles and decreased sounds in one of the lobes. Only a tiny expiratory wheeze when she took a really deep breath.

The City

2006-06-21T23:06:00.000-04:00

Seven calls in 12 hours in the city.

Did a lady who fell down three stairs, severely breaking her forearm and twisting her ankle. She was crying in pain. I asked her about allergies, and whether she could take morphine. She said it always made her sick. I convinced her to let me give her some phenergan first, then then I gave some morphine very slowly. I ended up giving her 12.5 of morphine, and it helped a great deal. No nausea.

The most interesting call was for an unresponsive. Obese male in his thirties with IDDM and kidney problems who hadn't been taking his insulin was found incontinent and thrashing about on the ground. His heart rate was 140. Pressure 200/100. Pupils dilated and non-reactive. Altered breathing. Respiratory rate in the 30's. I did a finger stick and only got 375. I did again and got 377. He was feverish and the hospital later said it was 103 degrees. He was a very difficult extrication. We had to use a scoop and at several places stand him up straight. I thought at one point when we were carrying up the steep narrow basement stairs that he had coded.

In the ambulance I put him on the capnography and was surprised to see a good number of 38. With the nonrebreather he was SATTing at 98. I felt a little better about the immediate prospect of him coding. Still we took him in on a priority. The hospital got 666 for a blood sugar. They knocked him out and intubated him.

Other calls were for an MVA, a neighbor hit on the head with a cane by a fellow tenant, a guy with walking pneumonia, an uncooperative nursing home patient, and a woman who fell and scraped her legs.

Could Be Old, Could Be New

2006-06-20T21:52:00.000-04:00

Back at work. Slow day. A woman at a group home claiming first abdominal pain, and then knee pain. A nursing home call for an old fall with a questionable xray. Could be an old fracture of the shoulder, could be a new one. Patient not in much distress. Then a motor vehicle with no injuries.

I’m not complaining.

New Report on EMS

2006-06-19T10:06:00.000-04:00

The Institute of Medicine has just released a series of reports about the nation's EMS system, including one prehospital care. I am still away, and have only glanced at it, but plan on reading it in detail. Here's a summary:

"Emergency Medical Services (EMS) is a critical component of our nation s emergency and trauma care system, providing response and medical transport to millions of sick and injured Americans each year. At its best, EMS is a crucial link to survival in the chain of care, but within the last several years, complex problems facing the emergency care system have emerged. Press coverage has highlighted instances of slow EMS response times, ambulance diversions, trauma center closures, and ground and air medical crashes. This heightened public awareness of problems that have been building over time has underscored the need for a review of the U.S. emergency care system. Emergency Medical Services provides the first comprehensive study on this topic. This new book examines the operational structure of EMS by presenting an in-depth analysis of the current organization, delivery, and financing of these types of services and systems. By addressing its strengths, limitations, and future challenges this book draws upon a range of concerns:

The evolving role of EMS as an integral component of the overall health care system.
EMS system planning, preparedness, and coordination at the federal, state, and local levels.
EMS funding and infrastructure investments.
EMS workforce trends and professional education.
EMS research priorities and funding.
Emergency Medical Services is one of three books in the Future of Emergency Care series. This book will be of particular interest to emergency care providers, professional organizations, and policy makers looking to address the deficiencies in emergency care systems. "

Here's the link to read it on-line:

Emergency Medical Services:
At the Crossroads

Away

2006-06-16T10:58:00.000-04:00

I am away for a few days. I will be back posting on Tuesday.

Clearance

2006-06-15T19:40:00.000-04:00

Eight hours. Four calls.

Started off with a man in his thirties with sciatica. His pain was so bad that he couldn't move. He was allergic to sulfa drugs so I couldn't medicate him. I have run into a number of morphine or sulfa allergies lately and it has me wondering about investigating alternative drugs for us to carry so these people won't be denied pain relief prehospitally.

We were called for an unresponsive and found a man cold and clammy out cold leaning against a fence. I was think ETOH, but when I checked his sugar I found it was LO -- less than 20, so I gave him some D50 and he woke up. He was fasting and on his way to see his doctor to have his blood work drawn.

We did a long distance VA transfer and then an MVA. The woman was cspined when we got there. There were two victims -- each going to different hospitals. On assessement, her pain was just in her shoulder and across the seat belt harness. I went through the clearance with her and was able to take her off the board en route. That made her much more comfortable. She had been carsick, nauseous and anxious.

I really want to push the BLS spinal clearance. It is an easy protocol to follow. The other day I saw a woman c-spined in triage and she was crying because she had to pee and they wouldn't let her off the board, and she didn't really even have an injury -- she'd been in a low speed MVA, and her she was all in her business suit and she had to pee and the truage line was long and they were yelling at her to quit moving around.

In a Row

2006-06-14T21:41:00.000-04:00

Worked 12 hours in the city. Six calls. Six emergencies.

A chest pain at a medical facility. They gave the poor guy three nitro, 2 of morphine and he says 10 baby aspirin. The nurse said three, but he said other nurses gave him more. So they were on their toes about the need to give ASA for chest pain. The problem was his pain was in his back and it was clearly reproducable. he flinched when you touched a certain spot. been going on for two days. Good 12 lead. The drugs they gave him dropped his pressure to 80, but then it came back up to 100. He was a COPDer on a cannuala at 2. The nurse said he couldn't get more than two. She said when she put him up to three, his SAT dropped from 91 to 86. I asked how that was possible. She said it was because he was a COPDer. But his SAt still will go up if you increase his oxygen. he's a COPDer, she said. I just looked at her. Since he was a little short of breath, I bumped it up to 3 in the ambulance, his SAT went up to 95 and he said he felt better.

We did a nursing home hemoturia, a 31 year old with abd pain, a 34 year old with a sore throat, a 60 year old obese woman with an arthritic hip, and an unresponsive diabetic.

The lady with the arthritic hip was the great grandmother. She weighed about 350, the grandmother was three hundred, the mother was 250, and the daughter who was maybe five was a little fatty at maybe 100. I wanted to line them all up and take a photo.

Working eight tomorrow.

No Quorum

2006-06-13T20:55:00.000-04:00

We didn't have a quorum at the Regional meetings today, but we still talked about the agenda items. There was some contention about my proposals for spinal clearance for basics and morphine for undifferentiated abdominal pain, but more support than opposition.

I went into work afterwards, but the only call so far has been for an abd pain with fever.

2-0

2006-06-12T19:35:00.000-04:00

Two calls -- an MVA for neck pain and a nursing home fall with no apparent injury. I've been watching World Cup Soccer and was hoping to be able to see the USA-Check game. The Checks were up 2-0 and in full control when we were called out, so that was okay. They lost 3-0.

Tomorrow I have my monthly EMS Regional meetings and then I am going in to work a four hour shift.

Insisted

2006-06-11T17:12:00.000-04:00

Checked another prisoner. Took a kid with some scrapes from falling off his bike to the hospital. Mom insisted on the ambulance.

Got lots of work done on my capnography site today. I'm leading a journal club discussion in another week or so on some capnography articles. Very interesting. One article points out that supplemental oxygen can obscure impedending ventilatory crisis unless you have capnography. Pulse oximetry is only good without supplemental 02.

Here's the article conclusions:

Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial.

Pediatrics. 2006 Jun;117(6):e1170-8.

CONCLUSIONS: The results of this controlled effectiveness trial support routine use of microstream capnography to detect alveolar hypoventilation and reduce hypoxemia during procedural sedation in children. In addition, capnography allowed early detection of arterial oxygen desaturation because of alveolar hypoventilation in the presence of supplemental oxygen. The current standard of care for monitoring all patients receiving sedation relies overtly on pulse oximetry, which does not measure ventilation. Most medical societies and regulatory organizations consider moderate sedation to be safe but also acknowledge serious associated risks, including suboptimal ventilation, airway obstruction, apnea, hypoxemia, hypoxia, and cardiopulmonary arrest. The results of this controlled trial suggest that microstream capnography improves the current standard of care for monitoring sedated children by allowing early detection of respiratory compromise, prompting intervention to minimize hypoxemia. Integrating capnography into patient monitoring protocols may ultimately improve the safety of nonintubated patients receiving moderate sedation.

Bottom Line for EMS:

Capnography provides early warning of respiratory compromise.

Supplemental oxygen impairs detection of hypoventilation by pulse oximetry.

Chest. 2004 Nov;126(5):1552-8.

CONCLUSION: Hypoventilation can be detected reliably by pulse oximetry only when patients breathe room air. In patients with spontaneous ventilation, supplemental oxygen often masked the ability to detect abnormalities in respiratory function in the PACU. Without the need for capnography and arterial blood gas analysis, pulse oximetry is a useful tool to assess ventilatory abnormalities, but only in the absence of supplemental inspired oxygen.

Bottom Line for EMS:

Without capnography, supplemental 02 can obscure impending respiratory problems.

Concordance between capnography and arterial blood gas measurements of carbon dioxide in acute asthma.

Ann Emerg Med. 2005 Oct;46(4):323-7.

CONCLUSION: In adult asthmatic patients with acute exacerbations, concordance between PetCO2 measured by capnography and PaCO2 measured by arterial blood gas was high. These findings must be validated before capnography replacement of arterial blood gas as an accurate means of assessing alveolar ventilation in acute asthma is recommended.

Bottom Line for EMS:

Capnography may provide a reading as accurate as ABGs.

Cold Pizza

2006-06-10T22:24:00.000-04:00

I worked a 16 in the suburb. A 16 can be great on a Saturday, but today we were busy at least early on. Started off with an MVA where we took a mother and a daughter to the hospital with neck and back pain. They were struck from behind at a low speed and did not appear to be too injured.

Then we did back to back nursing home pneumonias – both pretty severe. One patient had COPD. She was SATTING at 88% on a cannula at 2 lpm. Her temp was 103. Her respiratory rate was 60. I put her on the capnography and she was rebreathing, meaning she was breathing in before she was done exhaling. Her capnometer was 20, which is low. I put her on a nonrebreather at 15 lpm. Her SAT went up to 99%. Her respiratory rate went down to 36. Her wave form leveled off, and her capnometer went up to 32, close to normal. Then after about ten minutes, I tried to put her back down on a cannula –same thing happened – she went back into a higher respiratory rate with rebreathing, declining SAT, and declining capnometer. At the hospital the nurse said she was getting too much 02. I told her how I had tried to wean her down, showed her the capnography waves and numbers and made a remark about the hypoxic drive being more theory than clinical experience. She said maybe she would try her on a vented mask. Worth a try, I said. When I came back two hours later, she was still on a mask.

We checked out a prisoner with a bruised arm and took a man bleeding from his dialysis shunt to the hospital, even though the bleeding had stopped.

Doesn’t sound like a lot of calls, but all back to back, particularly when you had an uneaten large pepperoni, sausage and onion pizza in the front during two of them, it seemed like a lot.

The night ended quiet.

Report

2006-06-08T08:43:00.000-04:00

1:30 in the morning, the buzzer goes off. Call for a person at a nursing home who the nurse says is faking it and just wants to go to the hospital, but is complaining of chest pain. Great. I sleep walk out to the ambulance. We drive there without lights and sirens simply because we will get there in the same amount of time either way because no one else is on the road. The nurse meets us at the door. We wheel the stretcher in and ask which way. "Out of the way," she says, "I need to lock the door." Okay.

She leads us to the room. She seems very annoyed. On the way, she says, "I shouldn't be telling you this, but he is faking, There is nothing wrong with him, but I had to call the doctor and he said send him in."

The patient is familiar to me. I've taken him in in the past. He is a COPDer. The nurse is back with the paperwork, which she is giving to my partner. "I need that," I say. She looks at me, but then back at my partner, still trying to hand him the paperwork and talk to him. "No, you need to talk to me," I say.

"Don't talk to me like that," she says.

What? "Excuse me, you need to give me the report. What exactly is going on with the patient?"

"I'm not talking to you. He's an EMt, I can tell him."

"I'm the one who's going to be taking care of the patient, you need to give me the report."

"Well, how would I know that?"

"That's why I'm telling you, you need to talk to me."

"I'm not giving you the report."

I feel like I am in a dream. I haven't raised my voice, I haven't done anything and this nurse is yelling at me at two in the morning.

"Look, you dialed 911. You have to give a report."

The police officer has come over to intervene now.

"Let's think about the patient," he says to her. "You need to cooperate with us."

"He can read it, but I'm not talking to him."

"I can't read it," I say.

The light in the hallway is dim and the writing is not the clearest.

I finally get some semblance of a report. She says he was belligerent and threatened to kill himself because she wouldn't call an ambulance. And that he is all the time faking illness. I ask if he has psychiatric problems. He does, she says. Wht meds is he on? It should be on there, she says. I hand her the paperwork back. She looks at it. It lists nothing. She has to go get the med list for me. I talk to the patient. He refers to the nurse as a B----. He says he has chest pain, the runs and hurts all over. He says he just got out of the hospital following a three day stay for pneumonia. None of that is on the W-10. We load him on the stretcher and go.

I call for times and the dispatcher asks what did we do to the nurse. She called to complain about me in particular. I tell the dispatcher I'll write an incident report.

I do. I write about how she said the patient was faking and how he had to threaten to kill himself to get her to call for an ambulance.

She'll have to give another report to someone else.

Hoping

2006-06-07T22:33:00.000-04:00

Working a sixteen hour overnight. I taught skill sessions this morning, and then came to work. Did one call -- a woman with a possible infection. I get off at six in the morning, I don't like overnights so I am hoping it will be quit. Being up all night can wreck the rest of my week. Its so always a gamble. getting paid to sleep or getting paid to be sleep-deprived.

Expert

2006-06-06T21:17:00.000-04:00

I could be an expert in a lot of things I suppose. I could be like this super hedge fund guy -- a guru who knows the ins and outs of the market. I could be a lawyer specializing in the intracacies of the tax code or maybe a wilderness guide who knows the forest like a feral animal. Instead, like many of my peers in this profession we call EMS, I am an expert in picking people up off the floor. Today we used one of my favorite moves to get a huge person up. Lay them on a board, strap them in, then with a person on each side and me at the head, I lift the board up to a standing position while they balance the patient, and a family member gets the walker or wheel chair, then we unclip the patient, they thank us, we get a refusal, and put our board and clips away. Another job well done.

Two lift assists today and an old man with pneumonia.

No Where

2006-06-05T20:10:00.000-04:00

In the suburban town where I work several days a week there are four full-time medics, three ambulances and two sets of ALS bags, one LifePack 12. Each medic is assigned an ambulance. I share an ambulance with the other day medic, as well as the same set of ALS gear. I come in in the morning, check my gear, and then don't have to worry about it for the rest of my week as I am the only medic using it. What I do do each morning is switch the narcatics into my ambulance along with the Life Pac 12, the pedibox and the spare drug box. This week, the mechanics came early in the morning, woke us up and said they needed to take one of the ambulances. I took the gear out of the ambulance, but by mistake I left the other medic's ALS bag in the ambulance they took down to the garage so when he came in that night, he had to use my bag. This morning they brought the other ambulance back. I switched the narcs, the Life pack 12, the pedi box and the spare drug kit.

Our first call was for a minor motor vehicle that was going to be a refusal until at the last moment the man balked at signing the refusal and said, hell, he might as well go to the hospital. My partner, who is new because my regular partner is away this week, set up the stretcher, and then we took a nice ride in. Later in the day, we were sent for dsypnea at a cardiologist's office. After we pulled in, I glanced in back to see if all the gear was on the stretcher. Guess what? Where's the ALS bag? No where.

I threw the spare house bag and the spare drug kit on the stretcher and prayed that the patient would not need to be intubated. It turned out all right. He just needed a treatment and I was able to get a nebulizer off the shelf along with atrovent and albuterol from the spare drug kit. Still. A close one.

It wasn't the first time I have forgotten something. See : The Stretcher

We drove back to the base, got the ALS kit, only to discover we had the patient's cane. We took the cane back to the hospital and realized we had left our 02 tank at the hospital when we saw it sitting orphaned in the hallway. Then I went back to the ambulance and found my wallet had fallen into the doorway, and was half-in/half-out of the rig. What a day.

Last call was for a woman at a charity benefit with abdominal pain. It was right lower quadrant pain, dull and crampy, sudden onset. Did not increase with movement. I thought it might be kidney stones. The pain came and went. She was related to someone because two doctors met her at triage and started examining her there, much to the annoyance of the triage nurse. She didn't know the older doctor who was spouting possible diagnoses. The other doctor, an ER resident, looked apologetic and mouthed she was asked to examine the patient.

Dumdum

2006-06-04T21:51:00.000-04:00

Just two calls today -- a three year old who swallowed a dumdum lollypop and then told his mom his throat hurt and a 77 year old man with a TIA that resolved as we were arriving.

Note/SuperImposed

2006-06-03T17:09:00.000-04:00

We were sent to a group home for a fall only to find an apparently uninjured 50 year old woman with Down's laying on the floor, saying her back hurt and to call her mother with the bad news. The aide was on the phone telling her supervisor they had called the ambulance to cover themselves. The physical survey was unremarkable. The aide told me the woman had hit her while they were arguing over a napkin, then the woman had pulled at the napkin, then let go, hit against the wall, then fallen slowly to the floor.

I have been a really good paramedic since I came back from the Dominican. I just really have been at the top of my game both medically and as importantly with the bedside manner. I have been battling some bad news about the health of a friend and it was starting to break me today, and I snapped at the driver on the way to the call for going to slow looking for a turn when clearly there were no turns visible. Anyway, I have been to this home many times before often for similar calls, so I just ask which hospital, put the patient on the stretcher and take them in. It is easy than getting upset, and it isn't even my place to get upset.

So we're riding in and I am reading through the big blue book with all the patient's history, and here is the gist of the patient's story. Born to older parents, she lived with them at home for many years. Her mother is a nurse, and she often went in to work with her and volunteered helping the elderly patients. She was beloved. Her father died, and then, her mother aged now and in a wheelchair, was having a harder time taking care of her Down's daughter, who getting older herself started having some mental problems, and one day, attacked the mother. The mother scared of her daughter could no longer care for her and the daughter had to be removed and was placed in this home a few years ago.

Here is what the nurse wrote in the notes introducing the patient to the staff:

"This is a very difficult and confusing time for Y. She was born with disabilities and her family embraced her and cared for her throughout her life. Her parents aged. Her father died and her mother is increasingly frail. This is frightening to her and she has no idea how to manage in the future.

As a result of her Down Syndrome, she is more likely than we are to have problems with dementia. That means that her memory is failing her and that she has to come up with an explaination in her own mind for the things that no longer make sense because her memory is failing her. She has created a host of "friends" who are part of her everyday life, as well as the notion that she is pregnant and will soon have another child. What a wonderful way to surround yourself with the family that you see is dying off!

The false ideas that her mind creates serve to provide comfort and safety against fears of aloneness and isolation that she cannot imagine she could endure. We have to learn how to live with these things and to help her to feel more secure.

The memory loss that comes with Alzheimer's Type Dementia can be hard to deal with. And it can be seen as a wonderful protection against the many things that memory would serve to present as unbearable. Imagine being more than 50 years old and having nothing but the security of your parents love. So, as memory fails, and fears of being left alone in the world increase, you develop ideas about any number of people who will be here to share your life.

As we care for Y and come to learn her strengths and limitations, we must also understand that her life has been very different from ours and from the lives of people whom we are accustomed to serving. Until today, she has been protected by the love of family that many we serve have never known. And it was her behavior that brought that to a halt.

While we have many thoughts about how wonderful it is to serve people who would, without the care we give, be in institutions, we must understand that Y has known a lifetime of family and safety. We are not rescuing her from something awful, we are supporting her in a time of tremendous loss and separation."

You find poetry in most unexpected places.

***

Only other call was for an old obese woman diabetic, short of breath with a high blood sugar.

***

I was supposed to work in the city tonight starting at six. Ten minutes to six a call came in for a motor vehicle and we responded to find a Saab wrapped around a telephone pole. The patient was pinned in the driver's seat, the door against her hip, the airbag deployed, the steering colum broken, and the patient was screaming about how bad her head hurt. It was split open in back. I didn't think we were going to be able to get her out of the car with out the fire department. Two of the cops were banging away against the passenger door. I was talking to the patient through the window. I made sure to tell him my name and say I would stay with him. I kept looking up at the wires on the telephone pole. They weren't loose or anything, but I was standing right under them. the car was rocking. It was on an incline. Glass was flying. I got an 02 mask on him and a collar, and amazingly the cops got the door open. I still didn't think we were going to get him out. The door was halfway across the front seat. I went in through the now open passenger door and was able to link and pull her him out onto a board. He was very pale. His hip was killing him now. We got going to the hospital right away. His heart rate was up 160. He was screaming for me to give him something for his pain, but he wasn't stable enough for me to give it to him. The night medic had met me on scene so he rode in with me which was great. We got the trauma room and he was headed for surgery when we left. The x-ray of his pelvis looked like two people superimposed. The left side was almost on the right.

I was in the EMS room writing my report when I saw the other five people reach for their pagers. Then all said at once to me, they're looking for you, you're supposed to be in the city. You're on the schedule. I called in and told the supervisor I had arranged with another supervisor a couple days ago for them to come get me in an ambulance at the suburban post at six and then drop me off there at midnight, and he said it was all set. The message didn't get through. I told the supervisor I was still at the hospital. They didn't have anyone to work with me anyway, and since I was beat, they said I could just go home, so tonight instead of eating in the ambulance in the rain, I've had a steak and a beer and some fried green plantain, and am soon for bed.

TPA

2006-06-02T21:24:00.000-04:00

35 year old male sudden onset of difficulty speaking and extreme right-sided weakness -- unable to move right arm, facial droop. 3 out of 3 on the Cincinnati Stroke Scale. No prior history of CVA. Mother calls 911. We are there within ten minutes of onset. Quick stair-chair down to the ambulance. We do everything en route -- Vitals, 02 by cannula, IV, Blood sugar check, 12 lead ECG -- notify the hospital of a stroke alert. We are at the hospital within 25 minutes of onset. We are talking to the doctor within 30 minutes. The patient is whisked right off to CAT scan. He comes back with a clean head CT -- no bleeding. The doctor tells the nurse to get the TPA ready. When we come back two hours later, the patient can move his right arm, shake my hand, and while his speech isn't perfect, he can now say his name.

So many times you get called, and the symptoms are hours old or no one can pinpoint the start time or if they can, and its within the window, there is an exclusionary factor. It was great to have a case where it all worked the way it was supposed too.

Did three other calls -- a woman who took a coworker's pepcid and felt quesey, an old man who'd been on the floor since 4:30 the other's day's afternoon and who had horrible cellulitis with weeping sores, and an old woman with dehydration who I had taken in two weeks before for the same problem.

Morphine Proposals

2006-06-01T22:18:00.000-04:00

Two days off. I did some EMS project work. I put together three proposed protocol changes along with the backing science. One involves asthma -- making SoluMedrol a standing order and adding Magnesium for severe asthma, also on standing order. The other two both involved Morphine, and are an excellent example of how research is changing the way we practice (although I am not certain the committee will go along with my suggestion). I am proposing to make morphine for undifferentiated abdominal pain a standing order at a "judicious" dose of .05mg/kg before having to call medical control. The dose for fractures and burns is .1/mg/kg. I am also proposing that morphine for chest pain be taken off standing order and returned to a medical control option because of recent research suggesting that not only may morphine may not help patients with Acute Coronary Syndrome, it may contribute to their deaths.

Here's an excerpt from my proposal:

Proposed Protocol Change # 1:
Morphine for Undifferentiated Abdominal Pain

The Change:

In the Pain algorithm under Other Pain, change the heading to “Abdominal Pain (possible kidney stone, sickle cell anemia or undifferentiated pain)” and include the following:

If patient is hemodynamically stable: Administer .05 mg/kg Morphine Sulfate (MS) SIVP to a max of 5mg.

Establish Medical Control

Possible Physican Orders:

Additional MS

Also, add the following footnote:

“This change is due to recent research that shows morphine does not hinder abdominal pain assessment, and may in fact improve diagnoisis. Thus paramedics may give “a judicious dose” of morphine (.05 mg/kg) on standing order to patients with non-traumatic abdominal pain. Additional needed morphine may be requested upon contact with medical control.”

Background:

Withholding morphine for abdominal pain in the belief that it might mask pain, delay diagnosis and contribute to mortality has been a long-standing practice in medicine despite the lack of any research supporting such a practice. As medicine has turned to evidence-based practice and with a concern toward alieviateing patient pain, as well as the presence of increased laboratory and imaging tools, there has been a paradigm shift on this issue.

“The judicious use of analgesics in the setting of acute abdominal pain is appropriate.”
-Cope’s Early Diagnosis of the Acute Abdomen
2000 Edition

“Administration of narcotics to patients with abdominal pain to facilitate the diagnostic evaluation is safe, humane, and in some cases, improves diagnostic accuracy. Incremental doses of an intraneneous narcotic agent can eliminate pain but not palpation tenderness. Analgesics decrease patient anxiety and cause relaxation of their abdominal muscles, thus potentially improving the information obtained from the physical examination. There is evidence that pain treatment does not obscure abdominal findings, or cause increased morbidity or mortality.”
-Clinical Policy: Critical Issues for the Initial Evaluation and Management of Patients Presenting With the Chief Complaint of NonTraumatic Acute Abdominal Pain
American College of Emergency Physicians, 2000

“It should be recognized that no study establishing negative outcomes (of giving MS to patients prior to surgical exam) of any sort has been published. Humane treatment of suffering should therefore be the only argument required to treat abdominal pain.”
-Pain Management and Sedation: Emergency Department Management
McGraw Hill, 2006

Studies- (Full Abstracts and Additional Related Studies attached in Science Document)

1. Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial.
J Am Coll Surg. 2003 Jan;196(1):18-31, Thomas SH, Silen W, Cheema F, Reisner A, Aman S, Goldstein JN, Kumar AM, Stair TO.

CONCLUSIONS: Results of this study support a practice of early provision of analgesia to patients with undifferentiated abdominal pain. Copyright 2003 by the American College of Surgeons

2. Intravenous morphine for early pain relief in patients with acute abdominal pain. Acad Emerg Med. 1996 Dec;3(12):1086-92. Pace S, Burke TF.

CONCLUSIONS: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients.

3. Intravenous Morphine in Emergency Department Patients with Acute Abdominal Pain Does Not Alter Disposition Decision, Acad Emerg Med Volume 12, Number 5_suppl_1 18-19, David Esses, Polly Bijur, Conroy Lee, Michael Lahn and E. John Gallagher

Conclusions: The decisions to admit or discharge patients with acute abdominal pain were comparable, regardless of the administration of morphine.

Proposed Protocol Change #3: Make Morphine Medical Control Option in ACS

While Morphine as been a tradition of ACS care (evidence MONA), recent research suggests it may increase mortality. While not removing it entirely from the protocol, I suggest it now require a medical control option.

Am Heart J. 2005 Jun;149(6):1043-9.

Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative.
Meine TJ, Roe MT, Chen AY, Patel MR, Washam JB, Ohman EM, Peacock WF, Pollack CV Jr, Gibler WB, Peterson ED; CRUSADE Investigators.

BACKGROUND: Although intravenous morphine is commonly used for the treatment of chest pain in patients presenting with non-ST-segment elevation acute coronary syndromes (NSTE ACS), its safety has not been evaluated. The CRUSADE Initiative is a nonrandomized, retrospective, observational registry enrolling patients with NSTE ACS to evaluate acute medications and interventions, inhospital outcomes, and discharge treatments. METHODS: The study population comprised patients presenting with NSTE ACS at 443 hospitals across the United States from January 2001 through June 2003 (n = 57,039). Outcomes were evaluated in patients receiving morphine versus not and between patients treated with morphine versus intravenous nitroglycerin. RESULTS: A total of 17,003 patients (29.8%) received morphine within 24 hours of presentation. Patients treated with any morphine had a higher adjusted risk of death (odds ratio [OR] 1.48, 95% CI 1.33-1.64) than patients not treated with morphine. Relative to those receiving nitroglycerin, patients treated with morphine also had a higher adjusted likelihood of death (OR 1.50, 95% CI 1.26-1.78). Utilizing a propensity score matching method, the use of morphine was associated with increased inhospital mortality (OR 1.41, 95% CI 1.26-1.57). The increased risk of death in patients receiving morphine persisted across all measured subgroups. CONCLUSIONS: Use of morphine either alone or in combination with nitroglycerin for patients presenting with NSTE ACS was associated with higher mortality even after risk adjustment and matching on propensity score for treatment. This analysis raises concerns regarding the safety of using morphine in patients with NSTE ACS and emphasizes the need for a randomized trial.

As I said, we'll see if the committee goes along with me. I expect that in five years what I am proposing will be standard everywhere. But the reaction now may be. We don't want to ruffle the surgeon's feathers, even if most of them agree with giving pain meds prior to their exam, and since MONA is still in the 2005 ECG Guidelines, who are we to change it. My arguements will be EMS doesn't always have to be the tail. We can be the dog. And as far as surgeons who are concerned that morphine may take away their ability to conduct an exam, as I read in a book in the medical store bookstore(Having already bought one $60 pain management book) one word to them NARCAN. Let them explain to the patient that they need to put them back in excruciating pain in order to try to figue out what is wrong with them.

Uplifted

2006-05-30T19:06:00.000-04:00

A man with his finger slashed by a lawn-mower, a nursing home aspiration pneumonia, and a young mother having a hard time dealing with stress. I'm doing a good job today of being thorough and being nice. Even though physically I'm still a little tired from trip. Mentally, I am quite uplifted.

Last call was for a woman worried she might have chest pain and feeling a little short of breath. Under stress. We took her in and made her feel better.

I'm off tomorrow.

Shock

2006-05-29T19:23:00.000-04:00

Went to a nursing home for the unresponsive. The nurse explained the man was dying of lung cancer and was a full code and had no family. He was awake now, she said, but she had to sent him in because he was a full code. The man was fully alert and had no pain and good vitals. I think he was just sleeping.

Today was the Memorial Parade and the ambulance was supposed to be in it -- all three of our ambulances. I was glad when we got a call. I'm just not a parade kind of guy. The call was for a man's defibrillator going off.

When we arrived, it had gone off four times already. I put him on the monitor and it looked like V-tack.

Then all of a sudden, his whole body convulsed in pain and he cried out. The artifact was caused by the wires moving as his body convulsed with in pain.

It shocked him once more before I could get the line in and start giving him some 150 mg of Amiodarone over 10 minutes.

Here's the initial 12-Lead:

Shocking is incredibly painful. This guy, who even though he was diaphoretic, was joking with us, and then when the defibrillator went off, his whole body winced in pain, and he started cussing at me to hurry up and give him the medicine. I also gave him some Versed, and then hung an Amio drip at 30 mg/hr. He didn't get shocked again and felt much better.

His final rhythm was hard to determine. It was still very funky, but his rate slowed from the 150s to 100 and he was perfusing better. It was irregular. His wife said he only had 1/3 of a functioning heart.

In the hospital his rate was down in the 80's and showed his pacemaker kicking in.

He was better and thankful to his defibrillator and to us. We missed the parade and I was thankful to him.

Last call was at the same nursing home for the unresponsive diabetic with a CVA history and a blood sugar of 150 according to the home. We took her out to the ambulance and checked it. 28. Fixed that.

Back to Work

2006-05-28T14:26:00.000-04:00

I'm at work. Tired, but here.

First two calls were for an assault on which we got canceled and a young woman with vomiting. She looked very sick -- the kind of sick where you don't feel like talking or even getting up to sit on the stretcher. Only in her twenties, renal diaylsis, hypertension, obese. I've been picking her up for years. Today she had a fever and looked like she'd put on another thirty pounds since last I saw her.

Last call was for a man who broke his leg in his driveway. He was in some serious pain. I ended up giving him 15 of morphine. At the hospital he thanked me for taking such good care of him. He was finally high by then, but at least I took some of the pain away.

Saturday - Arrival Home

2006-05-27T23:45:00.000-04:00

We awoke at five-thirty, loaded our bags on the school bus, grabbed a quick bite to eat, and then were off on a four and a half hour bus ride. We went a different route than we came -- more highway but longer. The trip featured two types of traffic jams -- cows in the country, and standstill traffic of people and cars and scooters in downtown Santo Domingo.

A number of people on the trip were having GI problems and we had to make one unscheduled rest stop so people could run to the bathroom. I was lucky -- other than a brief episode one night, I came off fine. At the scheduled rest stop I finally got my tostones - fried green plantain -- and they were very good. The airport and customs at San Juan were all a pain, but we made it through fine. I always get stopped and searched. I think it has to do with my passport photo where I have long hair and a big mustache and look like a drug Lord. This time on my MP3 player I had Arlo Guthrie's "Coming into Los Angeles" playing. (Coming into Los Angeleez, Bringing in a couple of keys...Don't touch my bags if you please, Mr. Customs, man."

I read the Da Vinci Code on the plane. It kept me turning the pages, but I was never really engaged. When we landed home at 9:40 P.M. I still had twenty pages to go, but no real desire to finish. After picking up our bags, we said quick good-byes, and then went our seperate ways. Everyone was very tired. I crashed as soon as I got home.

Good to be home, but still, I'd love to go back soon.

Friday

2006-05-26T20:48:00.000-04:00

We just had a half day today, doing small cases, and then packing and loading.

For the week we did sixty surgeries and almost two hundred consults.

In the afternoon a small group of us went with some of our local hosts on a boat trip through a mangrove swamp and out into the ocean, where we were taken to a spectacular beach.

The Dominican is a poor, but beautiful country. The people were so nice to us. They were so grateful. I am grateful to them. Trips like these help all of us. They remind you of what the world, of what we all should be about.

I hope to always come back.

Thursday

2006-05-25T23:54:00.000-04:00

Since we are all done with triage, I went into the OR this morning. Going in there is like being in the Discovery Channel. Last year I scrubbed in on a gall bladder and got to stick my hands in the body to hold up the liver for the surgeons. I really wanted to do the thyroidectomy this time. I got to palpate the trachea and the crico-thyroid membrane with all the skin removed. Fascinating. The doctor told me, even with the skin all pulled back it is a difficult job to insert an airway into the membrane. There just isn't a lot of space.

Later one of the nurse anesthetists let me put in an LMA, which was very cool and very easy to insert. We may be getting them on our rigs in several months. While it doesn't secure the trachea, it takes no time at all to put in.

Post-op was slow with triage done and pre-op done for the day; there were more nurses than patients. I went back for the first lunch. I felt like I had nothing to do, but then I started looking around and while the things to do were not the big things, they were important -- getting water for patients, talking with them, making them more comfortable. I felt like a nurse. Imagine that. It wasn't bad. Say what you want about nurses, some of them here are very good and they have an eye -- not for what procedure can I do, but what can I do to make the patient feel better.

I did take care of one man in particular who I oversaw all post-op care for. An old man who all his life had a hernia, which was so big that when he walked in the day before, you could see it through his pants. The top doctor here kept saying "no more patients, but then someone in need would come in and he would say, okay, add him, add her. He is a great man. Anyway, the patient was so gracious and happy. He was a gardener for an old woman and she came and sat with him and told me how she had watched him labor all these years and how nice it was to see him without it.

A very gratifying day.

At night we were invited into town for a party thrown in our honor by the people who paid for our stay. It turns out they were the local version of the Lion's Club. They raised funds to house us at the resort and they all gave speeches and hoped we would come back every year. They had local musicians play for us and they served a big spread of roast pork and chicken and pasta and bread, and papaya for desert. The pork was fantastic. I told them I liked the skin -- cuerito -- so they gave me two huge pieces of it. So good, but so much fat.

I awoke in the middle of the night with a knife in my stomach. I was worried I had gotten some horrible GI bug, but I think it was just the pork skin and fat. A half hour later after emptying my stomach a couple times I was back to normal.

Wednesday

2006-05-24T21:30:00.000-04:00

Another busy day in triage and post-op. I am amazed at the stamina of the two surgeons. They are doing ten cases a day, ranging from gallbladders, hernias, tubal ligations, mastectomies, to simple cyst removal. Tomorrow I will scrub in for a thyroidectomy.

Everyday I wear a baseball cap from the Dominican national team. They all talk baseball with me. They love the Red Sox, who have four Dominicans on the team, including their favorite and mine David "Big Papi" Ortiz. The Dominicans are not as crazy for Pedro Martinez anymore, although they follow his individual stats.

After work the bus went for gas. We saw a roadside bar and one of the great friends I have made, went in and bought us all Presidentes in the big 22 ounce bottles. Muy frio.

I told him.

Un hombre que me compra un Presidente es mi amigo para la vida.

A man who buys me a Presidente is my friend for life.

Tuesday

2006-05-23T22:21:00.000-04:00

Before we started, we meet out front with the patients and sing a song called "Alabara mi Senor." It is the only official religious moment of the day.

Back to triage to start the day. The hospital was packed. I had a hallfull of people all talking a hundred miles and hour in Spanish. I got their names, dates of birth, towns they were from. I took their vitals, weighed and measured them, and got the gist of their complain, and then turned them over to a nurse who grew up in Cuba, who got their full history and did a full exam. And then those we think need surgery are told to wairt until the doctor gets out of surgery, and he comes down and examines them and they get booked. I make certain to say Buenas Dias and tell them all my name. Now whenever I walk down the hall, they all smile and call my name and have questions for me. In pre-op in the afternoon, I was talking if not in hundred mile and hour Spanish, at least going fifty-five.

I worked hard today and felt less guilty about my beer -- this time in La Mar -- the ocean.

Monday

2006-05-22T21:16:00.000-04:00

I was going to start the day in triage, but the young college girl, who was going to interpret in Pre-op was sick, so they switched me with one of the pre-op nurses, so I did IVs and Spanish in pre-op. The IVs here are very easy as all of the Dominicans have ropes for veins. My Spanish was much improved. They bused us back to the resort for lunch, and since I went in the second wave and all my preop work was done, all of us in the second wave got to stay. Back to the swim-up bar.

Una cerveza para mi mano derecho y una otra cerveza para mi mano izquierda.

La Vida.

Sunday

2006-05-21T21:21:00.000-04:00

This morning we set up the hospital, which is really pretty amazing. We walk into this cement building, and then with the medical equipment we all carried in one of our checked bags, and the equipment trucked in on the MMI van, in just three hours we have a functioning operating room.

After setting up, I work in the triage area, intervewing patients. Since it is Sunday and a day of rest around here, not too many come in. We target five for surgery to begin tomorrow morning. We expect a bigger line to be out the door.

I am having some trouble with my Spanish as many of the older Dommincans mumble and their dialect takes a little getting used to.

We got off ealy and I spent a couple hours at the swimup bar, drinking cervezas. Ah, the missionary life.

The food here is great. It doesn't look that good -- lots of potato, rice, chicken and pork dishes, but it is excellent. I had oxtails for lunch that were terrific. The cheese is also fantastic and I am not a cheese eater. It is just so fresh nd quite unlike what I have had before.

Tonight we meet as a group on the beach under the stars to go over the day ahead. I am assigned to triage to start the day, and then post-op in the afternoon. I am always anxious about what I will get to do, particuarly this time when there are so few surgeons (just a surgeon and a resident) and they have added a number of helpers and two college student translators who were not origionally on the list)and while my preference would be to be in pre-op where I can talk Spanish and start all the patient's IVs, in triage I will get to speak lots of Spanish (hopefully better than today), meet the patients for the first time, and then later in post-op, take care of them when they come out of surgery. I don't feel this trip that they are unaware of what I can do. I feel like I am being treated on par with the nurses, which
is all I ask.

Saturday

2006-05-20T23:07:00.000-04:00

We had a long trip yesterday. I had to get up at three in the morning to get to the airport on time. Our flight from San Juan to Santo Domingo was delayed a couple hours. Once we arrived in the the Domonican capitol city, we then had to take a four plus hour bus ride over the mountains to arrive at this beach side village after dark. After staying under mosquito netting last year with often no electricity or running water, I am embarassed to say, we are all housed at a four star all-inclusive resort. It seems when the mission people were trying to find housing for us, some wealthy Dommincans overheard and were so impressed with what we were doing for people of the town -- free surgeries -- they offered to pay for us all to stay for the week at the resort in town.

Gas

2006-05-19T17:09:00.000-04:00

Day started off with a man with gas who wanted a ride to the VA hospital. The only other call was an old woman at a doctor's office who hadn't eaten for three days and had been vomiting and was fairly short of breath. I ended up having to put a non-rebreather on her. I couldn't get a great history as she didn't feel up to talking. She had a pacemaker that was actively pacing so I couldn't get much from the ECG. No pain. Clear lungs. I gave some fluid. Aside from being dehydrated, I would love to know what else was wrong with her.

Off

2006-05-18T23:55:00.000-04:00

Could have, but didn't work today. Spent the day moving furniture, working on the lawn and getting ready for my trip. Cut the grass low so it won't be too wild when I come back after all the rain we are getting.

Neck Pain

2006-05-17T17:18:00.000-04:00

Went to the gym at 4:00 A.M. again this morning. Good time.

Three calls in eight hours. A woman with neck pain who had surgery on her neck fusing C4-5-6 two days ago. She was laying in bed and said her neck hurt whenever she moved. What was causing the pain? I don't know, but we c-spined her where she lay.

We did a lady with MS who's left side was spasming, and she was completely flipped out by it. We called and got permission to give her some ativan, which shut down both the spasms and the anxiety.

The last call was an intercept for chest pain for a patient from the I want to get out of work warehouse, and she walked out of the hospital before we were done with our paperwork.

Off

2006-05-16T18:18:00.000-04:00

Spent the day doing errands and cleaning up around the house. Poured rain again. I was glad I wasn't working. It was some serious prolonged downpour. I'm working the next three days, then its off to the Dominican for eight.

Excited

2006-05-15T15:36:00.000-04:00

I was just really excited to go to work this morning. I love my job. I awoke up thinking what interesting calls am I going to have today.

Well, I've had three and they were all pretty boring -- two MVAs and an I want to get out of work abdominal pain from the warehouse where we always go for i want to get out of work calls. Still, I've had a good day. I've been working on the computer, getting lots of good work done, particuarly gthering reasearch on the new protocol changes I want to propose, including steroids on standing order and magnesium for asthma, and morphine for undifferentiated abdominal pain. While at one hospital I went into their bookstore and bought a book about pain management and it had a great couple pages about how in age of advanced diagnostic tools and tests denying morphine to patients with severe abd pain is archaic and inhumane and how all the research shows it helps rather than harms diagnosis. I looked at another book, which said pretty much the same thing, including what to say to the surgeon if he is angry at the ER doc for giving morphine. The doc should suggest the surgeon give the patient narcan after first explaining to the patient that he needs to put him back in extreme pain in order to help see what is wrong with him.

I'm only working till four again today as I have to go to a meeting for my trip to the Domminican on Saturday. I'm off tomorrow, but back on Wednesday.

Hacuna Matata

2006-05-14T16:59:00.000-04:00

Rainy Sunday. Only worked ten hours because I am soon off to see The Lion King.

Did a diabetic with a blood sugar of 36, and then was called for a stroke. Found a man in bed with a flaccid right side and difficulty speaking. His family found him this morning unable to get out of bed. He had a blood sugar of 56, but that was because he couldn't get out of bed to eat. I gave him an amp of D50 and it caused no improvement. The last call was for a "blown aneurysm in the arm." It was a pass from the commercial service, sending us lights and sirens. Our patient, at a nursing home, met us by walking down the hall. The nurse said there was just some yellow discharge from the site of the "anerysm." He was very stable.

My relief who I asked to come in two hours early for me, came in two hours and twenty minutes early, which was great.

Hacuna Matata.

Rain

2006-05-13T11:12:00.000-04:00

Back from Boston. My friend and I decided to just go to his house and drink beer and eat barbeque rather than brave the rains at the ballpark. It turned out to be the right decision as even though they played the game -- it was called after five innings of downpour with the Red Sox losing 6-0. I ate some killer barbeque, but passed out on the couch well before ten with only a few beers in me. At least I woke up refreshed this morning. I have been behind on my sleep lately. I'm home now and am getting ready to go teach the new AHA to a paramedic refresher class.

Bledsoe Column

2006-05-12T09:09:00.000-04:00

It's pouring rain. I'm supposed to go to Fenway Park tonight. Not looking good.

I just read the latest Bryan Bledsoe column at jems.com. Here's the link:

All Things in Moderation

Here's some excerpts:

"...during an average EMS career, a provider will reach a point when they suffer a significant amount of disillusionment. It’s not uncommon. We all encounter it. The causes are usually varied, but a common feature is the realization that the majority of EMS calls are non-emergencies. That means that all of the skills and technology we were trained to use are rarely required. This is the dirty truth of EMS."

"...some people in EMS will respond to this inevitable disillusionment in a different way. They determine, often subconsciously, that they’ll continue to use their skills and practices even if the patient does not stand to benefit. As this evolves, they’ll find ways to rationalize their behavior. Before they know it, they will have violated medicine’s most sacrosanct dictum — primum non nocere (first, do no harm)."

"Today, it seems the sign of a good paramedic is one who puts the most needles into bones, frequently calls the helicopter, intubates a child when a BVM will work, immobilizes somebody on a backboard even though most have a less than a 1% chance of a spinal injury, and runs “precautionary Code 3” just for jollies. I’ve been in nearly every state in this great union and often heard war stories from people proud of the number of crichs they’ve done, the number of IOs they’ve done, or the numbers if chests they’ve needled. I always want to ask (but never do) if the patient got better."

"An old internal medicine professor at Texas Tech once told me two things that I follow to this day:
1. Being a good clinician is more about knowing when not to do something as opposed to knowing when to do something; and
2. Never be the first to use a new drug or procedure nor the last to give up an old one."

Here's my favorite line:

"We’re not happy simply taking somebody to the hospital."

Something to think about.

Science Teacher

2006-05-11T23:31:00.000-04:00

Worked 12 hours. Did three dialysis transfers. I don't think they were boning me, I just think we were in the wrong place when the calls came in.

I did a syncope at a college where a guy gave me a report prefacing it by saying, he didn't think the guy needed to go to the hospital. I did as I always do. I looked him in the eyes listened to his report and thanked him. He said he was a science teacher and he dropped the name of a guy I know and respect who he said he has taught with. The teacher started to leave, then he turned around and said, "Do you have a heart monitor? You might want to put him on the heart monitor?"

"We have one," I said.

"And the pulse ox, you should put him on the pulse ox."

"We have it under control," I said.

I told the patient who didn't remember passing out, he needed to go.

"But the EMT said I didn't have too."

"He was a science teacher," the guy's friend said. "This is the paramedic."

We took him in. When we stood him up to do orthostatics, he got very dizzy.

Later we sat for three hours, then did a woman with abdominal pain and then an MVA. We just missed a shooting that came in near where we were posted right after we were sent to the abd pain. It got very busy in the city. A rainy night. I was tired.

I'm off to Fenway Park tomorrow. I can use the break.

Preparation

2006-05-10T23:58:00.000-04:00

Spent the day working on some projects and cleaning the house and trying to fix my computer which has been connecting to the internet at extremely low speeds. It turns out I had a bad phone line. I ended up ordering DSL, starting in June. I have a full calendar coming up. I'm teaching an AHA update class, going to Fenway Park, helping my father clear his furniture out of storage, going to the Lion King, and in little over a week, I'm going back to the Dominican Republic for another medical mission. I am starting to worry that I haven't worked as hard on my Spanish as I should. I think next week I will be in around the clock Spanish mode -- only Spanish TV, spanish newspapers, and as much Spanish conversation as I can drum up around the hospital.

Tomorrow I work 12 hours in the city.

Meetings

2006-05-09T23:48:00.000-04:00

I went to my monthly regional educational and medical advisory meetings today. I was able to get the committee to agree to issue protocols immediately to permit paramedics to start utlilzing some of the changes recommended by the new AHA guidleines, while waiting until January to implement others.

The immediate changes:

CPR

Place emphasis on continuous quality CPR, with compressions at a rate of 100 per minute, 1 1/2" to 2" deep, allowing full chest recoil. Try to keep compression interruptions to less than 10 seconds. Compress while charging. Compress while intubating if possible. Non-intubated patients should receive CPR at a rate of 30:2, intubated patients should receive continuous compressions.

Ventilations for patients in cardiac arrest should be no more than 8-10 per minutes with each ventilation lasting no more than 1 second and containing only enough tidal volume to make the chest rise. Intubated patients not in cardiac arrest should be ventilated at 10-12 per minute. Do not hyperventilate.

Defibrillation

Instead of three stacked shocks, use 1 shock at maximum setting. After shocking, immediately do 2 minutes of CPR before checking for rhythm.

Patients in ventricular fibrillation who have suffered an unwitnessed arrest or for whom response time is greater than 4 minutes should have 2 minutes of CPR prior to defibrillation.

Intubation

Patients in ventricular fibrillation may have intubation delayed.

A Combi-tube and an LMA are considered 1st line airways along with ET.

Traumatic arrests should be intubated en route to the hospital if at all.

Drugs may only be given down the ET tube if IV access or IO access is unavailable.

IO

Adults may receive IO provided the device used has FDA approval. IO access should only be obtained on patients in extremis.

Asystole/PEA

Pacing is no longer recommended in cardiac arrest.

Additional changes to regional protocols, as a result of the new AHA guidelines will be implanted with regular protocol updates scheduled for January 1, 2007.

***

The new guidelines were produced by the International Liaison Committee for Resuscitation, after comprehensive review of scientific evidence from published studies.

Research shows the CPR currently being performed results in excessive ventilations (which decreases cardiac output), frequent interruptions of compressions and chest compressions too shallow and slow to produce results.

Hyperventilation increases intrathoracic pressure, which inhibits venous return. Since venous return determines cardiac output, hyperventilation reduces cardiac output, causing reduced oxygenation.

The new guidelines are about maintaining blood flow. Push hard, push deep, allow the chest to fully recoil. Minimize interruptions. When compressions stop, blood flow stops. Do not hyperventilate. When a patient is hyperventilated blood flow is compromised.

The question of shocking or doing CPR first is related to the patient’s physiological state. In the first 4 minutes of ventricular fibrillation, the patient is in the “electrical phase” of arrest, during which time the body has adequate oxygen and energy stores, a normal PH, and is unlikely to have suffered heart damage. The science shows this phase responds best to electricity. Intubation is not the priority during the electrical phase.

During the next six minutes, the body is in the” circulatory phase.” The v-fib is now fine or absent. There is inadequate oxygen in the heart, inadequate energy, acidosis, and heart ischemia. Effective circulation is needed to deliver oxygen to the hypoxic tissues to improve chances of successful defibrillation. Evidence suggests defibrillation before CPR in this phase may be detrimental.

Know the phase of arrest your patient is in.

The Committee also passed a lights and sirens document I put together for them without more than a minute of discussion. I was amazed. Sometimes documents takes years to get passed.

LIGHTS AND SIREN USE

GUIDELINES

Ambulances should use emergency lights or sirens only when transporting or responding to a call involving a patient believed to need immediate medical intervention.

Patient Response

Ambulances should respond lights and sirens only when directed by their dispatch center based on EMD criteria. Should additional information suggesting that the call no longer merits a lights and sirens response be received by the dispatch center while the ambulance is enroute to the scene, the ambulance should be downgraded to nonlights and sirens mode.

Patient Transport:

The crew member responsible for patient care during transportation will advise the driver of the appropriate mode of transportation based upon the medical condition of the patient.

When transporting the patient, the need for immediate medical intervention should be beyond the capabilities of the ambulance crew using available supplies and equipment.

Such conditions include, but are not limited to:

1. Unstable airway or severe respiratory distress

2. Shock

3. Patient with anatomic or physiologic criteria for Level One Trauma Center

4. Acute Stroke within the last three hours

5. Status Epilepticus

6. ST Elevation MI

7. Cardiac arrest with persistent ventricular fibrillation, hypothermia, overdose/ or poisoning

When in doubt, contact medical control.

Mode of transport for interfacility transfers should be based upon the directions of the referring physician or medical control physician who provides the orders for patient care during the transport. Generally, interfacility transport patients have been stabilized to a point where the minimal time saved by L&S transport is not of importance to patient outcome.

Lights and sirens use should be documented and justified on the patient care report (e.g., “flail chest”, “systolic BP<90”,>

Notes: In most cases (up to 95% of EMS incidents), EMS personnel can stabilize the patient’s condition to a point where the small amount of time gained by L&S transport will not affect the patient’s medical condition or outcome. In previous studies and in most situations, L&S transport generally only decreases transport time by a couple of minutes or less.

The American Heart Association gives a class III recommendation to L&S transport of patients in cardiac arrest. A Class III indication is not helpful and is potentially harmful. Providing CPR during L&S transport may increase the risk for injury to EMS personnel.

Exceptions to these policies can be made under extraordinary circumstances (e.g., disaster conditions or a back log of high priority calls where the demand for EMS ambulances exceeds available resources). These exceptions should be documented.

(The above document was adapted from Pennsylvania Guidelines.)

I have a lot on my plate for next month's meeting. We are going to start discussion of protocol changes. I am also giving presentations on the case for letting basics utilize the selective spinal immobilization protocol and a presentation on the ResQpod device.

ResQpod

Death of The Hypoxic Drive Theory

2006-05-08T14:17:00.000-04:00

Three calls so far:

An old man with weakness in one of his legs times three days. He was a bit testy and didn't like answering questions. At the hospital, he told them he had gout.

We took an 80 year old lady with shortness of breath in. She had a COPD history, but wasn't wheezing. She'd just come out of the hospital following a five day stay in the critical care wing for heart, lung and kidney problems. She was short of breath even on a cannula, so I put her on a mask. The nurse said she had been belching, which can be a sign of an inferior MI. Her twelve lead had no significant ST changes, but she had all the conditions for a silent MI -- female, elderly, diabetic, ex-smoker, high cholestrol, cardiac history. I'll be interested to follow up on her.

Both the nurse on scene and the nurse at the hospital were concerned about having the patient on 02 by mask given her COPD history. I didn't go into it with them, but in addition to the EMS tenet that no one who needs it shall be deprived of oxygen, I came across an interesting article by a respiratory therapist named Jeff Whitnack called:

The Death of The Hypoxic Drive Theroy

Very interesting reading. Here's an excerpt:

In the May 98 issue of Clinical Pulmonary Medicine is an article titled Acute Respiratory Failure in Chronic Obstructive Pulmonary Disease” by Schiavi. In it the author concludes that…… “....The traditional idea that oxygen induces hypoventilation by suppressing hypoxic ventilatory drive at the level of peripheral chemoreceptors is no longer tenable.”

Here's the guy's home page, which includes a link to his powerpoint presentation.

Jeff Whitnack's RT Page

Last call was for decreased mental status in an elderly DNR patient with a COPD history. He was breathing in a strange way. He wouldn't open his mouth, so his exhalation would puff up his cheek's like a frog, then the air would go up out his nose. It produced a capnography wave similar to a bronchospasm. When I made him open his mouth to breath, his wave form straightened up.

Last call was for a middle aged man with chest pain and heart palpitations. He was very diaphoretic and looked uncomfortable. I put him on the monitor -- saw a rate in the 180's, and followed it with a 12-Lead.

It looked regular to me at the time, so I tried 6 mg of Adenosine, which briefly slowed it to reveal an irregular underlying rythmn, then he was back up in the 180's.

I gave him 25 mg of Cardizem. He was a big man and I was thinking maybe I should even give him a little more. His weight could have taken 30 mg in a first dose. The 25 worked.

My partner took a sharp turn and I dumped the contents of my med kit on the floor. I was a little late preparing a Cardizem drip. I got it hung as we pulled in to the hospital and was running it at 5 mg hour, then as we were wheeling him down the hall, he went back up into a rapid afib. I opened up the drip and tried squeezing it in, but he stayed up. I had about 15 mg in, when I turned over care. I came back from writing my report and he was finally back down in the 70's without any more meds than the drip.

Here's the heart rate trend summary, a feature I am just getting used to using:

Always

2006-05-07T21:32:00.000-04:00

Started with a COPD/?respiratory infection. Gave her a combivent and she was much improved. I used the capnography. She only had a slight shark fin to start, but it did level off.

Next call was a refusal for an old man who fell due to poor balance.

Then we did an unresponsive diabetic. I've been there many times before. Old 93 year old man just doesn't eat much anymore. He has the tiniest little wife who is always glad to see me. He is always in bed. He is a hard stick, but I always get it on my second or third try. Today I got a 24 in the hand. He wakes up slow. I always ask him if he recognizes the pretty lady standing next to me. He always says "That's my wife." She always says, "he's back to himself again." Today when he told my partner he was 93, my partner says he is shocked he is so old. Today I say, "93? Then how did you get such a young wife?" She is likely in her 80's. "Now I remember why I like you," the wife says. "Cradle robber!" I say. "Me?" he says.
As we leave the wife says as she always says, "Well I hope to see you again, but not under these circumstances." I agree with her that I hope so too. But likely, I will see her again under the same circumstances, and the call will go the same as it always goes.

Back to Back X 7

2006-05-06T23:50:00.000-04:00

8 transports, including 7 back to back, which is a lot for a suburban town where the transports are longer than the city. Making matters worse for me today -- I had little sleep, the pollen is killing me. I can't stop rubbing my eyes -- the night medic gave me some benadryl to take. Anything to stop the itching. So now here my eyes are swelling shut from the pollen, they are closing because of the benadryl, plus I am natuarly squinting because of the bright sun -- all the awhile the calls are nonstop.I will post about the day soon, but right now I need to take a little nap. I have never had allergies this bad. The news said Hartford is the worst pollen in the nation right now. All the cars are yellow. The wind is blowing and you see all these mini Tasmanian Devil twisters of pollen swirling everywhere.

The day started off okay -- no calls for the first two hours, but instead of sleeping, I am working on mt Capnography project.

See:

Ten Things Every Paramedic Should Know About Capnography

Then at eight no relief comes in for the night EMT, so she agrees to stay until we can get someone. Then the tones sound and we're off:

1. 83 year old with dsypnea and chest pain
2. 68 year old fell and broke wrist
3. 86 year old with pnemonia and dehydration

We are just about back to the base when we are sent for

4. 16 year old eight months pregant with side pain

We swing by the base on the way, drop off the night EMT and pick up my preceptee. We contact the medical EMD dispatch and they tell us, "Immentent delievery, baby is halfway out." I am flying down the road, my preceptee is saying he can't find the OB kit, I am trying to tell him where it it. I go flying past the turn, not because I didn't know where it was but because I am going to fast. Then we get there. No immenent delivery, just a 16 year old with a pain in her side.

5. 82 year old with a question of slurred speech for a day
6. 85 year old with soreness from prior day fall.

On scene the PD is very upset because this is the third "Code Three" we have gone to that has been passed to us from the commerical service that has turned out to be a routine transfer. (See 3 and 5, although 3 actually was pretty sick).

7. 50 year old with dizziness

Then we finally, finally get back to our base.

Last call is for:

8. 62 year old with syncope and a question of a couple cocktails and anxiety.

I drive home, have two cold beers, wish I could have four more, but have to be up at 5 in the morning to do it all over again, so I go right to bed.

The end.

Two of Ten

2006-05-05T23:43:00.000-04:00

Had the day off, spent the morning working on a document called "Ten Things Every Paramedic Should Know about Capnography," which I hope to post soon.

Here's the first 2 Things:

***

1. Definitions

Capnography – the measurement of carbon dioxide (C02) in exhaled breath.

Capnometer – the numeric measurement of C02.

Capnograph – the wave form.

“End Tidal CO2 reading without a waveform is like a heart rate without an ECG recording.” – Bob Page “Riding the Waves”

2. Oxygenation versus Ventilation

Oxygenation is how we get oxygen to the tissue. Oxygen is inhaled through the lungs and transported through the blood. Pulse oximetry measures oxygenation.

At the cellular level, oxygen and glucose combine to produce energy. Carbon dioxide, a waste product of this process (The Krebs cycle), diffuses into the blood.

Ventilation is how we get rid of carbon dioxide. Carbon dioxide is carried back through the blood and exhaled by the lungs. Capnography measures ventilation.

Capnography provides an immediate picture of patient condition. Pulse oximetry is delayed. Hold your breath. Capnography will show immediate apnea, while pulse oximetry will show a high saturation for a couple minutes or more.

“Pulse oximetry may provide a false sense of security, even as C02 levels rise to dangerous levels.”

-Baruch Krauss, M.D.
Capnography in EMS
JEMS, January 2003

Stretcher

2006-05-04T23:37:00.000-04:00

I worked ten hours in the city with my preceptee. Normally he rides as a third, but it was just the two of us. We were cranking all day, but didn't do one ALS call. We did a psych, a fall at the new convention center, an old woman who cut her finger, a severe abdominal pain from the clinic across the street from the hospital, who was a direct admit, a nursing home abdominal pain, a transfer and we were on our way to another call when the transmission started slipping, so we had to be cancelled off that call. We did another call, but I can't remember what it was.

I almost left the stretcher at the hospital one time. I'm not used to being the person who takes care of the stretcher. I left it in the hallway outside the room while I talked to somebody, then went and got something to eat. I was standing outside the ER when the guy who normally uses the ambulance we were in (he was there working for another service,) opened the back of the ambulance, presumably to see if we were keeping it clean for him(he had sealed all of the cabinets with the brakeoff ties), when I noticed there was no stretcher in the back, so I quickly went and got it. That would have been embarrasing.

I drove halfway to one call with the sirens on, but no lights. Once we'd switched ambulances, the controls to turn the lights on are different. The first ambulance, you just hit the emergency master, the second, you had to hit the mastwer and thenb the individual light buttons, and since they don't light up on the inside, you can't tell if they are on. I only noticed I didn't have the lights on beacuse cars were looking confused and not reacting properly to us.

The day wore me down all the driving and carting the stretcher around, plus the pollen continues to be terrible.

No chance to use capnography today.

I'm off tomorrow.

Excited

2006-05-03T23:31:00.000-04:00

I used to hate difficulty breathing calls. I get them often in the suburban town. usually first thing in the morning at one of the nursing homes. A bad COPD or pnemonia. But now I like them because I get the chance to use capnography -- the chance to learn something new.

Started off with a nonverbal former stroke patient DNR/DNI with a fever of 103.4 in respiratory distress. He had a good capnography wave form with a number in the high twenties. Not that exciting, but it just adds another frame of reference for me.

The other call was for a young woman who rolled her car. She was just banged up, but we still c-spined her and took her in for evaluation.

I was tired. I went to the gym again at 4 A.M. I'm getting excited about it again. I have a tendency to get really excited about things and then just really get into them. That's how I became a paramedic, how I became a writer, how I got into poker, for awhile I was a gym rat and hope to be again, and now how I am getting into capnography. I'm just really excited about it.

Check it:

Capnography for Paramedics

The Picture of Health

2006-05-02T21:09:00.000-04:00

Did my second CHF is just a couple days. When I first started in EMS, CHF was an extremely common call, but it has been increasingly rare over the years. Someone said it was because of Ace inhibitors. I don't know. I just don't do as many as I used to. This gentleman was on dialysis when he started having a hard time. Nitro and Lasix fixed him. I had my preceptee with me today so it was good for him to do a CHF.

The other three calls today were for a woman with abdominal pain, a young woman feeling light headed and an eighteen year old who fell from ground level and was "in and out of conciousness." The call was at a local distribution warehouse with hundred of young employees where we have been often in the past for similar calls. The guy said he fell because he was dizzy. He had no injuries or marks on his body. His skin was warm and dry and his vitals were the picture of health. They had a house EMT on scene who seemed horrified that we didn't c-spine the kid. He was fully alert, but told me he was too weak to wiggle his toes, but when I pressed against his feet, he had plenty of strength. When we went to pick him up, he sat bolt upright. The call came in at crew change so the night medic met me on scene. He said later the patient talked on his cellphone all the way to the hospital. At the hospital, they put him in the waiting room.

The other notable thing from the day is the nurse at the business where the woman had abdominal pain refused to let the first responders have access to the patient or to share medical information with him. I talked to her about it and told her it was their job and their legal responsibility. She said it had never happened to her in any of her clinics that first responders got to interview one of her patients. She was new.

I spent a good part of the day working on collecting information about capnography for a project I am working on.

? Posterior MI

2006-05-01T20:00:00.000-04:00

Went to the gym at four this morning. All right for me.

Four calls today.

1. A woman vomiting for a couple days, who insisted on going to a hospital out of our range, so we had to call the commercial ambulance to take her. She was very stable and ambulatory. I was glad we didn't have to take her because the next call in ...

2. At a doctor's office, a man with a BP of 70, dizzy, not feeling well for two days. I got 68/34. He was pale and gray and did not look well. His capnography number was in the low to mid twenties, showing poor perfusion. I did a twelve lead and leads V2-V3 caught my attention.

The shape is often indicative of a posterior MI. I put a lead on his back and this is what it looked like.

I would have liked to have gotten a better tracing, but we were going on a priority. I tossed him some aspirin. The hospital looked up his old twelve lead from a month ago and it looked nothing like that. Then he started having chest pain and nausea in the ED. They were getting him ready for the cath lab when I left.

3. We had a nursing home patient with lethargy and a fever.

4. A man with vertigo.

The last three calls were back to back and the last call had a triage wait of 40 minutes, so I was late getting off. I admit to being on the tired side tonight.

Getting Worse

2006-04-30T16:18:00.000-04:00

Nursing home lethargic patient with fever of 103, rhonchi, tachypnea. SAT 72% on room air. The nonrebreather got the SAT up to 100%. I had the patient on capnography and it was in the high 30's when all of a sudden it shot up to the 50's. His respiratory rate was also went up to the 50's. His SAT only went down to 96%, and he soon looked like he was having a harder time breathing. We were just pulling into the ER. At triage, they put him in the less severe wing. I told them the nurse was getting worse, but I think he already had it in his mind -- nursing home pneumonia. It took a little while for me to find a nurse in the wing we went to. I gave the report, but he's getting visibly worse, I said. Twenty minutes later he was intubated. I later read, in sepsis, you can expect a high respiratory rate and a high C02. I am still learning the capnography, but I was impressed with the sudden leap in C02 seeming to flag the oncoming change in condition.

Twenty Minutes Early

2006-04-28T20:19:00.000-04:00

So I worked the high performance transfer car. There was no medic gear in it, so I asked if I could have some just in case they needed us for an emergency. You are only going to be doing transfers. You won't do any emergencies.

The deal again with the so called HP car is you do 8 transfers, you go home and get paid for eight hours. They promise to feed you calls -- all of short transport -- and if you are kept waiting or a call is cancelled when you get there, it still counts. If you do more than eight calls, you start getting paid overtime as soon as you've finished your eighth call. The car often is done with eight calls after six to six and a half hours.

My old partner's Arthur's favorite line whenever we were kept waiting was "That's okay, we get paid by the hour." By when you are paid by the call, well, its another thing. You hump. We had four calls banged out in the first three hours. No breaks, no lunch, just charging ahead with the stretcher. We were on our way to a fifth when we were sent on, you guessed it, an emergency. They were out of cars and someone was having trouble breathing. We pull up in front of the house and the fire department is there, and I just know they are thinking I am a slacker, when I only pull the stretcher and come in with a makeshift in-bag. No monitor or big house bag. The bad news is the lady has an MI history and is a diabetic. The good news is she has been having diarrhea and vomiting. My assessment is she is dehydrated. My partner asks me if I want to call a medic.

At the hospital I have to explain why I have no Blood sugar or 12 lead.

My partner tells me we should get credit for two calls, the cancelled call and the emergency, but since they never sent us the tag for the first call, it only counted as one.

So three calls to go and instead of short trips, it's from one side of town to the other, picking up someone and taking them out of town. To make matters worse, the staff at the places we go are slow. Talk about standing there, tapping your feet. Com'on, already.

We do our eight calls and punch out all of twenty minutes early.

It will be awhile before I work the HP car again.

CHF - Trend Summary

2006-04-27T23:52:00.000-04:00

I am the tallest person in the company and today I worked with one of the shortest. The day started off slow, just sitting covering an area. Unfortunately, the area was close to the base. When a call came in for the bareatric ambulance, it went to us. So we had to drive back to the base, switch into the big ambulance and were sent off to pick up the 400-500 pound patient. Fortunately, they had to send another ambulance to back us up as is required by policy. My partner who has taken this guy before said he looked like he had gotten bigger. He was so big that when he got on the big stretcher, which is rated for up over 1000 pounds in the down position and 800 in the up position, he thought he was on the regular stretcher because he was hanging off both ends. Yeah, he's getting bigger, she said.

The problem with doing one big person run is you can never get back to the base to get in your regular ambulance. We were just about back when they sent us to another big person call. This lady was probably 500 with legs the size of an average person's torso. She could stand and pivot, but the stretcher in the medium position was too high, so we made the mistake of putting it all the way down so she could sit on it. My partner doesn't lift well, so we thought about calling for another person to have four strong lifters instead of three, but I said, I could take the end and the two guys from the other ambulance could take the head. I got down in squat position, squeezed the release and drove my legs up, but the stretcher stayed down. I had to stop or I would have ripped every muscle in my back. I was a little embarrassed. One of the other guys took the end then, he's younger than me by a good deal and very strong and squat. He got it up, although his head and throat turned purple. I think the stretcher was just too low for me. That and I haven't been as regular at the gym as I used to be, although that is changing. I was in the gym this morning for cardio.

Anyway, we finally got back to the base. While my back was slightly strained, I wasn't hurt. We got in our regular ambulance and went back out on post. We were sent priority into the city for a child struck by a car, but it just turned out to be a thirteen year old who had his foot run over. It hurt when I pressed against it, but he was very stoic. Thirteen year old wearing a do-rag, looking like Tu-Pac.

We were a half an hour from crew change when we cleared the hospital and instead of being told to come in, we got sent to the one area they send you too when they have no other cars available. Sure enough we got a priority one call. Difficulty breathing at the nursing home. It turned out to be a good one. CHF in a DNR patient. She was sucking when we got there. Altered mental status, cool, pale, clammy. As usual the staff didn't have much to say other than it came on very quickly. They said she was wheezing and they gave her a nebulizer by mask. I listened, but couldn't hear any wheezes. I did hear a lot of rhonchi and rales. I used the capnography and she had a decent wave form indicating no bronchospasm.

Her CO2 reading was in the 50's, which is high. Her respiratory rate was around 30. Her BP 180/115. Heart rate was 116. Her Sat was 80%. We switched her to a non-rebreather. I got a line and gave her three nitros, and her Sat was now 99%. Her heart rate and BP came down, and she was finally able to converse with me. Her capnography stayed on the 50s. Still she looked like a different person at the hospital. I printed out a trend summary afterwards.

It is amazing we had this feature on our monitors for some time and I at least never knew about. I have been trying to spread the word, and have only found one other medic who knew about it.

For any of you with Lifepack 12's out there, do the following:

Hit Options.

Hit Print on the options menu

Hit Report, which on ours is defaulted to Code summary.

You should get a trend summary option. Hit that.

Then hit print again on the options menu and the trend summary should print out.

I have found one monitor that doesn't have the trending software on it. Yours may or may not, but if it does, that's how to get it.

Looking at this trend summary, you can see the gradual reduction in heart rate (3rd graph), as well as the early SAT readings and later ones(4th graph). Next time I will try to get the capnography on in the room, rather than waiting to get out to the ambulance, as well as trying to keep the pulse SAT on.

When I got home, I tried to read more about capnography. The literature is so sparse, I can't always find the answers. This is about what I came up with. Her wave form shows no bronchospasm. Her high CO2 indicates tht she is getting tired and was in a hypoventilation state. Even though she is breathing at a higher than normal rate, she is not getting enough ventilation with each breath. She did look very tired. The literature I read said a sudden decline in her ETCO2 from the 60 area down to the 20s would let you know that in a few minutes or so you would find out she was completely flashing, fluid filling the lungs preventing poor CO2 diffusion. Fortunately we avoided that state. When I was done with my paperwork, I checked on her and we were able to have a good conversation. Unfortunately the hospital didn't have capnography as I would be curious to see what her numbers were.

Anyway, I am excited to learn about this all. I apologize if I am explaining any of it incorrectly as I am still a novice at it.

Tomorrow I am working 8 hours. All they had open was the so-called High Performance car, which is a transfer truck, where they let you go home after 8 calls and pay you for 8 hours even if you finish earlier. I wanted a regular shift, but told them if they could get my friend to work it, I'd work it, so they promised me that if I would come in. I don't particuarly like transfers, but I'll do them if I can hang out with someone I like working with.

Presentation

2006-04-26T21:52:00.000-04:00

Went to the gym this morning -- I'm actually getting back into shape -- then in to work for six hours. Only did one call, a woman with a broken ankle. Tonight I gave my presentation at the hospital on the new AHA changes. It went over pretty well. A couple people asked me to email them my presentation. It was my first powerpoint attempt and I had no frills or anything in it. I think next time I could really liven it up.

I'm working eight hours tomorrow in the city.

Shark Fin

2006-04-25T19:11:00.000-04:00

We had an eighty-year COPDer with Sats in the 80's not moving too much air. We gave her two back to back combi-nebs and monitored her with capnography. It was the first time I used capnography on a COPDer.

Here are the wave forms. Keep in mind a slanted "shark fin" wave form shows the person is struggling to exhale through resistance. A more box like wave form shows no resistance. Here's a normal wave form and a bronchospastic wave form:

And here's our patient's wave forms, initially, during the first treatment(combi-vent, which bronchodilates) and after two treatments:

Way cool, I thought. It really shows how effective our treatment was. The woman felt much better and was breathing easy. The nurse was impressed that we had capnography. She asked what the funny looking cannula was for. We tried to show her the wave forms, but she just nodded, and it seemed to me the wave forms meant nothing to her. A couple weeks ago, they would have meant nothing to me, too.

***

Only other call was for a woman with heartburn and a history of throat cancer.

***

For more information on capnography:

Capnography

Ow!

2006-04-24T14:49:00.000-04:00

Just as we were arriving at a back pain, a cardiac arrest came in at the high school. They sent an ambulance from the city to that one, which was too bad because we heard later the teacher -- a substitute -- didn't make it. We were only a couple minutes away. Who knows if it would have made a difference? It was just bad timing.

The lady with back pain was a major pain herself. She yelled at the police officer for tracking a leaf onto her carpet. We couldn't do anything right. She had an alarm system and wouldn't tell the police officer how to set it. She insisted on doing it herself. She wouldn't tell her best friend either. It took us 40 minutes to get her out of bed and onto a stair chair, then we had to go through getting her off it, so she could set her alarm. She would say "Ow!" whenever we hit a bump. "Ow!" it seems to me is a sound that requires a mental decision to make as opposed to a true sound of pain. Anyway, I wanted to give her some morphine, but she said it made her sick. On the way to the hospital, she got upset about the direction we were going. We took the highway instead of going through the city which would have been far worse with all the rotten roads. We hit one bump on the highway and she said "I have news for you, this is the bumpier way." Not.

She liked me because I took care of her husband when he was alive. She said to me, "I know I'm such a bear." I felt like saying, "If you know your behavior is so bad, you need to correct it."

She had a mastectomy so she couldn't have a BP done in her left arm. She told it to me, she told it to the triage nurse, who wrote it down. We went to the room, and as I was giving my report to the nurse, she got out the automatic blood pressure cuff and took the woman's left arm, the woman said, "You haven't done your job, you haven't read what your supposed to. I can't have a blood pressure done on my left arm. What if I were unconsious?" She made the nurse make a sign, saying No BP or shots in the left arm.

***

We took in an old woman who refused to take her medicine because an aide was "forcing" it on her. Her presure was on the high side nd she had some increased water retention and some dementia. We were able to persuade her to go to the hospital with us.

Later we did a syncopal, who we couldn't get to go.

Alone in Back

2006-04-23T23:37:00.000-04:00

Called to the group home for respiratory distress. Updated en route that the patient is choking and cyanotic. We arrive to find the thirty-year old with cerebral palsy agitated, but breathing quite fine. He is tube fed, and occasionally vomits and aspirates. His lungs sound clear. The aide has a machine BP cuff on his arm and is concerned because the reading is 280/230. I tell her it’s not an accurate reading. We retake it manually and its 130/70. There is no question but he is going to the hospital. That's just the way it is at a group home. They call us, we come, and the supervisor says transport. No matter what or how temporary the emergency. I don't mean to belittle what happened. I've taken this patient in many times before, often for this same thing. He is an aspiration risk so he goes. An aide comes with us. On the way I read his medical folder. There is a chart for his BMs. I easily decipher the code. LBM, MBM, and SBM, stand for large, medium and small BM respectively.

At the hospital, I get out of the back and my partner comes round and helps me pull the stretcher. At that same moment, the patient's parents arrive. The mother screams at the aide, who rode in the front "What you left him alone in the back by himself?"

"No," I say, "I was in the back with him."

I don't know what they told her, but she is frantic. She kisses her baby, and asks what happened.

I tell her he has been fine with us, very stable. It takes her awhile, but she finally starts to see that everything is okay. In triage, she asks the aide if he had a BM. She doesn't know. I consult the BM chart. "No," I say, "Not this morning."

Later, the mother thanks us.

***

It is a day for mothers. Our next call, on the radio a cop tells dispatch that he is with a motorist who says her son is having an asthma attack at home. We are sent to the home on a priority. The cops slow us down en route. The cop has driven the mother there and the boy is fine after having a treatment. Lungs clear. The mother thanks us for our response.

Awhile later we are sent for another child asthma, only to fine the boy is breathing fine. His lungs are clear. He says, it is not his breathing, but his chest hurts. He says he was rolling around and felt pain like someone stabbed him with a pin. His mother starts crying, "Is my boy having a heart attack?" "No," we say, "He isn't." We take him to the kid's hospital. I let the mom ride in back with him.

***

It was a busy morning. Five back to back calls. Also did a nursing home fall, possible pelvic fracture and a woman with a bad disc, who I had to give morphine too.

And then nothing for the rest of the shift.