Extended Leave

It'll be awhile longer than promised before I get back to regular posts. I was in a car accident on the 26th on my way to work. It wrecked my car, but thankfully I'm okay, just very, very sore.

Anyways, I'll be dealing with the insurance company, the body shop, and possibly a dealership in the next few weeks.

Until I get back to regular postings, stay safe.

Merry Christmas

Merry Christmas to everyone in blogger land (even though it's almost over). I took some time for the holidays, but I'll be back with regular posting and Drunks 3 soon.

Happy New Year everyone! Stay safe and enjoy the holidays.
- Medix 311

Drunks 2

The second in a series of 3 on drunk cases.

“Medic 2, code 3 for an unknown medical, possible psychiatric problem.”

It was 2:30 in the morning and I rolled out of bed with a groan. I looked at the address on my pager: Warrenton. Great. I knew I’d be up for an hour, at least. I pulled my pants on, then sweatshirt, and finally my boots, then trudged out to the rig. My partner already had it running and put us en route as I climbed into the passenger seat. Dispatch repeated the address and nature of the call as we pulled onto the highway, our red and white strobes casting about us in the light fog.

We made for the roundabout, then south across the bay towards Warrenton. Rescue would be responding also, so I punched the SCAN key on the radio, but all was quiet—either they were already responding, or no one was. We’ll find out when we get there I thought to myself.

Going through Warrenton, we took a left at the main light, and shortly approached the scene. The fire department’s rescue unit was parked in the driveway of the single level house, its red rotators mixing with the pulsing blue and red of the police cars parked opposite the house. Everyone had come out for the show.

My partner marked us on scene, I pulled on a pair of exam gloves, then got out of the unit. We piled our equipment on the cot and wheeled towards the open front door. A police officer met stopped us short of going inside and gave me the rundown.

“So this kid shows up at these people’s home, completely drenched and drunk. He pounds on the door until they open up, then starts rambling about how it’s his parent’s place and he wants in. He’s in the living room, but he’s tweakin’ pretty good. I think he’s on mushrooms or meth.”

Our patient, a male in his early twenties, sits in a living room recliner. He’s dressed in his work uniform from a fast-food joint, soaked to the bone, and wrapped in one of FDs wool blankets. He’s fidgety and anxious, partly because he has no clue what’s going on, partly because the firemen are crowded around him, and partly (I thought) because he was high. I made a hole through the firemen, then crouch down so that I’m was at least eye level with him.

“Where are my parents?” he starts. “I don’t know who all these people are. What’s going on? Why are you all in my house?” He’s angry with us.

“Listen, partner. This isn’t your parent’s house. You woke up some poor folks and they called us. We’re going to take you to the hospital to figure this out.”

I questioned him some, tried to figure out what he’d been up to. He thought it was only 11pm. He didn’t know how he’d gotten to this house, if he’d gotten into an accident at all, or if any one had been with him. He denied drug use and—image this—denied drinking. He still thought it was his place and we had to argue back and forth a little that the homeowners had no idea who he was. I think at some level, he finally just gave up the fight and allowed us to walk him over the cot. It was when we started to put the seatbelts on him that things start to get out of hand.

“What the fuck is going on?! Fuck you people! I want to know what’s happening!”

Now, most everyone there knew my rules and I made no hesitation to educate the patient. Forcefully and sternly I told him, “you need to watch your mouth. You need to calm down and cooperate with us, or things are going to turn out badly for you.”

He was still angry, but he apologized through clenched teeth and we continued to belt him in. During this time, he’d lost a pocket full of change and as I bent down to collect it for him, he opened his mouth again. “Look at me! You need to tell me what the fuck is going on!” When I raised my head up to look at him, he was pointing his finger at me and he was red faced with anger.

“Listen. That’s your second warning about your language. You dropped your money and I was picking it up for you. We’re taking you to the hospital because you’ve had too much to drunk and you don’t know what happened tonight. Calm down, trust me, and cooperate, or things will not go good for you.”

But it didn’t stop, his bad attitude and loud mouth persisted. We had a 15 minute transport time ahead of his, so after we loaded the patient, I told my partner to just get going, that I’d handle everything in route.

Several times during the transport, he’d go from compliant and amicable to verbally combative and verbally abusive. At one point, he took his cell phone out of his pocket and after finding the battery dead, threw it against the rear doors. This was the point that I thought that’s it. I opened up my drug kit and pulled out the ampule of inapsine and a 5cc syringe. I had one eye on the patient and the other on the drug as I drew up the sedative.

“ Whoa, hey! What are you doing! What the fuck are you going to stick in me? You’re not sticking me what that fucking needle!”

“If you don’t calm down and get your language under control, that's exactly what will happen.”

“Are you trying to threaten me?”

“Nope, just giving you fair warning.”

And warning it was. Look, this is the way I see it. When you watch Cops on TV and they bring a suspect back to their car, they tell them to put their hands on the hood and not to move. After a few seconds, the suspect will take his hands off the hood and try to reason with the cop. The cop will warn him to put his hands back on the hood. This repeats three or four times before the cop finally cuffs the suspect and sits him on the curb. The cop does this to control the scene—he does this by controlling the suspect and thereby controlling his safety. My tact with this kid was the same—I needed to control the environment to keep myself safe.

Lucky for him, he kept his mouth shut and his hands to himself for the rest of the transport and the syringe of inapsine sat next to me on the bench. We unloaded him at the ER bay, and while he looked angry as a hornet, he still kept his mouth shut. The ER nurses had prepped the psych room for him and waited for my partner and I to transfer him to the ER cot, only he wasn’t getting off of the cot.

“I’m not getting off this fucking thing until somebody tells me what’s going on!”

He had a death grip on head bar of the cot and he’d spread his legs, wrapping his feet around the frame of the Stryker. We tried doing to easy things at first, just lifting him over using the bed sheet, but he wouldn’t budge. And so my patience broke. I forcefully unwrapped his feet, roughly slamming his legs back onto the cot, then I loosed his grip, throwing his arms back onto his chest. Then we roughly tossed him to the ER cot in a kind of “1-2-3-heave!” motion.

Afterwards, I told me partner “sorry. I know I lost my cool, but guys like that really just piss me off.”

“You know, you were way too nice to him,” he replied.

Too nice, huh. I guess I’d broken my own rule. I should have used to inapsine, drawn up and sitting next to me on the bench, as it was.

ACLS Update

Today I took my ACLS update and I did my PALS update about two weeks ago. I'm now sure that a person's success at ACLS and running through the scenarios is inversely proportional to a person's pay scale. In other words, the more your get paid, the worse you do at ACLS.

To illustrate my point:

My group today for recertifications consisted of an ER physician, multiple nurses, and 3 paramedics. The worst performer of the group was the ER physician--he overlooked the BLS survey (the look, listen, and feel), didn't know drug dosages, and had to refer multiple times to his pocket guide to double check the algorhythm.

The ICU, CCU, and ER nurses in my group performed slightly better. About half remembered the BLS survey, although some would skip steps (such as not checking a pulse and jumping from giving breaths to starting compressions). Most of the nurses had trouble identifying the heart rythms, which I guess is understandable. The majority of the nurses had a firm grasp of what drugs to give when, although they seemed a little iffy on dosages.

By far, the best performers at the skill stations were the paramedics. The medics were on top of the BLS survery, made smooth transitions from assessments to treatments, knew the heart ryhtms without questions, and knew the algorithms by heart.

Now, I'm not trying to say that medics know better than nurses and physicians, but I think that with the way the ACLS course is taught, it creates an environment for medics to do better. The course starts with the BLS assessment and CPR, followed by field interventions, and skills that are performed by medics on a very regular basis. Conversely, many of the nurses in my classes had no prior training in field assessment skills, or more technical skills such as intubation or needle decompression. Many of the nurses were unsure of their roles and stated multiple times, "well, the doctor normally would do that," or "I'd call for the doctor."

Doctors, on the other hand, aren't expected to perform CPR in a clinical setting, or be the ones to start the IVs or push the drugs. They often aren't expected to be the ones to perform the BLS assessment (as an example, one of the physicians in my class was an oral surgeon).

Medics practice these skills on a daily or weekly basis, incorporating the BLS survey, ALS skills and interventions, and transportation and turnover into all of their patient contacts. Nurses and doctors don't have the beginning-to-end exposure that medics in the field do and can therefore lack the same skill set. Many of the nurses in my class talked about how the patients they see on a daily basis already have an IV or airway established, how the diagnosis and treatment has already been determined, in other words, much of the guess work is already been done for them.

So the other medic students and I spent over three hours (or our six hour day) this morning going over the CPR video (a skill that we should already come to class proficient in). We then watched corny DVD videos of nurses, doctors, and EMTs perform the cardiac arrest algorithms (all of which were done with far too much urgency and energy to seem realistic or reassuring). After this we performed basic airway adjuncts like the OPA and non-rebreather masks (skills that we learned in EMT-Basic school and should be proficient in). We spent only 1 hour of our 6 hour day practicing the "mega-code" scenarios. So I have to wonder, where is the "Advanced" in Advanced Cardiac Life Support? My partners and I wanted only to do our scenario and take our test--get in and out in an hour. Really, the science and skills hadn't changed in 2 years. These are the 2005 guidelines, right?

Ideally, I'd love it if ACLS was taught in such a way that it focused on the skill level of the providers. ACLS for paramedics would focus more on the core cardiac arrest cases. ACLS for basic level providers would focus on core CPR skills and basic science. ACLS for nurses would focus on in-hospital interventions and working as part of a team with a doctor in the lead. ACLS for doctors would focus on the more tertiary aspects of cardiac arrest management, identifying and correcting causes of cardiac arrest that can't necessarily be identified or corrected in the field.

But the AHA has their way of doing things and who are we to questions, other than the providers that render their standards of care.

Drunks

The first in a series of 3 drunk cases that have given me problems over the last few months.

There's a reason that I don't like drunks. I never get called to the happy drunk, the one that wants to buy you a pint and hang out. I don't get called to the funny drunk or even the silly drunk. No, I get called to the guys too drunk to walk, too drunk to stay conscious, too drunk to be a nice. And it's never at a convenient moment, always right before or after the bars close--in other words, past my bed time. So when I'm paged out at 0230 for an unresponsive male in the parking garage of the Ocean Inn, I'm not thinking diabetic problem, stroke, or cardiac arrest, I'm thinking--I know--it's a drunk.

We had to park on the street and hike the gurney and equipment into the garage. The cop gave us his name as we walked up, Brian, from the military dog tags around his neck. He was still sitting in his enlistment bonus when we arrived. A brand new Ford Mustang Cobra, black with the twin gray racing stripes. It was a sexy ride, aside from the douche-bag in the driver seat.

The hotel worker said he'd seen the guy earlier in the day and that he'd already had a half gallon of Captain Morgans. The cop said he'd already tried honking the car horn and doing a sternal rub, both without effect. The driver's door was open and you could smell the alcohol from 10 feet away. Brian was passed out... completely... the “I just bought myself” an intubation kind of unconscious.

So I turn to my partner. "Look, we're gonna pull him out, put him on the cot, and then we're going to put in an nasal airway. We'll see if that'll wake him up."

My partner and I pulled him out of the car, roughly setting him to the ground so we could readjust our grip. Coming up under his shoulders and knees, we hefted him to the cot, then started to strap him in. His button down shirt was open at the collar, I could see a set of dog tags resting on his chest, and a couple of tatoos. His jeans were wet at the crotch.

As we strapped him in, he woke up--wide eyed and with a scrambling of his limbs. "Easy there, partner," I started to soothe him, "we're the paramedics."

"What happened?" he asked, still wide eyed and confused.

"You had a little too much to drink tonight and the hotel called 911 when they couldn't wake you up."

"I haven't had too much to drink!" he tried sitting up and getting off the gurney and only got himself tangled in the straps.

"Easy, soldier. You had enough tonight that you're either going with me to the hospital, or going with this nice police officer here to sober up," the cop raises his hand and gave a little hello.

So Soldier Boy complies and relaxes a bit on the cot. The fire department had arrived then and I told them, "we got it guys, but thanks for coming out." My partner and I slung our kits onto our shoulders, and then rolled the patient out of the garage and into the ambulance. My partner sets up the IV bag, while I go about getting a blood pressure and setting him on the pulse ox. With the IV bag set up, I told my partner we can get going, that I'll start the line in route. My partner jumps up front and we start towards the hospital.

Brian passed out again, his head rolling onto his left shoulder. We weren’t more than fifty feet down the road. My partner is eyeing me through the rear view mirror as I put the sternal rub into Brian again. He awakes with a violent start this time, flailing his arms, kicking is legs, and getting enough momentum going that he crawled right up the head-end of the gurney and wound up wedging himself into the airway seat. Honestly, it reminded me of that scene in Signs where Joaquin Phoenix sees the alien on the news clip and backs himself into the closet out of shock.

“Park it, Shane! Get back here!” I yell up to my partner. I felt the rig lurch forward as he hit the brakes and parked it.

Brian was thoroughly freaking out right now, “what’s going on! What happened! Where am I?” Over and over he kept asking as I tried to talk him down and soothe him. My partner had crawled in back and was awaiting instructions. I was trying to calm Brian down, to get him back onto the cot, at the same time I gave instructions to my partner to get the Inapsine and a syringe.

Brian had calmed a lot and was now moving back to the cot as Shane placed the drug onto the bench next to me. I settled him onto the cot, securing the straps around him again, explaining that I wasn’t trying to restrain him, but keeping him safe. He was calm enough at that point, so I told Shane to get back up front and we’d get going again.

On the drive in, I talked with Brian trying to get a little more history out of him, the entire time the Inapsine and syringe on the bench next to me. I talked him into letting me take his blood pressure and to hook him up to the monitor. He even said it was okay to start an IV, which I wrapped copiously with coban to keep it in place.

I patched my report to the hospital and soon enough, the back-up alarm was sounding as we came into the ER bay. We unloaded the cot, Brian still resting comfortably and the Inapsine still on the bench.

The nurses met us in the ER hallway, silently pointing to bed 6. Brian had tried scratching and pulling at his IV a few times and I was glad that I’d tied it down. He’d also started to have this smoldering, angry look in his eyes and I knew he was trying to work up to something. But he transferred to the ER cot on his own and I exited the ER bay with an apologetic look to the nurses.

Just a few steps outside the room though, he started pulling at his IV line again and trying to scramble off the gurney. I turned on my heel and dashed back into the room to give the nurses a hand. Brian was getting more and more agitated and I had to use my forearm to keep his shoulder pressed into the ER cot. It took a minute or so, but an ER tech came in with a set of soft restraints that we tied Brian down with. I backed away from Brian, pulled my gloves off, apologized again to the nurses, and left the room.

Maybe I should have used the Inapsine.

Posting

At post 14. A cup of Starbucks on the dash, with my ballcap and sunglasses (didn't need those today).

Another gray, rainy day on the Oregon coast.

Why We Do

My brother’s little girl was born premature by 3 months. She had a lot of health problems in her first few years of life and today is mildly autistic. When she was born, my brother and his wife Tonya had moved to a little town outside of Portland and was working for a local utilities company. He was a volunteer firefighter in that town, the same as here in Seaside before he moved. He’s also a very proficient EMT.

One morning, Gordon’s wife was watching their little girl when she stopped breathing. It wasn’t unusual, and had happened a few times before. Tonya knew what to do and did the few stimulus activities that the NICU nurses had taught her… only this time they didn’t work. She cried for Gordon who came running into the room and saw his little girl turning blue and not breathing. He checked a pulse and not feeling one, started CPR.

***

I’ve asked myself and some of my coworkers over the years, “why do you enjoy being an EMT?” (or a firefighter, depending on who I’m asking). The answers are varied, of course. Most have some variation of “because I want to help people.” One of my fellow paramedics tells me he’s here because its less stressful than his lost job—he was cabinet maker before.

Many of my fellow EMTs tell me they’re here because its more interesting that what they did before. Whether it was surveying, delivering pizza, or drug running (seriously), they find working as an EMT more entertaining.

My supervisor was recently quoted in a local paper as saying “My favorite part is making a difference in someone’s life. Sometimes that means holding a patient’s hand and taking them to the hospital. Sometimes is means saving a life.”

For me, I’m not sure I have a simple answer to the question. I started in volunteering for the fire department my senior year of high school as my community service/graduation project. It was an easy way to get the hours and it let me spend time with my brother and dad. At the time, it was the era of the dotcom boom and all I wanted was a career in computers. Then the boom went flat and I was left looking for a new path. By the time I graduated, I enjoyed my time volunteering and moved into the fire station as a resident volunteer—but I still wasn’t sure it was what I really wanted.

I worked customer service, first as a floor manager at the local movie theatre, then as a front desk agent at a hotel before I started full time on the ambulance. But even as I became a full time, paid responder, I still wasn’t sure what I wanted. I was still testing for fire department jobs, but wasn’t thrilled about working 24-hour shifts, and neither was my wife.

This were different for my brother, though. He knew he wanted to be a fireman as soon as dad brought home his bunker boots when my brother and I were still little. Right out of high school he was applying for full time for jobs. He must have taken at least 50 in the last ten years and some times he’d get as close as the final chief’s interview before being cut. Time and again I saw him get cut down, only to get back up, dust himself off, and sign right back up for the test. If only I’d had that kind of dedication and drive.

Don’t get me wrong, I enjoy what I do. I love being a paramedic. I feel like I’m putting my skills and knowledge to use on a daily basis. I know that I’m helping people and most of the time that gets me through the shift. I’ve transported friends and family and known that I’ve made a difference for them. I have seen heartache and been on the calls that bring my family tragedy. I know that EMS is a team effort, but I know that because of my skills, there are a couple of people out there still alive and that makes me feel wonderful. Sometimes I think I’m here doing this because it’s what I’m comfortable doing—who wants to rock the boat, right? Right now, I can say for sure that I’m here because I have job security. With the economy as poor as it is, I know that I have a good paying job for my family that isn’t going to disappear. I just don’t know that I have a single, sum-it-all-up answer to “why do I do what I do?”

***

Gordon performed CPR on his little girls until the ambulance arrived. By that time, she was breathing on her own again and crying. She went in again for another stay in the NICU, my brother and his wife at her side.

Gordon once told me that if his whole purpose, his whole reason for taking all the fire classes, for becoming an EMT, for testing for all those fire jobs and getting shot down time and again, that if he was never meant to get a fire job—that his only reason for all of it was to save his daughter’s life that morning, it was all worth it.

I hope that someday I can have as noble an answer as my brother’s for why we do what we do.

Gordon is now a career firefighter/EMT for the Portland Fire Department.

The Boots We Wear

It was time to order new boots. My old pair, a very comfortable pair of Galls Atheltic style boots, was cracking at the heels and the sole was separating from the boot. I did some shopping around, specifically looking for a pair of leather, waterproof, zippered boots under $150. I settled on a pair of Bates Durashock boots; leather, zippered, and water resistant.

These boots were comfortable out of the box, but still needed a couple of days to get broken in well. They looked new from the factory, unscuffed of course, but also a little dull. So I bought a tin of boot polish and started to shine ‘em up. For the last three weeks, I’ve spent at least an hour every shift polishing my boots to a glossy shine.

*****

I believe that you can tell a lot about an EMT or a medic by the boots that they wear. I take the time to polish my boots, to put forth a professional image from head to toe. I like to think that I’m precise and polished in my skills—not perfect, mind you—but polished.

Other medics show to work with ugly boots, never once shined from the moment they left the box, or worse, shined with those awful all-in-one sponges. Their uniform shirts are wrinkled, often with more than a couple of old coffee stains. Similarly, their skills are rough and they lack that personal touch, but they’re still passable as medics.

My company SOGs state that footware shall be “black and polishable.” Note that it doesn’t state “boot” specifically, but “footware.” Many of our employees have come to exploit this as well.

While black romeos aren’t specifically against company policy, they are a poor idea. They offer very little traction and no ankle support. They are not made for hiking a trail to rescue hiker or wade into a flooded ditch. And those EMTs in my company that choose to wear the romeo would not make the effort to climb that mountain, or they’d send a fireman into the ditch for their patient. They’re lazy, unwilling to do the work of lacing up a pair of boots and unwilling to do the work of polished EMT.

I’ve seen a medic come to work in black loafers. Old man shoes (if you’ll excuse the expression, but he is an old man.) His shoes also keep him from hiking hills or crawling into ditches, but they do convey a sense of professionalism and formality. We won’t see these loafers rappelling down a cliff, but we will see them standing next to Mr. Jones and his loafers as we help him up from the floor. The loafers, and the medic they’re attached to, has a way of interacting with the elderly population and putting them at ease that isn’t reproduceable by the medics my age.

A new hire EMT is working in a pair of black danskos, a wonderful nursing clog, but a shoe for the field it is not. Her attitude is great, with a perky smile, and a cute little pony tail. Her footware betrays her inexperience. She hasn’t had to hike a mountain or crawl into a ditch yet. Likewise, she hasn’t yet rolled her ankle stepping out of the ambulance, or worse, carrying a patient down a flight of stairs. Her skills lack polish and experience, just like her clogs.

*****

The last time I was at my parent’s place, I asked my mother if she still had her dad’s shoe shine kit. It was a worn, wooden box with a shoe stand on the lid. The hinges and latch were tarnished brass. Inside, I remember he had all kinds of brushes, polishes, and rags. Mom still had the box, which she was happy to pass over to me. Inside were all of grandpa’s old horsehair brushes, used so many times they’re down soft. Old tins of Kiwi polish caked and dried, and old, oil stained rags that smell like wood and polish. The care that went into my grandfather’s old cowboy boots (and a cowboy he was) now are going into my work boots.

My boots are something I can feel proud of. I think they make me stand out a little from my coworkers, even if I’m the only one who notices how nice they look. The work that I put into them, in a very strange way, makes me feel like a better Paramedic.