On Sale Now!

The widely used Informed Pocket Guides, now for the iPhone/iPod Touch, are on sale in the iTunes App Store for just $9.99! They have the BLS, ALS, Emergency & Critical Care, RN, and NIMS guides available. I just picked up the new version of the Critical Care as it's my favorite of the bunch.

Just thought I'd share :)

9 Years

This month marks nine years in emergency services for me. I started nine years ago as a volunteer firefighter with Seaside. I still remember my first call—a drunk outside one of the bars downtown. It was the same night I’d first been issued my gear. My dad drove the rescue to the scene, me in one of the rear seats, feeling very out of place.

I remember a lot about that first year: structure fires, cardiac arrests, and car wrecks. I joined the department to fulfill my Senior community service project (called a “Pacifica Project) and didn’t have much intention of sticking with it long term. Nevertheless, I started the First Responder class a few months before graduation. Within a year, I knew where I wanted to go with my life.

A couple of weeks ago, I had to do the ambulance stand-by at the home high school football game. I watched the crowd just as much as I did the game: young men with the faces painted in red and columbia blue, young women with glittered ribbons tied into the hair. Parents were wrapped up into their kids’ letterman jackets, fathers in red Seaside ball caps, mothers in red Seaside hoodies. The Friday night lights were bright, shining onto the white-striped field. The band played fight songs and the cheerleaders lead the crowd in chants of “LET'S GET FIRED UP!” It was a beautiful slice of Americana—and it made me feel a sense of sickly nostalgia.

When I think that I’ve been out of high school for nine years, my 10-year reunion coming up next year, I have the undesired feeling of being old… or perhaps just older. But when I think of nine years in emergency services, I have a feeling that my career is just getting started and that I’m starting to develop the kind of experience that will make me an experienced and respected care provider.

It makes me wonder why I have such contradictory feelings about the passage of nine years. My wife likes to tell me that sometimes I’m still stuck in high school, and maybe there’s some truth in that. I miss a lot of the friendships, the experience, of being in the crowd, instead of functioning on the sidelines. But I’m excited about where I’m going, that I’m married, own a home, have a career, and a stable lifestyle.

Sometimes nine years can feel like a like time and sometimes like no time at all.

The Parapup and the Potato Chip

I was having a conversation with one of my firefighters about the topic of professionalism—what’s appropriate and what’s not in certain situations. We were talking specifically about an incident at a recent out-of-district training event and how bad it made out local volunteers look. As we talked, it reminded me of a few different “professionalism” moments. I thought I’d share.

***

Professionalism with your Superiors

It’s often been said in my company that they supervisors don’t get any respect because they work as regular crewmembers. There’s some truth to this as we all joke around together and the supervisors like to be friends to everyone. What develops from this though, is a lack of professional courtesy, something that is often passed on unwittingly to our new hires and our paramedic interns.

As a paramedic intern, when you arrive for you internship, you should be like an obedient puppy dog. Eager to learn, eager to run calls, but with an understanding that you are not a regular crewmember and that your rights and privileges are not the same.

I’m doing a fill-in shift and precepting a paramedic intern one spring day. I have a bag of chips and some salsa out on the counter. As a regular crewmember, it’s understood that to have a couple of chips here and there from someone else’s bag of Lays is okay. Partaking of the dip is acceptable. Just don’t empty the bag or drain the salsa bottle. Let me remind you of the point: interns are not regular crewmembers.

So when this wet nosed parapup reaches into my bag of Lays and withdraws friend potato wafer then places said chip in his mouth, you can imagine my reaction. “What the hell did you just do?”

The parapup look liked he had just piddled on the carpet.

“Did you just take a chip from my bag? Did someone tell you that you could have a chip from my bag? No? So who in the hell do you think you are?”

When is it taught to new paramedics that they need to have some respect and professional courtesy to those that are senior to them? At the very least, they should know how to act when they’re in someone else’s house.

***

Professionalism with our Peers

My brother is a firefighter for the City of Portland and arranged a training event at the Portland Training Tower for the Seaside and Gearhart volunteer fire departments. This was a rare opportunity for out departments to train together at a high-class training facility. We were able to use the live burn house then spent the afternoon in their high-rise building going over high-rise evolutions.

It was at the end of the day, as we were cleaning up, that one of the volunteer firefighters made his way over to one of the Portland firefighters that was observing. While I wasn’t within ear-shot to hear the conversation, the remark that was made quickly worked its way back to my brother and through the rest of the Clatsop County fire departments.

The remark from the volunteer firefighter went something like this: “I have all the same training and certifications that you do, and I have a real job.” (As a side note, this guy’s “real job” is working the counter at an auto parts store.)

It should go without saying that when you’re at someone else’s firehouse/training facility/whatever and there’s a crew on duty, you try not to bother them. In addition, you have to realize who you’re representing and do so in the highest manner possible. Let’s just stop and think for a moment what one firefighter’s comment did to the professional image of every volunteer firefighter there that day and all the one’s that we were representing back home.

***

Professionalism with Families

On shift on the ambulance one fine afternoon and my partner and I took a cardiac arrest. In my system, we transport all full arrests and don’t call them in the field after running a few rounds of ACLS. So, we start CPR, I place the ET tube, and have the patient on the monitor. Asystole all the way, but we load and go. As expected given the circumstances, the hospital called the code shortly after arrival and the patient didn’t survive.

Talking with the family about resuscitation efforts has always been a difficult thing for me. I don’t like being involved in a families grieving process, and even worse, I don’t like have to deliver the news that we had done all we could but their loved one was gone. In a certain morbid saving grave, when we transport the code to the hospital, I am spared having to notify the family. It’s left to the doctors.

As was the case here. I was gathering my paperwork and helping my partner to clean up the ambulance. The family had been called into the ER bay by the physician and spent a few minutes inside before coming out crying. My partner was making up the gurney a few feet away from the grieving family what he thought he would offer some words of comfort.

“Well, you can look at it this way: everyone has to make the trip upstairs at some point.”

I was stuck, rooted to the spot, and dumbfounded. The family was a mix of mortified, dumbfounded, angry, and in disbelief. I think that maybe for an instant, the family was so mad at my partner that they pushed the thought of their loved on passing aside. Then a nurse quickly escorted them to an empty ER bay, all the while the RN was giving my partner a death glare. My partner, for his part, had the what did I do? look on his face.

My first knee jerk reaction was to take him by the ear and drag him outside. Instead, after the RN had closed the door to the ER bay, I walked up to my partner and told him we needed to have a conversation outside. I had to have a conversation with him about appropriate interaction with family members, how we don’t impart our personal believes upon the grieving, and how saying anything more than “I’m sorry for you loss” is unacceptable.

After that, I then had a talk with the family that went something like this: “Hello folks. I’m sorry we didn’t get a chance to talk earlier. My name’s Jeramy and I’m the paramedic in charge. My partner—Jake—works under my direction. First of all, I want to say how deeply sorry I am for your loss. Secondly, my partner spoke out of turn and does not speak for the rest of the company. I want you to know how sorry I am about his remark. Here is my business card and the name of my supervisor. If you’d like to file a complaint, I completely understand.”

How do you make up for it when an off-the-cuff remark destroys your professionalism and credibility to the ones who matter most: the patients and their families.

***

Professionalism in the profession of EMS is all about how we act around the public and our peers. As I explained to my firefighter during our discussion, we can goof around all we want at the stations, play practical jokes and what have you, but we are health care professionals when the call comes in. The public and our peers should see us at our absolute best. I thought I’d share a couple of the professionalism moments above because I’m a firm believer in learning from other peoples’ mistakes. And while the parapup and the potato chips may not be the most poignant example, it sure makes for a funny story.

Summer Hiatus

Sometimes you take time off without really meaning to. Summer kicked in this year and I found myself pulled in a lot of directions--all of which seemed to be away from keeping up with the blog world.

I played a lot of golf this summer, continued with the EMS Bike Program, went camping with the family and dogs, kept working, kept volunteering, and kept up with projects around the house. But I promise I'm back for now and I'll have new content up soon.

NOWS 2009

After rearranging my weekend schedule, I was able to participate in the Northwest Oregon Wildfire School at Camp Rilea. Every year, our county hosts a multi-agency, live fire, wildfire drill. This was my first year doing it and was looking forward to working with the other departments, the ODF crews, and the helicopters. However, due to rain, we couldn't even get a burn out completed on our safety zone Saturday. Yestereday was a total bust with thunder and lighting storms. Looking forward to next year, though.

2972, the Gearhart FD Unimog. My truck for the weekend.


Putting down a wet line.

Digging hand line.

The rest of the crew on the line.

Attempting to burn out the safety zone.

Lots of smoke, but very little fire.

An ODF lookout, keeping an eye on the (attempted) burnout operation.

Telemarketers and Baby Duckies

A ground level fall today at a care facility was the direct result of a telemarketer. Mr. Johnson got up from his wheelchair to answer his apartment phone at 3 pm today when a telemarketer called to sell ShamWows (or some such nonsense). Hanging up in disgust, then trying to sit back down, Mr. Johnson missed his wheelchair, fell back, and struck his head against the window sill. I advised the patient he should sue.

* ** ** ** *

A two vehicle, non-injury, non-blocking, everyone out exchaning insurance information MVA was the direct result of a momma duck and her long line of little baby ducks. The driver of the Toyota Tacoma slammed on the brakes when "all these baby ducks popped out onto the road from nowhere," causing the little Honda Civic behind him to rear end the truck. No one was hurt and by all reports, all the little duckies made it across the road.

With Little Fanfare

At the beginning of the month, I posted about how I'd be moving to a 12-hour day car. However, my little ambulance company is feeling the pinch of the economic downturn and we've had to cut a whole shift, as well as cut dispatchers and wheelie drivers. Because of seniority and our new shift bid process, my move to the 12-hour car was preempted by another employee, so I'll remain on 24s for the foreseeable future. As much as I was starting to look forward to the 12-hour days (sleeping in my own bed, no more midnight transfers, seven shifts per paycheck), I'm trying to find the bright side to remaining on 24s. I really like my current partner, I've started rotating through all the stations again, and everyday is a Friday (more time for golf).

Little of interest has happened in this last month, and I admit, I do feel neglectful of my blog. So I thought I'd post something juicy. Last year, I started the EMS Cyclist Program at my fire department and while it was a rocky start, I've had continued and increased interest this summer. My volunteers EMS providers are more willing to step up and the program has received a lot of positive support from local business owners and event organizers. The EMS Cyclist Program was also one of the reasons why I was awarded Firefighter of the Year for my department.

Based on this EMS Cyclist Program, my fire chief deemed it appropriate to submit my name to the Oregon Volunteer Firefighter Association for consideration of Volunteer Firefighter of the Year. Today, my wife and I just returned from Medford where last night I received my award plaque for 2009 Volunteer Firefighter of the Year.
I didn't get a chance to say thank you at the awards dinner last night, so I thought I put down a few of my thoughts here. I know that I've been recognized frequently in these last few years, and while my wife and family say it's because I work hard and deserve it, I can't help but feel so completely humbled and underserving of the praise. I feel this recognition needs to be shared with my fellow volunteers and my coworkers. I wouldn't be as lucky or successful today without them. The EMS Cyclist Program wouldn't be successful without the outstanding performance of the team members. Nothing that I do for the fire department (or my job on the ambulance) is an individual effort and I want to ensure that the efforts that I put forth benefit my organizations, not just me. So thank you to all of my fellow volunteers, fire, and EMS professionals.

How To Change It Up

Over the last six weeks I’ve been “reassigned” (i.e. “banished”) to our slowest station on the north side of the river. This has been through no fault of my own—it all has to do with scheduling and who is certified to work where. No big deal really, except that it’s a 70 mile round trip and has cost me a lot in gas to get back and forth. There have been some positives to working the slow station, though. Typically I’ve been sleeping all night. I’ve been able to get my prep work for class done while on shift.

But, the commute is a bitch and I’m blowing through gas money so quick that I feel like I should be just lighting piles of cash on fire. I have to get up earlier than normal to be to work on time. And I run very few calls (meaning I don’t get to practice many skills) and it weights my calls heavier when calculating my transportation (or non-transport) statistics.

So the plan: At the end of the month, I’m moving to a 12-hour day car. After four years working 24-hours shifts and rotating through stations, getting up in the middle of the night for calls, postings, and transfers, I’m trying something new.

My wife and I just celebrated our 5th wedding anniversary, so I think about it this way: for almost my entire marriage, I’ve been away from home, not sleeping in my own bed a third of the time. Time for a change I think.

As seen on CNN

After reading a short article on CNN.com, this was the "Ads by Google" that I saw at the bottom:

I have one thought about this: Fucking bottom feeders. God forbid we try to educate ourselves about the H1N1 virus, or that we talk about proper hand washing and prevention techniques. No. We have to put up with vendors trying to sell $179.95 (plus free shipping!) 5+ Person Flu Pandemic Kits. This "amazing" kit, a $279 dollar value, includes:

• Box of 35 N95 Masks (Latex Free): N95 Masks are the respiratory masks that are rated the best for preventing the spread of contagions (N95 masks are also good for chemical spills, wild fire, etc.)
  
• Box of 100 Exam Gloves (Latex Free, Powder Free)
  
• Box of 50 Disposable Isolation Gowns (Latex Free)
  
• Box of 100 Disposable Shoe Covers (Latex Free)
  
• Box of 100 Bouffant Cap Disposable Hair Covers (Latex Free)
  
• Five Pairs of Protective Safety Glasses (Latex Free)
  
• Five 4-oz Bottles of Epi Clenz Hand Sanitizer Gel

All this can be conveniently yours at a special discount price to make sure that your family is pandemic flu ready.

Gack! I think I've just thrown up a little in my mouth...

Occupational Hazards

Lt. Ray McCormack of the FDNY made a statement at the recent FDIC conference: the fire service needs a "culture of extinguishment not safety." Some of Lt. McCormack's remarks seem pretty inflammatory, but they're the same thoughts that I've occasionally had. Now, I'm just a volunteer firefighter on the Oregon coast, but if an FDNY lieutenant and a small town volunteer firefighter think the same thought, there must be a few people in the middle that feel the same.

I've been involved in the fire service for over 8 years and have worked as a full time EMT/Medic for 5. Even in that time, especially considering the post 9/11 period, emergency services are focusing more and more upon "ultimate" responder safety. As Lt. McCormack puts it:

"Attempting to make the job safer by teaching you to place yourself above those in need is wrong and goes against everything the fire service has ever stood for."

When I first started taking my fire service and EMT training, safety was a matter that was pressed upon us heavily. But it was always prefaced with a statement of: we're doing what no one else wants to do or can do. To put it another way: firefighters rush in while others are rushing out. What we do is inherently dangerous.

Police officers wear bullet proof vests and carry guns because they know they can be shot on any given shift. Firefighters wear turnouts and SCBAs because we know we're entering IDLH atmospheres. EMTs work and move around in the back of the moving ambulance because we know we have to taken care of our patients.

Safety has to be a concern of every emergency responder, but we all do our jobs understanding that there are certain, unavoidable occupational hazards. Even though a firefighter wears his turnouts and SCBA, he knows he may still die in a fire and even though an officer wears his vest, he knows he could die of a gunshot wound. As a medic, I know that when I'm not wearing my seatbelt in the back of the ambulance, that I could die if we get in an accident. My patient is restrained in the 5-point harness, but I take certain occupational risks to render care to my patient.

But I agree with Lt. McCormack that our evolving culture of safety is beginning to hinder our ability to do our jobs. As a medical professional, I attend conferences and read the professional journals. I'm aware of the crash helmets and restraint systems that are being advertised to the EMS community to make us "safer." Several months ago, my supervisors returned from a conference intent upon equipping us with crash helmets. It really just seems too much.

From the fire service, we're required to purchase SCBAs with PASS alarm devices that automatically engage and are engineered with Universal Air Connections (UACs) for the purpose of transfilling the tank. We are required to have RIT teams standing by, ready to spring into action at the first transmission of a "mayday." But in all the case studies the I've ready, I've yet to see a single one where these measures made the live-saving difference.

Lt. McCormack puts it this way: "If you put out the fire, safety is accomplished for everyone on the fireground." And he's right. Getting the job done quickly and efficiently keeps the situation from escalating too much, from becoming too complex, and as a reslut, will keep everyone safer. Our focus in emergency services needs to be on educating responders about a common sense approach to safety. And it also needs to be reinforcing the idea that what we do is dangerous and it is irresponsible to think that we can ever make our jobs 100% safe.

AMA

Overheard on the dispatch:

"Medic 2 respond code 3 for a traumatic injury; female with her hand slammed in a car door."

My partner's response: "that's not a traumatic injury, that's a dramatic injury!"

Laughed we did. But a few minutes later...

"Medic 2 from 44-51--we're on scene with a conscious female patient. Obvious deformity of the left hand, partial amputation at the wrist."

Ouch.

Another few minutes later, after Medic 2 arrived: "MedComm from Medic 2, we're clear with a signed patient refusal."

It begs the question: WTF?

Modest Recognition

So I was standing in line at the vet's office the other day. I was in my uniform since I'd just gotten off shift and was getting some prednisone for Boomer. Dr. Goza's office is always packed with people and pets; he's a great doc and very reasonably priced.

As I'm waiting, one of the vet techs walks out from an exam room, looks up from his paperwork and sees me: "hey, you saved my daughters life!"

My first reaction was to look around for who he was talking to. I know I had that are you talking to me? "I'm sorry?" was the only thing I could say. Usually, I can remember the 'we saved a life' calls.

"Yeah, it was during the snow storm this winter." He was all smiles as he was talking to me. I felt awkward because I didn't have clue what he was talking about and now I was holding up the line.

"I'm sorry, but are you sure it was me?" I didn't want to be rude, but I didn't want to be taking someone else's credit, either.

"Yeah," he went on. "Remember, you gave her an epinephrine shot after she had some peanuts. You saved her."

"Oh yeah! I remember now." And I did. We had been dispatched for an allergic reaction on top of one of the hills in town. I was concerned about making it to the scene since the roads were still snow covered and we'd already had a few instances of slipping and sliding.

But we pulled up to the house without incident, grabbed our kits, and headed up the front steps. Dad met us at the door, his little 18 month old in his arms. She was crying quietly, swollen in her faces, arms, and legs--all over really. It wasn't a matter of hives per se, but swelling all over. She looked miserable, but still awake and afraid of me, so I heaved a sigh of relief.

Dad told us he'd fed her some peanut butter, no big deal since she'd had it before, but she quickly developed a reaction. He had given her benadryl before calling 911, but she hadn't gotten much better in the last 45-minutes. He said he would have taken her to the ER himself, but he had a 3 year old to look after also.

I sat dad and baby down and took a quick listen to her lungs. They were tight and wheezy, so I had my partner get the epi ready while I talked to dad. A quick shot in the rump and we were ready to go. Dad sat in back with me with his other little girl in the airway seat. And within a minute or so of leaving the scene, baby was crying her little head off and sounding much better than when we first walked through the door.

***

I stuck out my hand for the vet tech, "how's she doing?"

"She's great--no more peanut butter for her, though."

We chatted for a few moments more. "I just wanted to say thank you. You guys do such great work."

"You're welcome." It was the most modest thing I could think to say. I front of an office full of people, I felt pretty humble and didn't want to ruin it by saying something non-challant like, "just doing my job, sir."

One of my EMT instructor used to tell us that if we were in teh job for the pay or the recognition, then we should best look somewhere else. I have to say though, it's nice when the recognition happens.

"Free" Health Care

Oregon has what's called the Oregon Health Plan--in essence, Medicaid for those without medicaid. Only a certain portion of the population have access to it and you must meet a certain low-income level to be eligible. It provides access to the health care system that some folks otherwise may not have had. Plan participants get extremely low premiums, low co-pays, and prescription drug coverage. Sounds great, right? Health care for those who wouldn't normally have it.

Here's my problem:

My partner and I took a call for back pain. We were in this closet sized apartment, packed to the breaking point with a couch, queen bed, recliner, kitchen nook, and big-ass TV with stacks of X-Box and Playstation games. All of this in the same little, tiny space. We could barely find a place to set our bags down, let alone stand.

Our patient was sitting in the recliner, moaning and with three yappy dogs circling around us. "So, what's going on?" I ask with a smile on my face.

She was a slow talker and while I felt impatient listening to her get to the point of her story, I listened attentively, taking occasional notes on my glove. But the gist of it all: she had a whiplash injury from about a week ago, had shoulder and upper back pain, and her prescribed pain meds weren't working. It hurt when she moved, hurt when she was lying down, hurt when she was just sitting up.

"So whiplash from a week ago, huh? What happened? Was it a car accident?" Just a curious, conversational, innocent question.

"No... I fell asleep in my recliner and pulled something." Now trust me, given my overall impression of the patient, this was a WTF? Seriously? You called for this?

I know that my partner had the same thought because I could see it in his face across the tiny little apartment. But, I thought that I could use this as an educational moment.

"You know, I'm more than happy to take you to the ER now, but this is something that can easily be followed up with your doctor. Do you have a primary care physician?"

"No. I'm in between doctors right now."

"Well, that's okay. Did you know that there's an urgent care clinic at the hospital and you can easily follow up with a physician there?"

"No. But I'm on OHP and I want to go to the emergency room. That's where I went first, they have all my records, that's where my caseworker knows I'm going to go."

So there it was. I tried to reason once more, explaining that records can be shared, but she wasn't having it.

From personal experience, I'm irritated with the mindset of the 'average' OHP clients that I've run on. They look at EMS and the ER system as their only option and in some cases, as free health care. Now, I know that there are OHP clients that use the system appropriately and I've run on them too, but from my experience as a prehospital care provider, they are the minority.

But the story goes on. I ask her to walk outside to the gurney because there was no way the gurney would fit into her little apartment. She used her cane and I let her hold my hand as we slowly made our way outside. She sat down with a huff, slung her legs onto the cot, and handed me her cane. Then she turned to her son, shouting over me shoulder: "I'll call you when I'm done so you can come get me."

I was left asking myself the question if she's able to walk to my cot (which is next to her parked car) and junior will be coming to pick her up from the ER, how come junior couldn't drive her up to the hospital? I could make the assumption that she just wanted pain medications, but I had already told her up front after looking at her pain medications that I had nothing stronger than what she was already taking. May she simply didn't know better, but I find that doubtful since when I tried to educate her, she wanted nothing to do with it.

Nope, I think it all has to do with her OHP Golden Ticket and her (nearly) free access to healthcare--no matter how unnecessary the access might be.

Happy Milestone!

Over 10,000 hits, baby! Pretty darn cool and I never thought I'd see the day. Thanks everyone, and I promise new content is coming soon.

The Science Of It All

A few years ago we had a paramedic that worked for us that used to refer to himself as a “Purple Box Paramedic.” His idea of care was pretty simple—he saw bradycardia on the ECG, open a purple box. Asystole? Open the tan box. Low blood sugar? Open the big blue box. For him, patient care wasn’t about clinical assessments or diagnosing, it was a matter of looking at the monitor or vital signs and opening the appropriately colored box. Wash, rinse, and repeat.

Some would argue that that’s what we do. That’s what protocols dictate we do. Find the protocol that the patient fits into and open the appropriately colored boxes. I would argue that you’re not doing enough for your patient. After reading the article on JEMS that Peter Canning recommended (EMS 12-lead ECGs after ROSC?), I noticed a comment by an anonymous poster. I’ll paraphrase: “what’s the point? It won’t change our treatment.”

I don’t want to belabor the argument (and there was a big list of objections), but the first thing I thought of after reading the comment was: Purple Box Paramedic. 12-lead ECG didn’t fit into his/her protocol for post-arrest treatment, so why bother with it? Because, as the science is starting to show, it’s probably a good idea. And as a follow up commentator stated, “if it doesn't change what I do within the next 5 minutes then I guess it has no value at all, right?” (the sarcasm is implied). In addition to the science of it all, we have to be willing to think past the purple box and think about he long term continuation of care.

I like to browse JEMS and other literature and try to keep up to date on how EMS is evolving. In some ways, I know that I can be a little quick to jump on the bandwagon. I’ll sometimes read an article, think that’s it’s the greatest thing since sliced bread, and want to implement it the next day, regardless of how “new” or “unproven” the concept may be. But this comes from being aware of something about myself as medic: I like to know why I’m doing something. If I’m informed about the science behind it, I’m more likely to 1) perform the assessment/intervention/whatever, 2) have greater confidence in my ability to perform it, and 3) have greater confidence in the potential outcome.

As an example, I recently helped recertify our volunteer firefighters/first responders at Seaside on their CPR cards. In addition to the standard stuff (“push hard and fast; 100 times a minute; think of ‘Stayin’ Alive’”) I also gave them a brief lecture on coronary perfusion pressure and why it’s so important that we get our rate and ratios right. I kept it simple, not because they wouldn’t have understood a long lecture, but because the concept can be kept simple. And I could tell by looking at them that they were getting it, I could see the light bulbs turning on. In fact, I had numerous firefighters tell me that it was the first time that they every really “got it.” And this is the same stuff we’ve been teaching for almost 5 years now.

I’m a strong believer in the science of it all. I went to a subpar paramedic school and came out with a less-than-stellar education. I’ve done a lot of research and studying on my own and still try to learn new things every single shift.

Here’s another example. One of the headline articles on JEMS right now is The Disappearing Endotrachael Tube. Research nationwide is beginning to show that prehospital intubation by EMTs is a poorly performed skill with a significantly high (relatively) failure rate and an alarming trend towards higher rates of mortality. I read this and I think about how I want to be able to perform the skill proficiently with an eye towards long term patient survivability. Now I couple this with everything that I’ve learned about quantitative capnography, and I begin to think of intubation from a perspective of performing the skill when appropriate with an eye towards the overall patient outcome, and in turn, I have more confidence in my decision to intubate when determined appropriate.

So much of what we do in EMS is based upon habit, anecdotal evidence, and presumption. We need to be open minded about emerging research, changing trends, and evolving treatments. If we want to be taken more seriously as a profession, then we need to be willing to get behind the science of it all. It’s also so important for us to understand that we’re part of a greater health care team and that everything we do will have an effect, whether positive or negative, on the remainder of the patient’s care in hospital.

And as the NAEMT Code of Ethics for EMTs reads: “The Emergency Medical Technician shall maintain professional competence and demonstrate concern for the competence of other members of the Emergency Medical Services health care team.”

Something to ponder the next time the question is asked, “but will it change the way we treat them?"

Unethical Decision Making

I was having a conversation with my partner today, telling “war” stories to one another when the topic of fatality MVAs came up. We are both in our 20s and have only a few years experience under us—we’re too young to have seen the really bad days of traffic accidents. We were reminded of an accident that we were both on, Spring Break a couple of years ago. For my medic partner and me (an EMT at the time) it was our second fatality of the day.

We were dispatched onto the beach at 11 pm for a rollover accident with injuries. There was a fog over the beach and a heavy March chill. The accident itself was a mile or so down of the beach access and we made our bearing on the lights of the fire units near the surf line.

As we approached, we could see a battered, black Toyota pickup in the surf, being rocked by waves. The rear doors of the fire department’s rescue unit was open and we could see 2 patient’s on the bench seat, and a third on the deck on a back board. We parked, positioning our scene lights on the pickup some 100 feet away in the surf. The firemen were crashing around in the surf, working on pulling another patient onto a backboard. With each wave, the pickup would shift a little more and the tide was coming in. Each wave was lapping against the tires of our ambulance.

Six firefighters, with a backboard and patient slung between them, were fast walking up the ambulance as we opened up the rear doors of the unit. The patient was lifeless, arms limp and dangling off of the board, gray in the face and soaking wet. We hoisted him up onto the gurney, expecting to get to work on him, but when he was slid forward, head resting near the airway seat and under the fluorescent lights, it was easy to see.

“He’s got brain matter showing. Get him out of my ambulance,” my partner told the firemen. He was pulseless and apneic, a clear DBA now that we could properly assess him.

***

The other three—the patient’s brother and their girlfriends—we took to the hospital as mandatory trauma system entries (death of a same vehicle occupant). It turns out that all four of them were crammed into the front seats of the pickup and as the truck rolled, the patient had his head roll out the open passenger side window. The driver and the two girls were relatively uninjured in the accident and alcohol appeared to be a factor. Two ambulances took all three to the area trauma hospital.

The State Police arrived at the hospital to investigate the accident. We had to hang around the hospital to do the criminal blood draws, so we got to see this all go down. The trooper made his way from patient to patient, starting with the two women. The questions the trooper asked were all the same, “what happened?” “How much have you had to drink?” “Were you wearing your seatbelts?”

Finally, he makes his way to the driver’s room. The trooper had enough of the details before even starting his questions. He knew that the passenger had died--he’d seen the body on scene. And he knew the driver and passenger were family. The driver didn’t know. When he was asking questions about his brother on scene, we deflected. “There are lots of ambulances here, another crew is with him.” “We taking care of you right now, there are others taking care of your brother.” But we knew.

So when the trooper walked into the driver’s room and the patient saw him, the first question he asked the trooper was, “how’s my brother?”

Without a pause, the trooper answers. “Your brother’s fine, he’s at another hospital. I have some questions for you.”

***

Our partner and I, plus the nurses in the ED all had the same knee-jerk reaction. What the hell was this trooper doing? He was outright lying to this man. His brother was dead and the trooper knew it, but he was being told he was okay and at another hospital.

Unethical, right? The trooper thought he was going to get better answer out of the driver if he though that his brother was okay. But does that justify such a horrendous lie? I don’t think so, and neither did my partner or the nurses. And as my partner and I talked about it today, we were reminded again about how upset we were two years ago about this.

But it does beg the question, is it unethical to deflect those tough questions on the scene? Is it okay to tell a family member that there loved ones, who we know to be DBAs, that they are being looked after by other crewmembers?

Jaws Training

It's been 3 weeks since my last post and all for lack of anything exciting (or worth mentioning) happening. Yesterday though, I taught an MVA Trauma and Jaws class for the local EMT-Basic class. What's better than getting to cut up old cars with expensive, hydraulic tools?

Me and the Supervisor that I frequently write about. One of my best friends and the instructor for the EMT Class.
My good friend Mark, one of my fellow volunteers.

My older brother, Gordon, and the Supervisor.

A bit of good news--it looks like I'll be teaching the EMT Communications and Transportation class at the local community college next semester. My Supervisor recommended me for the job and I'm looking forward to injecting some fresh ideas into what has traditionally been a dull prerequisite class.

More to come soon, I promise.

Protocols

PDXEMT asked a questions about my protocols regarding terminating a field resuscitation. As luck would have it, we just received our 2009 protocol book at the beginning of the month. I'd thought maybe I'd share a few of my favorite tidbits.

First, a little background. I've been working for my company for almost 5 years, since just before we were bought out by the Big Ambulance Company in the Valley. When I started as part timer, our protocol book was a 12-page, photocopied, stapled packet of typewritten (yes, from an actual TYPEWRITER) material. It barely talked about drug doses and said little more than things like "follow current ACLS protocols."

Our current version of the protocols is a 3/4", color-coded by section, spiral bound tome of medical knowledge with such classic protocols as Epistaxis, Anxiety/Stress, and Vomiting. So, on the topic of cardiac arrests, we work everything but the obvious exclusions (dependent lividity, cold in a warm environment, injuries not compatible with life, etc.). Our physician adviser asks that we work everything to the hospital, regardless of rhythm and non-response to drugs. That's what he wants, so that's what we do. There has to be a set of extenuating circumstances for us to call it in the field and working a code on the beach doesn't fit that.

The protocols are extensive and comprehensive and often give us latitude to approach a problem from different directions.

• Under Pain Control, we can use Morphine, Dilaudid, or Demerol at our discretion without contacting OLMC.
• For pre-sedation in RSI, we have the option of using Versed or Etomidate.
• In Hypovolemia/Shock, if we are unable to establish peripheral vascularl access, we are directed to start a central line in the femoral vein.
• Under Ventricular Ectopy, we have the option of Lidocaine or Amiodarone, at Paramedic preference.

Our Paramedics use RSI in the field, quantitave capnography, and have recently added CPAP and EZ-IO s to our toolboxes. We are only required to contact OLMC for one circumstance: administering magnesium to a pregnanct seizure patient. There are only 6 other circumstances where it is recommended that we call in.

The protcols that we work under imply a large amount of trust being our physician advisors into the abilities of the medics and EMTs. And while I enjoy working in such a liberal system, I know that there's a huge amount of responsibility in this skill set and that I need to represent my physicians well in the field.

To Die at the Beach

Some say the people come to the beach to die, and maybe there’s some truth to that. Partly, I think it’s because of the demographic at the beach. Many retirees want to spend their retirement at the ocean shore—it’s gorgeous here and I don’t blame them. However, we do have a high number of those that choose to end their lives at the beach, many from the valley that have specifically chosen the ocean to be their final memories.

When I was a First Responder some 7 years ago, one of the first cardiac arrests that I worked on was a surfer at a place we call The Cove. It’s a popular place in Oregon to surf, but also very dangerous since the shoreline is large, boulderous rock, large drift wood, and smaller, wave worn stones. This surfer had been found by others in the water to be floating face down, being tossed by the waves. They paddled her to shore, to a spot at the edge of the surf line and called for help. A few off-duty EMTs were nearby, working on remodeling a beach home, when they heard the shouts. They rushed to help, scrambling over the rocks, and when I arrived with the rescue, I could see them at the surf line performing CPR. She was packaged to a scoop, then brought up to the ambulance waiting in the parking lot and taken to the local ER. Sadly, she passed. She was in her 60s.

She was well known to the local surfing population, mainly teens and college age guys, though there are a fair amount of middle-aged men in the mix. The Cove is a territorial place for surfing, but she belonged there; she’d been surfing all of her life. She was gray haired, but slim and athletic, with very few health problems that her fellow surfers knew of. But she passed in the ocean, where she wanted to be, and among those that knew her.

*****

A week ago, I was working an extra shift with an EMT whom I’d rarely worked with. We were posting, covering the south end of the county, and waiting for the Medic 4 crew to return to service. The tones sounded, our pagers chirped, and the dispatcher told us to respond to the Sunset Beach approach for a cardiac arrest, CPR in progress. Our post was less than a mile from the beach approach, and as we pulled into the graveled parking lot, we were far ahead of the closet fire department unit of county sheriff. I told my partner to keep the ambulance on the hard pack and we drove onto the beach.

The patient was another mile from the approach and we drove past over 100 cars and trucks, parked on the beach while their owners were out clam digging. Their owner were all along the surf line, hip waders on and clam shovels in hand. We pulled up next to a red Dodge pickup with its 4-ways on and looked down towards the surf where the driver was pointing. At the edge of the breaking surf, we could see a huddle of men, performing CPR on another clammer. Working a code on the beach is a difficult chore, nothing like Baywatch. You can’t shock on wet sand, sand gets all over the equipment, there’s an audience, the wind is always blowing at you, and it’s just plain tiring to be moving back in forth in the sand. I told my partner that our only immediate priority was to get him up from the surf line and into the ambulance where we could work on him properly.

He was in his mid-sixties and had a true beer-belly. Witnesses say that he just fell face forward onto the sand—he didn’t even try to stop his fall. He had a hematoma over the bridge of the nose, and blood streaking in his eye. A retired paramedic was there, supervising other bystanders as they gave mouth-to-mouth and did compressions. I asked about history, but he was alone on the beach. No friends, no family, no wallet in his pockets, no name that we knew of.
We worked the arrest for 45 minutes on the way to the hospital. He received all 3 doses of atropine, 5 of epinephrine, 2mg of narcan, 1000ml of saline, and 50 mlEq of sodium bicarb. He had two IVs in and a combitube placed after my unsuccessful intubation attempts. We established quantitative ETCO2 monitoring and were able to adjust our CPR and other treatments accordingly. But despite all of this, he started in asystole and stayed in asystole.

After a few hours, after hard work by the state troopers, he was identified. He was from the valley, here at the beach alone for a day of clam digging. And here at the beach is where his life ended. But I like to believe that it was peaceful for him, I hope that he was doing what he wanted and had good memories before he passed.

Zombie-pocolypse

An actual traffic advisory sign in Texas. Check out the news story here.

By the way, this happens to be my one irrational fear.

Things to Come?

A spiraling economy + collapsing healthcare system = this

Is this what we'll be seeing more and more of in the next year? Everyone seems to be cutting jobs--OHSU: 1000, Starbucks: 6000, Boeing: 10,000, Circuit City: 30,000. My state of Oregon has lost nearly 9000 jobs a month since August. We have an unemployment rate of 9%.

I fear that this story of a father murdering his family and taking his own life becuase of job loss and economic depression is something that we are going to see repeated again and again. And while we all know that things will get worse before it gets better, how much worse can we expect it to get?

JEMS State of the Science 2009

The Journal of Emergency Medical Services (JEMS) has a great supplement for download on their website. Called "State of the Science 2009," the 32-page insert has great articles on CPR, the changing roles of MS, lasix, and beta-blockers, the wide spread use of field 12-leads, research into hypothermic induction in a cardiac arrest, and other topics. You can find it on the JEMS website here. Look for the Download This Supplement link near the bottom of the page.

Vehicle Fire

Responded with my fire department to a vehicle fire last night. While I wasn't there early enough to get pictures of the pickup while it was fully involved, I did get a few good ones. Enjoy.

After the knock down

At the command post

That's my brother, Gordon, on the circular saw

Feast or Famine

I’ve learned that EMS is very feast or famine—you’re either busy, or you’re not. Recently, I haven’t been busy. Now I know that I’ve posted in the past about being too busy, but right now I’m only running (on average) one call per 24-hour shift. In some ways, I feel like I’m not pulling weight.

In some ways, it sounds great, right? Getting paid to sit around all day—yeah, not so much. First of all, it gets boring. And secondly, it makes me a little concerned.

The rumor mill in my company is always working, and right now, the rumor is that our parent company has laid off medics and EMTs at some of our sister companies. Apparently (according to the rumor), ours is the only company that is managing to keep its “numbers” up. That’s concerning because we only have so much control over our numbers. We can’t control the number of 911 calls we take or the number of transfers we send, the only thing we have any influence over is our transport rate. As a private company, we need to transport patients to pay the bills. No county subsidy for us.

It used to be that health care had job security written all over. People will always get sick and we will always need the EMTs, nurses, and doctors to take care of them. But here’s a news story that makes me shiver: the Oregon Health Sciences University in Portland may cut up to 1000 jobs of its 12,900 employees. That’s almost 8% of its total work force. My partner’s wife works at OHSU and he’s worried. Now, I’m high enough on the seniority least in my company that my job isn’t in questions, but I worry about my friends and coworkers.

Feast or famine—and right now, it is very much famine.

In Response

While I knew that Drunks 3 could ruffle a few feathers, I didn’t know that the first comment would be from an anonymous poster only hours after the post went up. I’d like to thank them for taking the time to comment and I’d like to respond. First, here is their comment:

While I agree that you (and other medics) need to do what you need to do to protect yourself, your writing style seems to show a disturbing level of enjoyment . The fact that you "got even" with your altered patient by "knocking her out and cutting up her leather coat" shows that you may need to look at your patient care/compassion skills.

I think medics should be allowed chemical sedation when needed, but from reading your take on this event, and the other "drunks" you've dealt with, you seem a little "quick on the plunger" when it comes to the potential use of inapsine.

While I will refrain from making baseless accusations about the anonymous commentator, it does sound as if this person is not a paramedic. I would like to say that the “enjoyment” they refer to is something that any paramedic or EMT takes in any skill that they perform. As an example, is it wrong for a medic to take a certain amount of enthusiastic joy in intubating someone? The medic is practicing a life saving skill on a patient having a very, very bad day, often a cardiac arrest or multi-systems trauma. Let’s be honest with ourselves, those are calls that we consider “good” in a sense that we get to practice a variety of our skills. So, is it selfish or self serving to give ourselves a high-five, pat on the back and tell our coworkers what a great job we did, after the fact? Of course not.

I performed a necessary intervention (i.e. patient care skill) when I chemically sedated this patient. I won’t lie and say that I didn’t feel an amount of justification (and the gut feeling of “getting even”) in sedating the patient. Especially considering this person had sexually assaulted my partner and myself, and caused physical injury to me. I was honest in how I felt. I wrote about the feelings that I had at the time of the incident and it is implied that I used the appropriate interventions and patient care skills to mitigate the situation and treat the patient. To imply that I am “too quick on the plunger,” well, let me quote directly from my treatment protocols.

Always consider your safety…if patient is combative [with] no known trauma cause for AMS, consider Inapsine 5mg IV or 10mg IM.

In actuality, I gave the patient an underdose of inapsine. As a paramedic, I am also thoroughly aware and take into consideration the risk versus benefit of every medication that I administer.

Finally, to imply that I need to reevaluate my patient care/compassion skills, I say to you: how dare you think you can judge me and my skills based upon one anecdotal story. I would refer you to such posts as Screamin’ Eagle, Why We Do, or Tragic to “demonstrate” my compassion and patient care. I would also like to refer you to Force, a brief essay on use of force in restraining a patient, a topic that I feel strongly about. But even if that isn’t enough to demonstrate that patient care and compassion are always at the forefront of every call I run, I’ll refer you to the two EMS Provider of the Year awards bestowed upon me by my fire department. Or even better, I’ll refer you to the Meritorious Service Medal for EMT-Intermediate of the Year and the Medal of Valor, both bestowed upon me by the State of Oregon. Oh, and after that, would you like to ask my wife, who wants nothing more than for me to come home safely after every shift, if it was acceptable patient care?

Drunks 3

And now the long awaited third in the series of drunk cases. Enjoy.

It was only eight in the evening, and really, it had been a slow shift. I was working with a part-timer that night, a cop that had just certified as an EMT-Basic. The plektron on the desk sounded and we lifted ourselves out of the recliners as the dispatcher intoned “medic 4, respond for an intoxicated female, unconscious, lying in front of the Sheldon Apartments.”

At least there won’t be any surprises.

My partner, Chris, hadn’t worked much at the south end of the county so I gave him the turn by turn directions to the apartment complex. We pulled into the parking lot to see two police cruisers and another two police SUVs parked in front of one of the five buildings. All four of the cops had shit-eatin grins on their faces and just pointed down the hallway as we walked approached. Clearly, they were enjoying themselves.

Our patient was a 230 pound female in her 50s, wearing a too-short little black dress and white leather jacket. Apparently, she already had been out on the town as she was fall over drunk. Her neighbor was standing at her side, supporting her when we came up. She was droopy eyed, smelled like booze, and had an extreme slur to her words. Of course, she told us she’d only had “a couple” of drinks, but the neighbor was reporting it was at least a whole bottle of vodka.

I directed my partner to bring the gurney up since I didn’t want her walking and falling. We spun her around and sat her on the edge of the gurney and all the while she was trying to flirt with us. “You’re cute,” she would say, dragging the words out. We started to belt her in, when I noticed a large bulge in the sleeve of her coat. I straightened her arm and extracted a near empty bottle of Smirnov Vodka from her sleeve.

“Hey guys,” I hollered over to the cops. “Do you think you might have missed something?”

“Where’d you find that?” the sergeant replied.

“Up her sleeve, man. That could have done some damage.”

At first, our patient was compliant, but became restless after we took her booze away. Chris and I were having a little trouble getting the seatbelts fastened since she wouldn’t stop moving around. I was standing next to the cot, trying to get the waist belt clasped when it happened.

She reached out with her left hand, quickly and with purpose, and grabbed hold of my crotch.

Immediately, I went from irritated to full-on pissed off. I took a step back, unlatched her hand and fired off a “you keep your hands to yourself!” I was stunned and it was the only thing I could think to say. But oh, things would get worse.

She was a loud drunk, with few inhibitions, and as my partner and I tried to finish packaging her, she started yelling. “Boy, you’ve got soft balls! I want to touch your balls!”

The cops were still standing by and began laughing. “Guys, could we get some help?”

With the cops help, we finished with the seatbelts and wheeled her towards the ambulance. I was red faced with anger and she wouldn’t stop yelling, “your balls are so soft!” And when we were just about ready to load the gurney, she reached out with her right hand and got a hold of my partner.

My patience was gone. As soon as the gurney was locked into place, I told Chris to get the restraints out. He was in the CPR seat, trying to dodge her groping and get the restraints, while I was on the bench doing the same. Through continued cries of “I want your balls!” we fought to keep her hands off of us. She was kicking her legs now, loosening the leg straps and doing her best to get off of the cot. And again, while the cops were standing by and laughing, I had to ask to get them inside to help us. One of the cops sat on her knees while the other climbed into the airway seat and put her into a kind of headlock.

She was getting more and more violent. I had to pin her arm against the edge of the cot with my knee and I worried (but only slightly) that I would break it as she fought against us. She kept trying to pick her head up and bite anyone that came near. We put the restraints on, but with her fighting, couldn’t get them tight enough to do any good. Chris put an oxygen mask over her face to keep her from biting or spitting. Her writhing and fighting was getting worse and worse. She would growl, trying to move the mask with her tongue, then try to bite it out of the way. Then she’d launch into another “I want your balls! Let me touch your balls!” It honestly reminded me of something out of The Exorcist.

Enough was enough. With two previous belligerent drunks, I wasn’t going to let another get the best of me or my partner. I opened up the drug kit and pulled out the inapsine. Using my trauma shears, I cut up the sleeve of her leather coat from cuff to collar without even a second thought and jammed that needle into her arm. I gave her a 5mg dose, slamming the plunger. I told everyone to back off, that she’d relax in a minute.

Within the next ten minutes, we were rolling were rolling our patient into the ER. By that time she was well and truly unconscious. She had snoring respirations at maybe 8 per minute and was only rousable by a deep sternal rub. If we had been any further out from the hospital, I would have considered some airway adjuncts of the nasal kind. Casey, a short, blonde ER nurse with a “if you tell me I’m cute I’ll kick your ass” kind of attitude, met as in the hall. She had her hands on her hips and her eyes were a little squinted when she asked, “you gave her five of inapsine?”

Without breaking my stride, “that’s right.” You see, this hospital recently had a patient with a poor outcome after allegedly receiving too much inapsine. They didn’t want a repeat performance. Frankly, I couldn’t have given a damn.

The cops walked in behind us, still grinning from ear to ear when I began my report. They only nodded their heads up and down in verification as I relayed the events, pantomiming the “violation” when the nurses asked, “what do you mean she grabbed you?” Having heard the entirety of the events, the nurses were sympathetic and didn’t question me again about the sedation.

I took a breath and stepped back then. The nurses were at work getting her clothes off, drawing blood and placing a catheter. Still simmering with anger, I took my gloves off only to discover three deep scratches on my left wrist. “Damnit!”

“What?” Chris looked over at me.

“She fucking scratched me! Do you realize the amount of paperwork I have to fill out now? Fucking incident and exposure forms, and I’ve got to call the Sup. Damnit!”

The officers, having had their fill of fun watching the ambulance do what should have been there job, looked at me. “Do you want to file charges?”

“No. It’s not worth the trouble.” Besides, I’d got to knock her ass out and cut up her fancy leather coat. I figured we were even, in a sense.

*****

There’s a lesson in all of these. For starters, don’t let me mislead you to think that I take pleasure in “kicking the ass” of a patient. It is my sincere hope that a call doesn’t escalate to the point where restraint of any kind is necessary. However, it is my primary responsibility to protect myself, my partner, and other responders first, sometimes to the determinant of the patient. In this particular case, it was necessary to chemically restrain the patient, to “knock her ass out,” to control the scene and maintain our safety.

The lesson here, and what I preach to my partners but took three calls to put into action, is maintaining control of the scene to maintain your safety. A drunk patient may not be acting of sound mind (we know this, of course) and may in fact want to do us harm. Do what needs to be done to protect yourself.

Stay safe.

Compliance

All us paramedics were handed the monthly Compliance Report today during our crew meeting. We (my company, that is) track the percentage of transported patients versus calls dispatched to and report this as a monthly percentage. Nationally accepted "standards" are right around 20% no transport, that is, we take about 80% of our patients to the hospital. These statistics also track the calls Cancelled by Fire, the DBAs, the No Patient found, and all Patient Refusals. So, here are my numbers.

• Sept 08: 16.2% no transport
• Oct 08: 20.5%
• Nov 08: 13.5%

I think those are numbers to be proud of.

We also started a new shift bidding process today and I found out that I rank 4th in overall seniority in the company (not counting the three supervisors). Kinda cool, huh?

In Service, Available

Medix 311 is back in service, available.

It's been a rough couple weeks since Christmas. While my little car accident didn't incapacitate me, it did make me surlier than usual. My wife and I have been down to one vehicle, which isn't so fun for her when she has to drive me to and from work on my 24s. Oh, I also got the damage estimate back on my car.

Drum roll please... $8000. That's right--8-K, 8-grand, 8-Gs.

$8000 on a car worth $1100. So needless to say, Allstate is going to total my car. Right now, my twisted wreckage of an automobile is somewhere in Central Oregon awaiting an Allstate service tech to verify the damage so they can cut me a check. Looks like I'll be new car shopping at the end of the month.

Additionally, I just had to drop $1000 today for a new washer and dryer as my current washer that is 20+ years old crapped out on me. My wife and I figured that it's better to replace them both at the same time.

My water heater has been acting up. I'm hoping it's because the washer was causing it trip its breaker. But who knows...

Oh, but I do have one piece of good news. Great news, really. Last night was my fire department's annual awards banquet and guess who was awarded Firefighter of the Year. That's right--me. Really, I'm honored and pretty humbled by it. My fire chief had so many nice things to say about me that I was a little embarrassed to receive the award.

That's it for now. Again, I promise I'll be back soon with Drunks 3, and it will be well worth the wait. Take care.