Saturday, March 29, 2008

My Storm Story, Part I

On December 2nd, 2007 my partner and I were working our normal 24 hour shift at Station 2 when the worst storm in 40 years hit the Oregon coast. For a few days prior to the shift, we had been hearing cautions about the impending storm, that it would be worse than the December storm of the previous year. My wife and I had survived the previous year's storm with very few problems--in fact we'd learned quite a few things to better prepare ourselves this time around. I'd stocked up on extra candles and matches, extra blankets, and extra canned and boxed food. In retrospect through, December 2nd and 3rd were the two worst storm days that I'd ever seen.

Throughout the day on the 2nd, the winds were getting stronger and rains a little heavier. The talk among all the crews was the incoming storm and calls we could expect it to generate. At the beginning of the shift, I had set out my rain gear and cold weather gloves, I like to be prepared for the elements. As the day progressed, we experienced short, small power outages in Astoria. When these would hit, we'd often be dispatched for activated medical alarms, or difficulty breathing calls as patient's switched from their oxygen generators to portable tanks.

As the day progressed, I phoned home a few times to check on my wife and see about the plans she was making for the day. I let her know that the storm may be worse than we'd originally planned and that she should be prepared for a power outage later in the evening. My partner and I had been listening to the fire frequencies all day, keeping up with the down tree and down power line reports that were keeping the crews busy. Our company had sent a few transfers to the Portland area and had updated on the road conditions over US 26 and US 30. Overall, this seemed no different than a usual December storm. As the evening progressed though, so the winds increased. We'd made a few runs throughout the city and had been stopped by down lines and trees a few times. These were promptly secured though to keep the roads open for emergency vehicles. It wasn't until the evening, wind sustained winds reached 70-80 mpg and gusts were above 100 mph, that our night turned to hell.

We were dispatched to a traumatic back injury at a private residence just off of US 202 a few miles away from our Astoria station. Taking the left turn out the drive, we headed towards the 202 junction and came upon an unbelievable mess. Just a few hours earlier, we'd passed the junction and nothing was amiss. Now, the first half dozen utility poles leading down 202 were snapped at their base, leaning awkwardly over the road. Utility lines spaghetti \ed across the road and hung precariously low overhead. Pacific Power was on scene already, amber warning lights flashing everywhere, and we were met be a flagger. Earnestly, he told us "follow that truck
exactly. He'll lead you through--but I have no idea how you'll get back!"

For the next two hundred yards, we followed the utility truck. Some utility lines we drove around, others we just drove over, and there were plenty that I was afraid we wouldn't clear under. As we approached the nearest intact utility pole, the Pacific Power truck pulled to the shoulder and let us continue to the call. During this short obstacle course, we'd received a dispatch update that Walluski Loop, the road the private residence was on, was completely blocked by trees. We made sure that fire was responding to cut us a path, and my partner and I continued.

Our ambulance, top heavy as it was, was being whipped around hard by the winds. My partner slowed to 30 just to maintain control of the vehicle. The entire highway was covered in debris from the trees around us and we knew at any time, we'd come around a corner and be stopped dead by a fallen tree. But we continued. I was constantly checking for updates from fire, but there was so much activity in the county by this time, it was hard to get through. The storm's intensity was peaking, and we were taking a call in the middle of it all.

Walluski Loop makes an east-west loop onto US 202 with a nearer and further turnoff. The address we needed to find was at the furthest end of Walluski Loop, so we passed the first turn off to continue to the second. Rounding a blind corner, we came across what we feared, a downed utility pole blocking the roadway. My partner pulled the unit up close and we radioed in the delay. We surveyed the road to see if there was a way around, but it was uphill on one side and down on the other. We turned the unit around and headed back towards the west side of Walluski Loop to take the long way around.

The turn around would easily add another 15 minutes to the response, and knowing this only put my partner and I further on edge. Turning onto Walluski Loop, we followed the country road for another two miles before coming across another road block. A large tree had fallen across the road and again, there was no way around. This time, there was no alternate route to the scene. I radiod for the nearest fire unit, which was only a few minutes behind, and asked them to pick up their response. When Walluksi fire arrived in their brush unit, I hopped out of my ambulance to talk with the crew.

Only after I was standing on that dark country road did I truly understand the danger that we were all in. Last year, I was stuck on US 26 during a winter storm that shutdown the highway and kept me on it over night. For a few short hours, high winds knocked down trees and kept me from getting home, but the storm passed quickly and I drove home in just a few hours. This night though, I was scared. In the short walk from my ambulance to the fire department's brush truck, I heard over a dozen explosions in the woods around me. These explosions were trees cracking and breaking, falling from the hurricane force winds. At any moment, I was expecting another tree to fall and hit me, my ambulance, the firemen--it didn't matter, we were all in danger.

But there was a job to do, a patient to reach. I spoke with the fireman, told them "get your chainsaw and get me through this mess!" I literally had to yell to be heard above the noise of the storm. The firemen, themselves looking nervous told me we don't have it with us. How could a fire department's brush unit not have a chainsaw?

"You have an ax, don't you?" I walked to the tree now, sizing it up, determining how long it would take to remove a section large enough to drive through. Too long. Again, we radioed the delay, this time indicating "we may not be able to make it to the patient."

A few minutes passed while we discussed options, then a plan was put in motion by the fire department. We would return to the downed utility pole we'd come across earlier, meet up with a FD pickup on the other side by foot, and continue to the patient that way. It was as good a plan as any so we turned the unit around and headed back on 202. We took it slow, we were still expecting trees to fall and block out path and even in the few short minutes since we'd last traveled in this direction, the highway looked different.

Driving over a downed guide wire, we tangled our front tire and axle and had to stop. We manuevered around debris, and drove over a few smaller trees. Eventually, we came to the utility pole again and met up with the FD truck. I had no idea how far down the patient still was or what condition he was is, so we planned for the worst. I grabbed the ALS kit and narcotics pouch from our unit. We grabbed a back board and spinal equipment just in case. We made sure the fire department had a stokes basket with blankets and tarps. Piling into the pickup, we headed towards the residence and I wondered with an amount of uncertainty, if our ambulance would still be in one piece when we returned.

The highway past the utility pole was just as bad with downed trees and debris. It was still doubtful if we could reach the patient, but worth an effort. After a mile or so we turned off of 202 onto Walluski Loop and about a mile later, pulled into the drive of the residence. A number of Walluski firemen and EMTs were here, tending to the patient and keeping us up on the storm situation. We were told the patient was inside the house, conscious and in pain.

Inside, the power was out and a window had blown out from the storm. It was cold and loud as the winds rattled the house. Our patient, a local 18 year old, was in the living room attended by a fire EMT. He was conscious and after I introduced myself, he told me his story.

The patient had been stuck on the highway by downed trees himself and decided to try logging roads to make it home. After being stopped by another tree, he had gotten out to clear it by hand. A second tree fell, hitting the patient and smashing him against his truck. A second vehicle was behind the patient and saw the tree hit. The occupants scooped up the patient and drove him to a local volunteer firefighter's house, which is where we found him.

The EMTs had him collared and supine on the floor. The patient was complaining of severe back and left leg pain, but he was conscious and alert with good vitals and skin signs. I radioed in to activate the trauma system based on his story, but really I was more concerned about just getting him back into town. The firemen quickly finished immobilizing him to the long board that we'd brought in while I set up the IV and administered some morphine.

We placed the patient into the stokes, covered him with blankets and tarps and tied them down. The patient in the stokes was loaded into the open bed of a fireman's pickup and my partner and I hopped in beside him to attend him. We kept our heads down against the wind and kept the tarp over the patient as we slowly headed back towards the ambulance. All around us, we heard the explosive cracking of trees falling in the woods and again I was left wondering if our unit would be in one piece.

We approached the downed utility pole on 202 and could see the headlights of the ambulance in the distance. The firemen pull the gurney and we load the patient to the ambulance. My partner turns the ambulance around and we put ourselves in route to the hospital. Under the lights of the ambulance, I get to work on the rest of my trauma protocols. I expose the patient and determine there's no significant injury, this I update the hospital on so they can release some of their trauma staff. I place second IV and put the patient on oxygen.

The going is slow back into town. We're still dodging debris, storm and road conditions are considerably worse. The fire department's brush unit is ahead of us, escorting us out, when we come across another down tree, at least 4 feet around and completely blocking the road. We'd only traveled a mile or two when I felt the ambulance stop and I looked up front to see the tree. A fireman flings the side door open.

"We've got a big tree down!"

Thanks, I'm thinking, I can see that.

"We're gonna try to cut through it!"

I've cleared trees with my fire department before and it's tough without heavy equipment and a crew. These were three fireman with one chainsaw. I was skeptical, but my patient needed to reach the hospital. The fireman closed the side door and a few moments later I heard a chainsaw begin digging into the tree.

The sounds of the chainsaw lasted only a few minutes before it stopped and the side door opened again. The firefighter was back and he had a worried look on his face.

"We've been ordered to stop cutting and get off the highway."

more to be posted soon...

My Storm Story, Part II

Wednesday, March 26, 2008

Last Moments

This last shift, I responded to a reported seizure at a local care facility. I obtained a report from the staff and interviewed the patient. She looked pale, was slow to respond, and was weak. Nothing too unusual for this particular care home, most of the residents were here because they were truly sick. I put her on the monitor after feeling a very slow radial pulse and sure enough, she was in 3rd degree heart block. Very soon, I had a feeling my patient's heart was going to stop.

I had had a feeling to dispatch rescue when we were first assigned to the
call and at this point, the engine crew walked in. I gave them the quick report and we went about starting an IV, getting the patient on oxygen, repeating vitals, and moving her to my cot. I held off on the Atropine because of the block, and considered pacing. She was stable, tolerating the rate well, with a good pressure, and so for the moment, I held off on the pacing (later, the ER doctor reassured me it was the right thing to do).

The nursing home is four blocks away from the ER, so I told my partner an easy code 1 return would be fine. I radioed my report, receiving a very emphatic and clipped NO! when I asked if there were any questions. We turned over the patient to the ER staff and bid the patient a good afternoon. My patient, 85 years old, had just spent some of her last moments with my partner and I.

A few shifts back, my partner and I had a candid discussion about how our patients often spend the last few waking moments of their lives. My company uses a Rapid Sequence Intubation (RSI) protocol to manage the airway in traumatic and medical cases when the patient is unable to maintain their it themselves. The procedure uses medications that cause sedation, retrograde amnesia, and paralysis to facilitate intubation. Sometimes, because of their condition, the patient dies and their last waking memory is some sweaty, adrenaline fueled paramedic looming over them saying "I'm going to put you to sleep now so I can take care of you."

This occurs frequently outside the realm of the RSI patient. We take a critical cardiac patient into our ambulance to be transported and they arrest during transit--again the Paramedic is the last person they see. We are cutting someone out of a mangled car, and they decline shortly after--the Paramedic and the firemen are the last people they see. A patient actively stroking, trying to tell their family I love you through a mouth that doesn't work, then finally hemorrhages in the ambulance--the Paramedic and his partner are the last people they see.

I've tried to take this to heart, realizing that often as the Paramedic, I am one of the few people to see a critical patient in their last minutes or hours of life. They can arrest on scene, in my ambulance, or at the ER after being turned over to the nurses and doctors. The patient may even have the prophetic impending sense of doom and know that their death is coming. As a Paramedic, my training is to prevent that, but I know that's it is often as much about factors outside my control as it is my skill level. So how would I want to be treated by a Paramedic in my last few minutes and hours?

I take this with me and use it to shape my attitude and relations towards my patients. I treat every patient with dignity and respect. I do my best to make sure they are comfortable on the cot and warm enough. And I try to reassure them that they'll be taken care of, whether it is their last moments or not.

My 85 year old arrested shortly after arrival in the ER. I had a feeling she would, so did the ER doctor and the nurses. Her heart would only tolerate a dysfunction like that for so long. My hope, for both her and her family, is that her last moments were as comfortable as they could be.

Thursday, March 20, 2008

My Growing Pup

My puppy is growing up I've realized. I knew she would, but deep down I wish that she would stay the same size she is now, sort of like a pygmy puppy. I'd be perfectly happy with that.

My wife tells me today that Boomer's tail is now at wagging height of the coffee table and can effectively clear it in one smooth swat. Her paws, once clownishly over sized, now fit her growing physique. She can keep up with and most times out run our older, larger dog. She is tall enough to jump on any piece of furniture in the house. And she thinks that everything that fits in her mouth, and lots of things that don't, are naturally hers. Boomer's favorite toy: my wife's underwear. I can't help but smile when Boomer comes bounding down the stairs at full run, a pair of Meghan's undies flapping in the wind.

Everyday my love for that pup grows and grows. Just looking at her brings a smile to my face. Today, I'm working a 48-hour shift, so I call my wife and ask her "can you bring Boomer into South so I can see her?" Then after a pause at the other end of the line I add "and I want to see you to."

My wife and I, even without children right now, have a family.

My Alzheimers

Of all the patient's I see, I can't tolerate drunks. I'm not talking about the happy drunk or the quiet drunk who doesn't bother anyone or gets themselves in trouble. I' talking about the angry or belligerent drunk who's behavior and actions have required my services. I have a zero tolerance policy for drunks--if you mouth off once you get a warning, again and it's chemical sedation. You threaten violence or come into physical contact with me or my partner, you've just bought yourself a tube and a very unpleasant experience. Woe be upon the drunk that finds themselves in the back of my bus.

Next to drunks, I have a hard time with Alzheimer's patients. I understand that they have a legitimate medical condition that has reverted them to an earlier point in their life, or causes them confusion, or severe dementia. However, just as often, I see family and care staff use Alzheimer's to defend a patient's behavior and actions during the patient's most lucid periods.

My partner and I were sent to Auburn a few shifts ago, which after doing the transfer math, I realized was a 6 hour round trip. Irritated by this, but resigned to the fact that I'm doing my job, I awaited the page for the assignment. Upon receiving said page, my irritation went into full blown contempt as I read it: COMBATIVE ALZHEIMERS PATIENT. A 3 hour trip with a combative psych patient did not seem like fun to me. Begrudgingly, I did my job and we placed ourselves in route and a few minutes later, on scene. The hospital, known for sending a high percentage of psych patients, is also home to some of the most irritating and burnt out nurses I've ever had the displeasure of working with. The nurse at the desk points to an ER room and says "she's in there, here's her paperwork." Without a further word, he turns is back and continues his crossword (or whatever it was he was doing).

I fling a disbelieving look at my partner before I ask the nurse, "so what's the deal with this patient?"

The nurse gives me a heavy sigh, "family tried checking her into a care facility earlier today, she became anxious and didn't want to be checked in. So family brought her here for a psych eval."

As if on cue, the family approaches me (smelling of alcohol, to top things off) and asks me "you're going to put her on that?" indicating my gurney. "She's gonna get combative. You're gonna have to give her something."

I stop the conversation at this point and turn to the nurse. "I'm hearing two things here, that's she's anxious or combative. Which is it?" I ask the question as I glance over at a very sweet looking short, elderly woman in a flowered sweater and blue wind breaker.

ETOH smelling son answers, "well, she can get combative."

"So she's actually been physically violent before?" I clarify.

"Well no, but your gonna to have a heck of a time with her if you don't give her something to settle her down."

Again I turn to the nurse as the ER doc walks up. "I carry Versed, Ativan, or Inapsine and she's going to get something before we leave."

This settles the issue as the doc writes a quick order for Inapsine. The patient gets her shot, we load her on the cot, and then we get going. For the first hour, everything goes smoothly. The patient is in a happy place, even though I'm ready to upchuck due to the winding road we're on, and I'm writing my chart. The patient and I make small talk, and once she says to me "you're cute."

"Thanks. My wife likes to think so," I answer. The patient quiets then and I move to the airway seat to check in with my partner. I then hear the patient's seatbelt unclick itself and fall to the ambulance floor. I remind the patient that the seat belts have to stay on for her safety, I secure her again, then return to the airway seat. A few minutes later, this happens again. I go through the routine again. This repeats twice more before I move to the bench next to the patient, then the mysteriously unfastening seatbelt settles down.

Shortly after, the patient tells me again "you're cute" and her hand finds its way to my left knee. Now, I should say at this point that the patient knows exactly what she is doing--I had watched her twice unfasten her seatbelt purposely, she was aware of her surroundings, and knew where she was going and why. In short, she was lucid. So casually I readjusted her arm to take a blood pressure, then placed her arm back at her side. I return to me chart and a few minutes later I hear it again "you're cute." The hand returns to my left leg, a little higher up this time. This time I readjust my position on the bench seat out of arms length of the patient.

We're about an hour from our destination at this time and I decide its time for more sedation. A little more inapsine and the patient was docile and hands-to-herself for the remainder of the trip. At the hospital, we turn the patient over and I get an "I love you" from patient, then my partner and I pack up the ambulance for the return 3 hour trip, thankful this is now behind me.

The point I'm trying to make is that I've been in EMS for 6 years, not a career by any stretch of the imagination, but long enough to understand when a patient is operating under their own free will. My problem with Alzheimer's patients are those that act and behave inappropriately under their own free will. And what happened with this patient? Chemical sedation. Inappropriate behavior is the same no matter what the age group and I shouldn't be at the receiving end of it no matter the circumstances.

Wednesday, March 5, 2008

My Award

So this happened back in September of 2007, but since I wasn't keeping up with my Blog at the time, I'll share now.

For the awards period of June 2006 - May 2007, I was awarded EMT-Intermediate of the Year for the State of Oregon. Here's an excerpt from the letter my Ops Chief sent to the state recommending me for the award:

"Jeramy has always been a good employee, however over the last year he has been exceptional... [He] contributes on a regular basis towards in-services, continuing education, and assisting with the EMT-Basic class at Clatsop Community College. He balances his time between work, school, and family life very well..."

So the letter goes on, but the State of Oregon Health Division found it appropriate to bestow this award upon me at the EMS Awards Banquet in Bend. Several awards are handed out every year including Medals of Valor, Meritous Servous, and Unit Citations to name a few. My wife and father (also a Seaside volunteer lieutenant) were also in attendance at the banquet and what a wonderful thing it was to share with them. I am so very proud and humbled.

Tuesday, March 4, 2008

Commercial Structure Fire

I responded with my fire department to a commercial fire at the Seaside Outlet Mall earlier this month. Check out the department's website for the full story and a photo gallery.

My Care Home Frustration

My partner and I took a call today at one of our assisted living facilities. We have 6 in our county, 8 in our total response area, and multiple adult foster care homes which are outside of the normal assisted living community. We were sent for low blood pressure, which happens quite frequently and is most often attributed to the med-aids' inability to take an accurate blood pressure. The staff tells me that they found the resident in his bathroom pale, sweaty, weak, and with a very low blood pressure.

My first impression of the patient as he's sitting in his wheelchair is that he has great skin signs and is alert and competent. My partner gets a quick set of vitals, after which I ask the staff "so what's his pressure normally?" I don't know was the immediate answer. I then ask the staff "what's his history?" I don't know, he's only been here four days and we don't know anything about him. Now, I should mention the patient is extremely hard of hearing and I have to communicate by pen and paper. He keeps saying he's been sick, but is non specific and the staff has no idea what he's referring to. His medical paperwork has no information regarding a previous history. At this point I realize I won't be getting anything from the staff or the facility, even though there are three med-aids in the room at this point all with the same blank I don't know expression.

So I take Mr. So-and-so to the hospital and turn him over to the ER nurse who asks me a multitude of questions that I wasn't able to answer because I couldn't get answers from the care staff. It should also be said that I'm on great terms with the ER nurses and they understand my frustrations and don't hold this against me.

It occurs to me that it's these care takers' jobs to know what their patient's conditions are. It's there job to know a medical history and their recent activities. It's there job to be able to give me an answer other than I don't know. Granted the resident was new to the facility... by 4 days. I might be able to forgive this after his first day, but after 4 days I would assume the staff had a clue regarding the patient's medical conditions and history. Given this, I know I wouldn't want my grandmother taken care of by these people.

This is just one more irritating example of the incompetence inherent in the assisted living system.

My Anticipation

As I posted a little earlier, I'm a big Star Trek fan. So when it was announced that a new Trek movie was in production with JJ Abrams in charge, I damn near had a Klingon kitten. So I watched the teaser trailer and felt indifferent. Abrams has already talked about approaching this as a reboot of the franchise and the theme of the trailer illustrates that. But, I circled Christmas day on my calender as the theatrical release date and began the countdown.

However, I find out yesterday that the release has been pushed back to May of 2009. Initially upset (I'll have to white out my calender) I then did some investigating. I find out that Paramount pushed the release back to make it a summer blockbuster contender and avoid holiday competition. My gut reaction was "what kind of BS is this?" What kind of holiday competition is a Trek movie concerned about? And the fact this is supposed to be a blockbuster contender? This just rubs me the wrong way. I feel like the movie is being marketed as a money maker, and not a true addition to the franchise.

I'm anticipating the movie, but the more I find out about it, the more apprehensive I get.

My Partner

As the Paramedic on my ambulance, I work with an EMT-Basic partner. The interesting this is, my partner is somebody I went to high school with, and he's dating the daughter of my supervisor who happens to be my best friend (the supervisor, not the daughter). He's a cool enough guy, we get along because we're both that early 20's demographic who are into computers and technology. We know all the same people, we have a lot of the same complaints, and we share a lot of similar interests.

The reason we get along so well as friends is also the reason we fail to get along as partners. He doesn't respect me as his Senior. He respects me as a Paramedic, but not as the Senior tech in charge of the crew. We never argue or have problems on scene, in front of patients or the firemen, but it's when we're in the ambulance or at the station that it starts. Some might say that we're just two guys poking fun at each other, but there has to be a basic level of respect and I don't see that.

I talked to my supervisor about it and she sees that same thing. She knows my partner respects me as a Medic, but that he thinks of me more as a buddy than a boss. It hasn't caused any major problems yet and I can't see that it will. He'll never contradict me on scene or undermine my authority as the Medic--and if he does it'll be that last thing he does as my partner.

I've talked to my partner about it and his common response is "you have sand in your vagina?" My supervisor understands that nature of the problem and is working on getting partners switched around. Not just for my benefit, there's other crew problems on my shift, I just hate to be someone that's causing waves.