Little Victories

I always enjoy the little victories, the little triumphs when you do something someone thought that you couldn't.

After returning an elderly man to his care home last night, the staff wanted to know how things had went. See, we'd picked him up earlier for being violent and refusing to take his ativan. Apparently, he'd hit a few of the staff members before we arrived.

Sure he was non-compliant when we arrived, but I managed to talk to him. I convinced him to get on my gurney and go to the hospital. I convinced him to let my partner take his blood pressure, to let me start and IV, and give him an IV dose of ativan. By the time we arrived at the ER, he was resting peacefully. He was polite and conversational.

My partner and I brought him back to his care home a few hours later and the staff was just amazed that we'd been able to do what we did. They were amazed at the patient's transformation. But even more so, they were amazed at our ability for my partner and I to do our job. And while they were amazed, I had to feel a little victorious.

Force

My mother had to witness someone get tased by police on her street a few weeks ago. This prompted a discussion at the next family visit about how she believes tasing to be inhuman, that "no one should have to go through that."

I'm a taser advocate. I have a brother who's a police officer, he's deployed his taser 3 times in the last year and a half. There are two police officers on my fire department who've conducted taser demonstrations. I like to think I'm pretty well versed in our local PD's use of force protocol.

So I posed the question to my mother, "would you rather he have been battoned, maced, tackled, or shot?" I explained to her that tasing is about protecting the police officer first, and limiting physical harm to the suspect second. It's about using an appropriate amount of force to control the situation, in the safest and quickest way possible. That given the situation, tasing was the most appropriate means of controlling the situation.

This got me to thinking about use of force in EMS, and how we apply force in the field. My protocols allow the use of physical restraints (including handcuffs and soft restraints) and chemical sedation (up to and including chemical paralysis). Use of restraints (meaning all type of restraint by force) is covered under my Patient Restraint protocol in situations where the behavior is a threat to themselves or others. It leaves a lot to interpretation and paramedic discretion.

What constitutes a threat? What defines a violent or combative patient? When do we use force to control the situation?

My definition of combative starts pretty early: abusive language, threatening language, or profanity. For others, combativeness doesn’t start until the patient throws a punch. If my patient gets combative, when do I apply force to control the situation? How much force do I apply? EMS has the ability to use force, but there is no Force Continuum (and no, that’s not a Star Wars reference).

A continuum of force is like a use of force ladder, it describes what level of force is warranted given the circumstances. Police officers use it to determine what to apply various levels of force up to lethal force. Where is our guide book in EMS? When is it appropriate to start right away by chemically sedating a patient? When do we start with just trying to talk? I believe some of these answers come from experience, from talking your way through the emotionally disturbed patient to having your ass kicked by the drunk that just snapped.

Should our application of force be a process we have to learn by doing or should there be more direction? Is it a question of protocol and how liberal or conservative we want them to be? Or should we as EMS responders have anything to do with application of force in controlling a patient? How many times have we heard that our safety is paramount? Call the cops for the combative or violent patient. Sometimes police aren’t available or your call goes suddenly south without warning.

I think as a field we know what not to do. We don’t clamshell our patients anymore. We don’t sit on their chest, place them prone, use a non-flowing non-rebreather, or hit them. We’re cautioned about medication use: Inapsine in rare cases can cause Torsades, Versed can cause respiratory depression. What do we do?

Outside of lackluster protocols, advice is mostly anecdotal. We’ve all heard stories from our coworkers about how they handled the unruly drunk or the tweaking meth-head. Why isn’t there more direction on how to apply force in the field?

It seems that in an emergency services system, where cops are being trained as EMTs and are carrying AEDs, where firefighters were bullet proof vests, and where fire investigators are armed, EMTs just aren’t keeping up.

Break

I just came off of my regular 24-hour shift and it was the much needed slow shift I’d been looking for. One traumatic fall down a flight of stairs, a public assist (no chart! woohoo!), and an asthmatic. I can’t ask for a shift to go much slower or easier for me. It was exactly the break that I was looking for. My many thanks to the EMS gods.

And thanks to all of you for sending out the good vibes. They were very much appreciated.

So Very Excited

I just brought home my new MacBook Pro. I am so very, very excited.

Just thought I'd share.

Tragic

Last shift, I worked a 21 year cardiac arrest. It's not the youngest code I've every worked, but it's the closest in age.

The case is still under investigation, so I can't share too many details.

It was a 45 minute response for us, out to a back country highway. 45 minutes there and 45 minutes back. An hour and a half this code was run before we turned her over to the ER. The ER team continued to work for another 30 minutes, refusing to give up. But after 2 hours of CPR, defibrillation, drugs, and finally asystole, she was pronounced.

This is one I struggled with (and am still struggling with). It was the start of a 48-hour shift, after a series of shifts of codes, major medicals, and a grueling wilderness rescue. I was already psychologically exhausted and this is only fraying at my nerves.

I ran the details through my head afterwards and kicked myself for all the little things that I should have done, or things that I would have done differently. But I have to face the truth of it, she was worked for 45 minutes before I even arrived on scene--she was dead when I arrived.

The circumstances are tragic--details I can't talk about. I feel for this girl, and her family. I feel for the firemen first responders, my partner, and the ER doc and nurses. I swear the ER doctor was close to tears. I reported in my HEAR report that she was 26, only then did I look at the paper work, and do the mental math on her birthday--21. Does 5 years really matter? No. She was still far too young. Far too tragic.

iPod Medic Software

With the release of the iPhone 3G and the 2.0 update for iPhone and iPod Touch, the Application Store is now available for downloading programs directly to your iPhone or Touch. I found two that I think will be particularly useful.

1. Epocrates Rx. Available as a free download, Epocrates Rx provides an in-your-pocket resource of drug information including dosing, safety precautions, and black box warnings. Additionally, Epocrates provides a pill identification guide that allows you to search by shape, color, and markings to identify by picture unknown pills. Originally available on Palm Pilots and Windows Smartphones, I'm pleased to see the jump to the iPhone and Touch. You are required to create a free account at Epocrates, after which you can update information at will and for free
2. ICE by Catalyst software. Available for only $0.99, ICE (In Case of Emergency) places your ICE listing right on your home screen. Not only does it list contact information for your ICE contacts, but it also provides separate listings for your allergies, medications, medical history, and personal information. Everything is very easy to read and intuitive. And, if using the iPhone, you can dial the ICE contacts directly from the program. The only negative about the program is that I had to make a separate entry in my Contacts list for myself to input my personal (or "owner") information. I also had to add custom fields for donor information and blood type. It would have been nice if these features were a part of ICE. Personally, I'm sharing this program with my coworkers and local ER staff to educate them about what a wonderful resource an iPhone or iPod Touch can be about their patients.
   

I've already used Epocrates quite a bit in the few days that I've had it loaded onto my iPod. I can't believe what a wonderful resource it is. As for ICE, there are a couple of other programs on iTunes that offer the same functionality, but ICE is the cheapest and is very identifiable by name.

I'm always interested in learning about new programs and tools. If you know of any, let me know.

Epocrates
Catalyst Software

How to MacGyver an IO

Responding to a cardiac arrest a few shifts ago resulted in a peculiar problem with an IO. We were at post and the call was a block away at a small, private residence. Getting out of the unit, we could hear hysteric crying through the open front door. I instructed my Paramedic Intern to grab the airway bag and Zoll as I grabbed the house kit.

Quick stepping through the front door, the distraught daughter began rattling out a history before we could even ask. The patient, her father, an obese man in his 70s, had gone to the bathroom and had been straining during a bowel movement, when he stopped breathing. The daughter called 911 within 30 seconds and we had arrived only minutes after the arrest, he still had a shot.

Grandpa Jack was found still sitting upright on the toilet, blue as a blueberry in his face, and still with a somewhat strained expression. We heave him to the floor, trailing his oxygen bottle behind him, and drag him to the living room. Grandpa Jack is huge, over 350 pounds with a shape that isn't round, or pear, or any other body shape I've seen before. He's simply big. Puffy arms and hands told me venous access would be a problem. A wide, short neck told me airway access would also be complicated.

I directed the firemen to start CPR, my intern to get to work on an airway, and I set to work on venous access. The Zoll quickpads were applied and he was in PEA at 40. Again, I studied Grandpa Jack's arms for a workable IV site as the fire department EMT-Intermediate stuck him in the hand. The EMT turned to me right away, "I think we're gonna have to go IO on this."

"Yeah, I know." The IO package was already in my hand and I was working my way around to the patient's feet.

My company has not in-serviced our new EZ-IOs yet, so they aren't on the units. Instead, I dug around the pediatric supplies and pulled out a pediatric IO. We use a 15g Baxter IO, and really, it's designed for pediatric use, not bariatric. I've heard tales of other paramedics in my company using our ped IOs on adult patients with less than stellar results. Some have told me that the IO has even broken during insertion, but I was undaunted.

Grandpa Jack's legs were just as puffy as his arms and his tibial tuberosity was difficult to palpate on the left. I knew it was there though, so I sunk in the needle expecting to hit bone and meet resistance. Instead, I sunk the IO to its flange into fatty tissue. "No good on the left," I said, "too much fatty deposit."

His right leg is better and I can clearly palpate the site. I swab it down, then again sink the needle, immediately contacting bone. I'd never done an IO before, so this was an entirely new experience for me, and while I was a little worried about fouling it up, I started to apply pressure. Using the twisting motion and straight down pressure, I sunk the IO slowly into the tibia, finally feeling the tell-tale lack of resistance. It took easily a minute of constant pressure and twisting to get placement.

I'm in! Great! I'm thinking. Without taking my hand or eyes from the upright IO, I ask the fireman for a syringe. With my free hand, I grasp the hub of the catheter and give a pull. No give.

Maybe a little twisting action, I think. Again, grasping the hub, I twist the catheter a little left, then a little right. Come on, you bugger. No give.

Removing my trauma shears (yes, I had them with me today), I dig into the hub with the blade. Again, I pull, then twist, then pull a little more. No give.

Back a few posts, in My Pockets, I wrote about what I carry with me when I'm at work. What I left out is that I occasionally (as in maybe once a month) wear a leatherman tool on my belt in a little holster with a mini-mag light. It's a knock-off leatherman, a generic multitool with pliers, a knife, and screwdrivers among other things. And it's here, as I struggle with a stubborn IO catheter, that I wish today was that one day of the month.

"I need a leatherman. Any of you guys have a leatherman?" I look at all the firemen in the room. We're over five minutes into the arrest without IV access and I'm uncomfortable with that.

"Guys, I need pliers. Get me pliers right now." My voice had a little edge to it.

"What king of pliers?" The fire lieutenant asks me.

You've got to be kidding I'm thinking. "Needle nose or regulars, it don't matter. I just need pliers."

The LT reaches into his bunker pocket, pulling out a well used leatherman. He flips it open, and hands me the needle nose set. Grasping the hub, I pull up on the catheter and hear a very satisfying shink as the catheter slides clear of the needle. It reminded me of a kung-fu movie, the sound the katana makes as it is pulled from its scabbard. Next, the syringe is attached and marrow is aspirated. I flush the IO, push the first epi, then attach the macro lines which drips steadily and triumphantly, if a little slowly, into the patient's leg.

*****

We transport Grandpa Jack with a combitube after a failed ETT attempt. We never established a patent IV so the IO was used throughout the code. Grandpa Jack never improved from a PEA. He was turned over to the ER where they continued to work the code for another 30 minutes. I have to admit that I felt a little bit of paramedic pride. The IO set was the primary access used during the resuscitation as the ER staff was unable to obtain IV access.

The ER doc called the arrest after the staff went above and beyond in their resuscitation efforts.

EMSDailyNews.com picked up this entry and ran it on July 13th. Thanks for the plug.

Rules (Or, Things My Patients Should Know)

Having worked three years on an ambulance, with almost a year now on my own as a medic, I've compiled a list of rules that are helpful for my patients and partners to know. Typically, patient's are only informed of the rules when they are close to violating them, but I like to give my partners the run down ahead of time. Here are my top three:

1. No vomiting. This is an absolute do not violate and may warrant banishment from my unit in future encounters. (Okay, maybe not banishment, but preemptive Zofran.) This rule has as much to do with maintaining your cleanliness, dignity, and comfort, as it does with my ability to keep down the breakfast and to continue to provide care. Also, my partner appreciates a puke free ambulance. If you get carsick, if you even think that you're nauseous, or have vomited on scene or even before we got there, you have just bought yourself an antiemetic. Enjoy. Take it home (or at least to the ER). It's yours to keep.
   
   
2. Don't stop breathing. Yes, this is rule number 2. Rule number 1 has absolute priority over all other rules, although a violation of rule number 1 is often times a bad omen of a near future violation of rule number 2. Now, it's not that I can't handle an apneic patient. On the contrary, they are often very easy to manage--drop an airway and bag 'em. But it can be inconvenient (for you and me), and telling the ER doc "well, he was breathing when we first got to him." Do your best to keep breathing and I'll do my best to help you stay that way.
   
   
3. No F*bombs. I will always speak to you in a civil tone and tongue, please have the courtesy to do the same. Now, I will allow the usage of the F*bomb as it relates to your level of pain or discomfort, your general dissatisfaction with a situation, or perhaps in describing the circumstances that we found you. The History of F* provides many educational examples. However, the moment you direct the F*bomb at me, my partner, the police, or firemen, then the fucking gloves come off. You have one warning. Do not be a repeat violator of this rule. Chemical sedation, tazing, and physical restrainment (among other things), have been brought down upon violators of rule number 3. Some people say that I'm too harsh about this rule, that I need to chill out. I cite physician precedence on rule number 3 though. An ER doctor in my county will chemically paralyze and intubate you for dropping the F*bomb three times in her ER. You have been warned.

There are many other rules of course: no country music, unless it's Carrie Underwood (she was America's Idol after all). No family in the unit while transporting code 3 (drive it like you stole it, as TJ liked to say). And no free evaluations--I'm an ambulance, I take people to the hospital, not check blood pressures and change dressings.

The list goes on, of course. But I'm curious to hear if any one else has developed their own set of rules or "unwritten" protocols. Leave a comment and let me know.

At Home EMT 3

Meghan and I went to go see the podiatrist again last Thursday and our appointment was blissfully short. The doctor came in, asked a few short questions then re-examined the foot. Everything looked good he said so on went the walking cast--a big, two piece ski-boot looking thing with air bladders. Meghan has officially graduated from Neanderthal foot to space boot status.

She should be upon on her own two feet first week of August. Here's hoping.