Outcomes

My partner, TJ, tells me that she was pretty before the accident. She still is, but you have to look past every thing else. We're assisting the medivan driver, helping to carry Christy in her wheelchair up to her parent's second floor duplex. She'd spent most of today on her crutches at school. Christy is 16, and a year ago her life changed forever.

*****

In EMS, we have such a rare opportunity to see how our patients do in the long run. There are exceptions, we all have our frequent fliers and system abusers and it always seems that everyone in the service knows how Mrs. Jones or Abe the Smelly Drunk is doing. But the patients we'd really like to learn about are usually the ones that were significantly sick or injured, the ones where we want to know if we made a difference, if our treatments mattered. Maybe we want to know so we can improve our skills, know what to do differently in the future. Maybe we want to know because the run really bothered us and we need some closure. Maybe we want to know because it was an interesting case and we're just curious. Or maybe because we really care and we hope that the patient makes it.

Due to numerous factors, the largest of which being HIPAA, but also because of the size of our systems, and the number of patients, doctors, and nurses that we see, we don't always know what happens to our patients. Dropping them in the ER bay may be the closest we ever come to knowing the outcome of care for a particular patient. I'm fortunate to work in a small system where I know all the ER doctors and nurses by first name. Often times, the critically ill or injured patient I transport to Portland is the same one I brought into the ER an hour earlier. I'm able to talk to the doctor and nurses, read the patient's paper work and past history, and have a good grasp of how the patient is doing and know what their treatment plan will be like. Other times, I'm able to ask the doctor about a particular patient and they can give me a quick run down of how they did in the ER. Usually though, it's a mystery we drop the patient off. Even still, I often wonder what happened to Mr. Thompson, who was from out of town and here on vacation, that had a heart attack at the hotel pool. He went to Portland from the ER, but did he make it from there? Or was his family's last happy memory of him at that little hotel pool?

*****

Christy was at a local state park last summer, enjoying a beautiful sunny day with family and friends before the start of school. She had climbed to the top of the waterfall, 65 feet above the pool below with rocky banks on either side. Christy misjudged the jump, and hit the cliff face of the falls before landing face down in the water. She was pulled to shore by friends and lay there until the fire department and ambulance arrived. Christy was conscious, but her body was broken, literally.

Based on the radio report the medic gave during transport, the air ambulance was waiting on the helicopter paid when Christy arrived at the hospital. She stayed a very short time in the level 3 ER, before being flown to Portland.

*****

As a medic, I always want to better my skills, to be the best paramedic that I can be. Part of it has to do with pride, I also want to be good at my job. Mostly, it's so I can take better care of the next patient. Part of the process of bettering my skills is evaluating how I've done on each call, what I could have done better or differently, and whether my interventions meant anything. Often, I'll ask the doctors or nurses if what I did was the right thing to do. Recently, I had this experience with a chest decompression. That particular patient went to Portland, but I don't know about her long term survivability. Chances are, I won't know until I see her again at the care home.

Because of the small area I live in, that's how I learn alot about patient outcomes. A patient will recognize me while I'm in line at the grocery store or walking downtown with my wife. Sometimes its a family member. Usually they'll thank me and tell me about how they did after I dropped them in the ER. It doesn't happen often, though.

*****

Christy spent months in rehab and started the school year late. At first, she was able to only get around by wheelchair. As the year has progressed, she has grown strong enough to use crutches for most of the day. She keeps up on her school work and attends a full day at the high school.

For a while, until we knew what happened with Christy, she was the talk of the company. She was the big trauma call that everyone wanted to be on. The call was dissected and arm chair quarterbacked. Decisions were analyzed and questioned until everyone in teh company had their own idea of how they would have run things. It wasn't until Christy came home that all that stopped.

*****

Christy holds her crutches across her lap as wheel carry her up the front stairs. The medivan driver holds on the top of the chair while TJ and I are at the bottom. She's a small girl, very petite with a fragile looking frame. TJ tells me she was quite small before the accident, too. Her hair looks healthier now, when we first started helping her, her long blond hair was stringy and thin looking. Her eyes are sunken back and her face looks hollow, but she wears a smile for us as we joke about how handsome men always have to carry her upstairs. She has a pretty smile, even without her two front teeth.

We set Christy down outside her front door on the landing. The medivan driver opens the front door then holds open the screen door. She smiles up at us, says thank you and wheels herself inside. We smile back, tell her that we'll see her in the morning and close the door behind her.

I didn't run on Christy the day she took her fall, I was at teh other end of the county. Just like everyone else in the company, there was that wish in the bottom of my gut that I wanted to be there, to be the medic taking care of the critically injured trauma patient. To tell you the truth, I'm much happier to be the medic helping to get Christy up and down the stairs every day for school. Though broken, she's recovering and her outcome is a positive one.

My Respects to Air Medicine

6 people--patients, nurses, EMTs, and pilots--died a in midair medivac collision yesterday in northern Arizona.

After reading the news on CNN.com last night and reading the story at EMS1.com this morning, I though I'd write about my changing attitude (and my company's general attitude) towards air medical crews.

First off, I am deeply saddened by this news, especially considering it involved two separate helicopters. My thoughts and prayers are with the family and friends of the patients' and crews'.

In my small area, air medical service comes primarily from the Portland Metro area, across the coast range. The service operates both fixed wing and rotor wing aircraft and while they do scene landings and transports, our primary use for them is interfacility transfers. Generally though, my company has a poor opinion of this air medical service, and I've allowed it to color my opinion.

We (in referring to my private transport company) often make fun of the air service. We joke about their hesitance to fly over the coast range, "it's dark out, they're not comin'," or "oh, I felt a drop of rain, I guess the helicopter isn't comin'." We are indignant towards the flight crews, as often they're treated like visiting dignitaries when they walk into the ER, "oh, you want an art line in the patient?" Oh, you want them foleyed? Sure, we'd be happy to do that for you. Can I get you a cup of coffee? A foot rub? Warm towel, perhaps?" It's true, some ER docs and nurses treat the flight crews better than the ground crews, but this is the exception rather than the rule. Some local fire departments seem to think that a helicopter is always the best choice in transport a critical multi-systems trauma, even though my ambulance can have them to a trauma center in less time it would take the helicopter to reach the scene.

There is a measure of professional pride (as ground ambulances) that colors our impression of the flight crews. A flight nurse and medic can perform more invasive procedures than the ground medic on an ambulance, a fact that one of our supervisors refuses to accept. Again, it has lead to a colored opinion in the company that "helicopters are no better than we are. Rubber over rotors." Also, it doesn't help to have an ER doc tell us "well, the helicopter wasn't available, so you were our next choice." Even though in my county we are the first and only choice of interfacility transport.

Again, I want to stress that when I say "we" or "our" I'm referring to my company and our position on the matter. Now, the company line on interagency cooperation is that we get along well with everyone, that we are all professionals, and that our highest priority is the patient. Keep in mind though that both we and the air medical service are for profit, private services.

What I've begun to realize and what was solidified this morning, is that my opinions (and those of my company) are misplaced and unfounded. I have no personal issue or quarrel with any of the flight nurses, medics, or pilots that I've met. These are people that are doing the same job I'm doing, they just have rotors instead of tires. Let management deal with the bureaucracy and politics between the companies.

The job of an air medical crew is extremely dangerous, more so than a ground crew. Weather is a much greater hazard to them than a ground ambulance. They must be concerned about weight and fuel restrictions. The are concerned with navigating in all conditions, not just following milepost markers or street signs. Usually, they have the most critical patients on board, where time is truly a factor in survivability.

I have the utmost respect for these air medical crews now, not just because of yesterday's accident, but because of a general reassessment of my attitude towards them. And while I may not be able to change my coworkers general attitudes, I can do my best to make sure that my partner and I are always speaking positively about them and towards them when we meet them. Again, I am deeply, deeply saddened by the loss of two crews and their patients. I hope that we can all take the time out today to think about them and their families. And I hope that we can all go about our jobs safely today.

Shaky Hands, A Follow Up

The ER doctor at Providence pulled me aside today after I'd dropped
off a fall patient. He wanted to tell me what a good job I had done
with Wendy. "You saved her life," he told me.

They had trouble placing the chest tube and had to make a second
attempt at it. By the time the tube was placed though, all the air in
her chest cavity had already vented out the needle. "Without the
decompression, she would have died in the ER," he told me.

I have never felt better about being a paramedic.

Shaky Hands, Part 3

Shaky Hands, Part 1
Shaky Hands, Part 2

For the next two seconds, I internally panic. I honestly think the only thing that didn't stop me in my tracks was that we were wheeling Wendy out to the ambulance. I second guess myself. Maybe she didn't have a pneumo. Maybe my needle placement was wrong. Maybe I should have been more aggressive up front. I debated whether or not I should intubate her. RSI would take too long. We're two miles from the hospital. Finally, I think back to the paperwork the med-aid handed me and that Wendy was very clearly a DNR patient. What will I do if she arrests? Will it be because of something I did or didn't do?

My internal conflict is over by the time we reached the back doors of the unit. I outlin my hasty plan to my partner. "Set me up a BVM. I'm gonna take one more listen to her left side, then I'll assist her on the way in. We don't have the time to intubate her. Let's just get going."

I put my ears on as my partner whips out the BVM. Terese, one of our Basics that's working an extra shift with me, moves swiftly in the ambulance, securing the equipment for travel and setting up the BVM. I listen to Wendy, no improvement in her lung sounds, but as I watch her breath, her work of breathing seems to have eased some.

"Wendy?" I ask. "Does your breathing feel any easier?" She looked up at me, desperation and fear in her eyes, and shakes her head no. She still can't talk, but at least now she's responding again to my questions. My tension eases, ever so slightly.

My partner is up front now. She places the ambulance in drive then flips on the lights and we start transporting. My hands are still shaking and now that I'm sitting in the airway seat, my legs have started to shake, too. Another nervous response of mine, both my knees are pumping up and down rapidly as I bounce my heels off the deck of the ambulance. I'm trying to take deep breaths, to be calm and cool, but it's not working well.

I have the BVM over Wendy's nose and mouth, her eyes are pleading up at me to help her. He jaw is so narrow and slight that I can't make a proper seal. Even in my attempt to assist her breathing, I can't seem to do it right. I'm forced to supplement her rapid breaths with puffs from the bag. I try to coach her, "breath in with me on three. 1, 2, 3... 1, 2, 3..." God I wish I could do more, I think. My hands are busy, so I tell my partner to give a report to the hospital when we're only 60 seconds out. The ER staff doesn't like it, but I can't effect how close the care centers are to the hospitals.

Terese unloads the cot by herself while I try to hold the bag in place over Wendy's face. We roll her through the ambulance bay doors and into the ER bay. The ER doc doesn't look happy to see us. The ER is full and they've had to clear a bed in a rush for my patient. The doc is smirking at us as we roll in, a tired, haggard and almost hateful smile. I can see it in her face, why the hell did you bring me this?

I should have taken another deep breath before starting my report, but the words just started tumbling out of my mouth. I couldn't even make sense of what I was saying and the nurses had to stop me a few times to clarify a point or ask me a question. I was ashamed as I take pride in having good turn over reports. The RT has arrived now and has taken over bagging the patient. Wendy is more alert now, tracking movement and responding to stimuli. Her work of breathing has improved considerably, but she still can't talk. I leave her side, slowly being pushed to the back of the bay as nurses and techs step in to assume care. The ER doc, standing at the back of the bay turns to me. "Why did you decompress her?"

Away from the patient's side, away from the immediacy of her care, I'm able to take a deep breath and calm myself. The doctor can see the stress in my face, the sweat on my brow, and gives me a knowing smile as I start over from the beginning. Eventually, I get to where I can answer her question, "I decompressed her because she could no longer breath adequately, her lungs sounds on the left had disappeared, she became lethargic, and subcutaneous emphysema developed all in less than 10 minutes. I did it because she needed it and I thought it was the right thing do to."

The doctor looked at me for a few long moments, then gave a knowing and reassuring smile. "Okay," she said then continued with her assessment. The doctor would later tell me that she now faced her own dilemma: whether to place a chest tube in this elderly woman with a DNR and send her to specialized care in Portland, or keep her under observation at Providence's own ICU where she would receive a lower standard of care, but be closer to home and adhere more closely to her DNR.

I now had paperwork to complete, demographic information to collect, and an ambulance to put back in service. But I was awash with emotions and couldn't focus too well. I was still anxious and nervous about whether I'd done the right thing, I was tired physically and emotionally exhausted, and I was excited and enthusiastic--I'd never done a needle decompression before and now I had a story to tell.

During the next 30 minutes while my partner and I attended to our tasks, I would poke my head into Wendy's ER bay. She was on a nasal cannula now with oxygen sats at 100%. Her heart rate and respirations were down. Her work of breathing had greatly improved. But best of all, her look of fear and desperation had disappeared. She was anxious, I could tell, but she knew she was being taken care of.

My partner and I returned to quarters after collecting my paperwork. I wrote my chart and had dinner while we waited for the night car to start its shift. I felt that I had done good work. My partner told me how impressed she was with me, that she knew I was one of the few medics in the company that would have decompressed her. She felt like we truly made a difference in the patient's outcome. With the shakiness gone, the anxiety and adrenaline subsided, I had to agree. "We did good work," I told her, shaky hands or not.

Wendy went to Portland with Medic 7 roughly 4 hours after arriving in the ER. She was diagnosed with a tension pneumothorax and subcutaneous emphysema extending along her entire left side and up into the left side of her neck. Her outcome, beyond that of being stable when she left Providence hospital, is unknown.

Shaky Hands, Part 2

Shaky Hands, Part 1

I like to think that I'm a good paramedic. Now, that's not to say that I'm cocky or overconfident. But I have had fellow paramedics, coworkers, and firemen tell me that I do a good job, that I always remain cool and calm, and that I always seem to know what to do. Sheepishly, I'll say thank you as I blush a little and turn away. I know that a lot of what they're seeing is the show that I'm putting up for everyone else's benefit. "Act like you know what you're doing, even if you don't," my Basic instructor always told me.

Having spent time in the field as a Basic and an Intermediate before becoming a Medic, I knew how scenes were supposed to go. I knew how to form a treatment protocol into a treatment plan in the field. I knew the operations side of things--how to run the equipment, talk on the radio, and give reports. I knew how to conduct patient interviews, how to interact with the firemen, doctors and nurses. I like to think that I had a pretty good handle on things when I was done with medic school and had a brand new patch on my shoulder.

My very first call as a medic straightened me right out.

I've been a medic for less than a year. If I take a shift off and have a long weekend, I come back to work nervous about how I'm going to do. There are still lots of skills that I've never performed and lots more than I've only done once or twice. There's plenty of calls that I've never had, lots of treatment protocols that I've never used in real life. And every time one of those calls comes up, my hands shake a little.

Wendy is now on my gurney now, barely breathing, barely conscious, and unable to speak. My heart rate, blood pressure, and respirations are up as my adrenaline starts to kick in. Using one hand to dig out a 14 gauge catheter from the house bag, I grab my portable radio with the other.

"Fire dispatch, medic 4." No response.

I'm feeling for the landmarks on Wendy's left chest, thinking back to the text book. Second intercostal space, mid-clavicular line. I notice that my hand is shaking as I press my fingers into the void space. I'm also thinking holy shit, I've never done this before.

"Fire dispatch, medic 4." I need a fire EMT to ride into the hospital in case she becomes apneic or arrests. As it is, I'm already thinking I'll be assisting her or RSI-ing her on the way in. Fire Comm can't hear me though, my partner and I are on our own.

I open the orange catheter pouch as the med-aid asks me what I'm about to do. My hands are still shaking as I bring the needle to the patient's chest. I start to rattle off a text book answer and she gets wide eyed as she realizes I'm about to stab this little old lady. My partner has been feverishly working to get the patient strapped to the gurney, on high-flow oxygen, and on the heart monitor.

I apply slight pressure to the needle and I'm in... and that's it. That's not right I'm thinking. That's not how the book said it would go. There was no pop, or hiss, or woosh of air. No sigh of great relief from the patient. There was no hitting the rib and sliding over like you're taught. There was no muscle mass to strain against, the needle just went right in, almost on its own before I could stop it. With the catheter sticking there, like a little flag planted in her chest, I prop it up with gauze, hastily repack the house kit and start fast walking Wendy to the ambulance. The problem is, she's not getting any better.

Oh fuck has now become oh holy fuck, now what?

to be continued...

Shaky Hands, Part 1

"Medic 4, code 3, Sandy Beaches Retirement for a fall."

Damn it, I'm thinking. I was deeply involved with Guitar Hero: On Tour at this point and did not want to be disturbed. This had better be important. It was my second fall patient at a care home this shift. I pull my ballcap on, slide on my eye protection and head out to the unit. My partner is waiting and puts us in route, "medic 4 responding."

We're two minutes away, not even worth the code 3 trip. We pull into the round-about drive at the front door and let the ambulance idle as we grab our equipment. I stuff the narcs pouch into my vest pocket, thinking I'd rather have it with me than to have to send my partner back out for it. We grag the house bag, toss it on the cot and roll inside.

A staff member meets us, one of the med-aids. "She's been on the bathroom floor for maybe a half hour. She was calling for help up until we found her."

I nod, then enter the apartment. From the door, I can hear the patient's raspy, quick breathing. Well, that's doesn't sound good. I introduce myself to the patient as I carefully step around her, kneeling by her side. She tells me her name is Wendy and that she fell when she got up off the toilet. Her breathing is fast and shallow. She's writhing in pain, and winces every time she moves. There's no blood, no visible trauma, which I'm thinking is a good thing.

I ask her if she's having a hard time breathing. "Yes." I ask her about her pain, and she points to her left flank, locating just below the rib cage. "10/10," she rates it without hesitation. I lift up her sweater and exam: no paradoxical movement, no crepitus, no subcutaneous emphysema, but her lung sounds are diminished on the left.

A lot of things are running through my head at this point: how to package her, how to medicate her, the possibility of a pulmonary contusion, a developing pneumothorax, the need to needle decompress or intubate. I want to relieve her pain before we begin to move her and I need to balance my scene time with the amount of care I need to do.

I have no working room, the bathroom is cramped and I'm squeezed between the toilet and trash can. We have to get her into the living room and on our cot to work on her properly. She denies neck or back pain, or a loss of consciousness so we forgo immobilizing her. I send my partner down to the rig for our megamover, then quickly start an IV and give her 1mg dilaudid. She's talking less now, in shorter sentences, and now I'm thinking I should enter her into the trauma system.

My partner arrives with the megamover and we roll her onto her right side to position it. While she's up, I feel her back and note subcutaneous emphysema along her entire left back. Her lung sounds on her left are so distant they're non-existent. I must have had an oh shit look on my face, but I calmly inform my partner that she has sub-q emphysema and that it's time to go. We roll her onto the megamover and she doesn't even wince at the pain. Her eyes are drooping, she's not talking anymore, and her respirations are 40 plus.

Oh shit has turned into oh fuck.

to be continued...

At Home EMT 2

I took my wife to see the podiatrist last Thursday and it was a mix of good and bad news. The x-rays he took of her foot after getting the splint off showed a 2.8mm avulsion fracture to the talus bone. The good news is that do to the small size of the fracture, surgery isn't likely and she should be in a walking cast in the first week of July. Hopefully, she'll be fully healed by the end of July.

The bad news is that the urgent care clinic where she had her follow up x-rays taken 2 weeks ago did a poor job of wrapping and splinting her foot. Due to insufficient padding, pinch points, and pressure points that were formed into the splint, my wife is developing ulcerations in her foot. We know about it now, so we're taking steps to make sure they heal up properly, but the podiatrist tells us his biggest concern at this point is this soft tissue damage.

Hopefully, all goes well. My wife is tired of not being on her feet. We're hurting for income since she's not working (why can't she hurt herself at work?). And summer is just starting, the weather is improving and we can't be out together enjoying it. Think good thoughts for us.

Helmet Education--The Traumatic Way

I'm a pretty big proponent of bicycle helmets, and motorcycle helmets for that matter. I've taken enough bad spills off of a bike to know what a helmet can do for you. One wreck in particular split my bike helmet completely in half, I'm sure it saved me from a serious head injury that day. Nothing pisses me off more than to see some 8 or 10 year old riding their little BMX bike around without a helmet, or worse, with the helmet on but the chin strap not clipped.

Two weeks ago, my partner and I ran a vehicle versus bicycle on the main highway through town. The location was on a little bridge at the north wye, it was 35 mph (which meant most people went 40-45), and the bridge was narrow with high sidewalks on either side. Locals would crab or fish off of the bridge and there was always plenty of pedestrian traffic.

As we approached, traffic was stopped in all directions, always a bad sign. Worse, a group of bystanders were crouched in the middle of the highway, waving us in. From experience, it's always bad when the bicyclist is still lying in the roadway when you arrive. He was prone, a small amount of blood around his head from a laceration we could see from the unit. But he was moving, frantically, and wouldn't hold still.

There was road rash to his back and flanks. He'd landed on his messenger bag that was slung around him, protecting his front side. Obviously, he hadn't been wearing his helmet. The driver that hit him said he'd just turned into traffic, then the car hit him and he was thrown up onto the car before rolling to the ground. Bystanders verified the story, as did the giant dent and spidering of the windshield on the driver's car. The kid's bike was pretty bent up, too.

We rolled the kid onto the backboard and it was then I recognized him. He was a local, someone everyone in town knew. Maybe not by name, but by face at least. He had a slight developmental disability and was always seen riding his bike around town, though never with a helmet. Numerous times, I'd seen him dart into traffic without looking, acting like he owned the road. And most times, I was expecting him to get hit.

He was asking repetitive questions, had a positive loss of consciousness, and was uncooperative, whether from the DD or the head injury, we didn't know. We put him into the trauma system which meant a 20 minute drive to the trauma center. Packaging the patient was rough as he wouldn't cooperate, but we did it quickly, had him loaded, and were on our way. Vitals were taken, IVs were started, oxygen was applied, and an ECG was obtained. All was normal.

We were met by the trauma team, nurses and doctors done up in paper gowns. Other specialists had arrived from the golf course or from their on-call day at home, wearing jeans or khakis. It's always an interesting collection of doctors and specialists that come together at the arrival of a level 1 trauma. The patient was calm and cooperative by this point, and no other injuries were found other than the superficial ones.

The kid was held at the trauma hospital overnight for observation and presumably released the next day with the addition of a few stitches.

Funny thing is, I was driving into town yesterday, and here was the kid riding along on a new bike. This time though, he had on a bright, shiny new red helmet.

At Home EMT

After attending my niece's 4th birthday party on Saturday, my wife took a bad fall down a few concrete steps and broke her foot. Due to the location and type of break, the doctor's have put her on bed rest until we meet with a podiatrist next week. Chances are though, she'll be on bed rest through the rest of the summer.

Because she is out of work from this, it has caused me to readjust my schedule, both at work and at home, so that I can take care of her. I've had to shift around a lot of priorities and my blog has had to move down the list some. I plan to keep writing, but it won't be as often or as much. I know that's its only a small fracture, but with the two dogs and cat at home, plus house work, taking care of Meghan, and picking up extra shifts to make up for lost income, I'm going to be busy.

I know my readership has grown a lot in the last month, for that I'm truly thankful. It's great to be in a community with so many like minded people. Keep checking back often and know that I'm still reading all of yours.

Thanks

My Tolerance

I said it before a couple months back, I have zero tolerance for drunks. In the county I'm in, it doesn't take long for someone to get drunk and stupid and require emergency services.

I responded with fire a few nights ago for a vehicle into a power pole, with secondary reports of lines down and arcing. The first arriving captain gave a size up as a power pole down and blocking the roadway, one vehicle off the road. The Rescue unit I was on was directed to loop around to the backside of the scene to control traffic, and as the paramedic on the Rescue, I was told to come up and evaluate the patient.

The accident occurred on a back road, at a wye intersection and from where the Rescue parked, I had to slog through a mud patch. Approaching the older model Ford pickup, I notice that he center punched the power pole and did a significant amount of damage to the front end of his truck. The pole was down, 50 yards behind him and sheered off at ground level. Power lines were drooping just 10 feet off of the ground over our heads. The driver was still in the pickup as I approached and my captain is telling me he doesn't want to go to the hospital, but he wants me to evaluate him anyways.

No problem I'm thinking. I'll ask a few quick questions, then cancel the ambulance crew so they can get back to bed. I approach the vehicle and first I notice the strong smell of alcohol coming from the cab of the truck.

"What happened, sir?" I ask.

"I hit a power pole."

"I see that. Are you hurt?"

"No." He responds.

"Does you neck hurt?"

He shakes his head no.

"How about your back?"

Again he responds, "no."

Finally the question "how much have you had to drink tonight?"

"Nothing." Not the unexpected response given the circumstances.

"Well sir," I respond back, "I can smell the alcohol. So you've either been drinking or there is an open container in your truck. Now, I'll ask you again, how much have you had to drink tonight?"

"A couple of beers." He was still lying, but not as blatantly. It seems every drunk I've ever been on has only been "a couple of beers."

At this point, my tolerance for this particular drunk has reached zero and I ask the question, "now sir, why did you lie to me just then?"

"Why wouldn't I?" he shoots right back.

Our conversation continues and he refuses transport, but at this time the ambulance crew has arrived, so I let the paramedic have a go at convincing him to be transported. The interview continues with more questions and I ask the driver, "I see where your truck is at and where the power pole is at. How fast do you think you were going?"

Without hesitation he answers "sixty." Never mind that the speed limit on this road is 30 and that he was defiantly going much faster than 60. The truck had center punched the pole and sheered it off at the ground. The truck was going fast enough that there was no secondary impact of the pole into the cab of the truck, no other damage at all in fact.

I'm keeping an eye on the driver during this conversation and it's now that he exits his truck to take a look at the damage. He looks around at the scene and his truck and the only thing he can say is, "my truck. Look what I did to my truck."

As politely as I can, I remind the driver how lucky he is that he didn't seriously injure himself or someone else. He didn't get it though, he was focused on his jacked up truck. I got the impression from the police officers that he was a repeat offender for this sort of thing, and given his behavior, I could believe it.

We cleared the scene as the officers were giving the driver a field sobriety test, of which he could hardly even keep upright to pass. Again, I had proven to myself that my zero tolerance for drunks was well deserved.

My Pockets

On a lot of the EMS blogs I've read, people having posted about what they carry with them while on shift. I've also been asked by new EMTs and First Responders, new firemen and new company employees about when they should carry. Over the years, I've paired down my list to just the essentials.

• Cook pager. A company requirement for receiving dispatch information.
• Portable radio. Again, a company requirement. My pager and radio are the only two things that ever sit on my belt. No Batman utility belt for me.
• Littman stethoscope. A high quality stethoscope is something I consider an essential piece of equipment. Mine was given to me by my best friend when I started Paramedic school.
• A black, fine tip Sharpie marker. Nothing works better for taking notes than writing on the back of my glove with my trusted Sharpie. I like these so much that my wife bought me a bunch of the colored mini-Sharpies last Christmas.
• Personal cell phone. For obvious reasons.
• My iPod touch. For killing time while sitting at post.

And that's it. Like others, some odds and ends make their way into my pockets on various shifts like unused gloves, a errant roll of tape, or the narcs pouch.

However, my fire turnouts and the complete opposite. Sometimes I think I keep a whole toolbox on me. While on the fire scene, I absolutely hate having to go back to the truck for a small tool, so I like to carry everything on me. I'm also a bit of a gadget nut, so new toys are always migrating through my gear.

• Bright Star Responder right angle flashlight. My favorite flashlight that always hangs on the front of my gear.
• Pelican Super Sabre 3C flashlight. My favorite handheld flashlight. I prefer this over the bulky light boxes we carry on the trucks.
• Two Res-Q-Renches by Task Force Tips. Great for quick coupling. Doesn't replace the regular aluminum spanners, though.
• Res-Q-Me keychain window punch. I can never find a window punch on the truck when I need one. These thing is awesome!
• Yates Escape Belt and bailout bag. My newest 'gadget.' I hope that I never have to use it.
• Informed Fire & Rescue Field Guide, 7th Edition. Has a great pump chart, some good hazmat info, and tips on how to cut up hybrid cars.
• Structural firefighting gloves.
• General, light duty gloves.
• Nomex hood.
• A leatherman-type multitool.
• An allen wrench multitool for opening alarm pull stations.
• Chemlights.
• Garrity LED flashlight.

All this stuff is in addition to my fire department pager and radio, SCBA mask, and turnouts that I take with my on every fire call. It's pretty obvious that I'm not as much of a minimalist when it comes to my fire stuff.

Difficult Arrests

I've had a string of difficult cardiac arrests lately. Not difficult from a skills stand point (they all go smoothly enough) but difficult from a circumstances stand point. Last night we were dispatched to a cardiac arrest reported by PD on scene. Fire was dispatched at the same time and arrived on scene right behind us. I walked up the stairs to the 2nd story condo and found one of the local (and very well liked and respected) police officers along with a county sheriff or two.

"I just need you to do a verification for me," the local cop said. Now, I immediately slowed down at this point, going from a resuscitation mode to a confirmation mode. The local cop is one of the deputy medical examiners (DME), he would know what a dead body looks like better than most.

My partner and I entered the bathroom and found the elderly female patient lying on the floor next to the toilet. The cops, firemen, and husband all had to wait in the living room while my partner and I went about confirming the confirmation.

First thing I noticed is the cyanosis in the face and left arm (she was lying on her left side). She was pale centrally, but no dependent lividity. Her core is not quite warm, but not quite cool either. And in checking a carotid pulse, I find her to still be very warm at the neck and chest. "She's still viable," I tell my partner, "we're gonna have to work it."

We pull her to the living room and start working the arrest. Firemen start CPR, while I get to work on the airway and my partner is working on an IV. I start to ask questions and find out that PD was sent to investigation after dispatch had received some peculiar 911 calls from the husband. Due to some communication difficulties on the husband's part, the request for an ambulance never made it through dispatch.

The officers arrived and found the patient arrested in the bathroom, made the determination that it was a DBA, but called a cardiac arrest anyways. We arrive and begin working the code. The patient had been down for up to 20 minutes by the time we start CPR. The patient remains in asystole throughout the arrest, but we transport (as our protocols say we do) and call it at the hospital.

Here's where I have difficulty with this call--I don't know whether I need to be upset at the local cops or not. The communications problem that resulted in our delay aside, it seems to me that a DME should know how to check to see if the patient is still viable or not. The determination that the patient was still viable was (to me) pretty obvious and given that determination, we started working the code right away. The police are CPR trained, it's a job requirement. The DME knew enough to call this as a cardiac arrest, not a possible DBA. So I ask myself, should they have started CPR?

My supervisor had a good point about this; the cops' CPR training is primarily for themselves. They are not medical responders and can't be expected to act as such. They may not have had gloves or a pocket mask available to them for their protection. And their training is in recognizing dead versus alive, not viable versus non-viable arrest.

I'm still wrestling with this today. Do I need to, or am I expecting more than I should from the cops?

As a side note: I try to learn something from every call. From this one, I went into it with the wrong mind set. I allowed myself to slow down when the officer asked me to confirm. I know in the future to treat every cardiac arrest like a workable cardiac arrest until proven otherwise.