Paramedic SuperMonkey

On Sale Now!

2009-10-14T16:29:00.000-07:00

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

2009-10-09T22:21:00.000-07:00

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

2009-10-05T19:14:00.000-07:00

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

2009-09-26T14:36:00.000-07:00

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

2009-07-13T13:59:00.000-07:00

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

2009-06-30T21:52:00.000-07:00

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

2009-06-28T19:26:00.000-07:00

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

2009-06-06T10:27:00.000-07:00

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

2009-05-01T09:00:00.000-07:00

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

2009-04-26T13:34:00.000-07:00

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

2009-04-25T19:58:00.000-07:00

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

2009-04-23T19:08:00.000-07:00

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

2009-04-10T20:05:00.000-07:00

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!

2009-03-29T16:51:00.000-07:00

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

2009-03-12T09:06:00.000-07:00

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

2009-03-08T13:57:00.000-07:00

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

2009-03-08T10:55:00.000-07:00

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

2009-02-15T11:28:00.001-08:00

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

2009-02-13T20:46:00.000-08:00

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

2009-01-28T19:59:00.000-08:00

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?

2009-01-28T14:17:00.000-08:00

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

2009-01-28T10:30:00.001-08:00

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

2009-01-24T19:14:00.000-08:00

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

2009-01-24T10:20:00.000-08:00

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

2009-01-15T16:58:00.000-08:00

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

2009-01-13T23:48:00.000-08:00

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

2009-01-12T20:30:00.000-08:00

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

2009-01-11T18:59:00.000-08:00

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.

Extended Leave

2008-12-28T22:13:00.000-08:00

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

2008-12-25T22:51:00.000-08:00

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

2008-12-13T21:09:00.000-08:00

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

2008-12-13T20:06:00.001-08:00

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

2008-12-10T15:16:00.000-08:00

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

2008-12-10T13:43:00.000-08:00

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

2008-12-06T10:54:00.000-08:00

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

2008-12-04T09:07:00.000-08:00

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.

Bookwormin' It

2008-11-13T17:04:00.000-08:00

Thanks Bernice over at I Just Call It As I See It for the Bookworm Award.

Rules:Pass it on to five other bloggers, and tell them to open the nearest book to page 56. Write out the fifth sentence on that page, and also the next two to five sentences. The CLOSEST BOOK, NOT YOUR FAVORITE, OR MOST INTELLECTUAL!

My closest book is actually a stack of books that my wife and I just purchased for our Hawaii trip. So I'll go five books down into the stack... On Call In Hell: A Doctor's Iraq War Story by Cdr. Richard Jadick. "... academic year, ROTC didn't amount to a whole lot more than putting on a uniform and marching around once in awhile. The summers, however, were an entirely different situation."

I'm looking forward to the read, especially knowing that I'll be reading it on a white sandy beach many, many miles away.

Now, my five picks:

WamBamThAmbulance
Yeah, I know he doesn't post frequently, but he's near my neck of the woods.

EMT to Paramedic
Another infrequent blogger, but someone I who I think has great potential. Show him some bloggin' love.

Sam over at On the Clock
Seriously, it's Sam. How could I not pass this award on to her.

As the Pump Turns
My new, favorite nursing blog about a very good nurse in a very tough job.

Epi over at Pink, Warm, and Dry
On any given day her writing can make me laugh, smile, or cry.

The EMS Gods Must Hate Me

2008-11-12T23:43:00.000-08:00

Today, I started my vacation. I'm not on shift again until the 26th. Friday, my wife and I leave for Hawaii. But yesterday, the EMS gods, or the vacation angels, or the demons of time-off were punishing me for taking vacation. In order of appearance:

A psychiatric making a scene in the dining room of McDonalds at 8:30 in the morning.
A sweet, little old lady with recurrent GI bleed needing cauterization in Portland. Of course, she wanted transport to the hospital at the other end of the county.
An 60-something female with transient chest pain with previous episodes earlier in the week. She was getting the RV ready to go to Mexico when the pain started.
At 1:30-ish, a man having a seizure in the lounge of a local restaurant. Turns out, he almost always has a seizure after one or two drinks. Seems like he shouldn't be drinking...
An MVA in the pouring rain. One car rear-ended a pickup when the pickup decided to make an illegal u-turn in the middle of the highway and the car couldn't swerve to avoid. The driver of the pickup, of course, was uninsured.
After fueling and getting back into our end of the county, we were called to an elderly diabetic. He was glassy eyed, staring at the TV, had a mouthful of oral glucose (puffed cheeks and all), and with a BGL of 25. He was an easy fix with IV D50 and a no-transport.
A 70-something female that nearly-feinted at a grade school fundraiser. She was awake and waving us away as we walked up. i had to yell to talk to her--not because she was hard of hearing, but because the bad cover band wouldn't stop playing.
A dementia patient that couldn't walk upright. She looked like Micheal Jackson in Thriller when she tried to stand up and walk.
A 50-something female with sudden onset, middle-lower abdominal pain, no radial pulses, no BP, and very delayed capillary refill. She had a diagnosis of pneumoperitoneum in the ER (along with many, many other diagnosis--she was a sick lady).
A 40-something male with a GI bleed the vomited blood all over his bathroom and kitchen. Turns out he'd been taking 6-8 adult aspirin a day for about two weeks because of back pain.
A hour later (at 12:30 am), we took the above GI bleed to Portland for extended care and returned by 5 am.

Upon returning from Portland, I finally slept away the last few hours of my shift, stumbling out the of senior tech room at 7:45 am by the sounds of the relief crew. I was so tired that I couldn't even do a proper shift turnover. "Narcs are out in the ambulance... somewhere. You're low on oxygen... and other... stuff. Sorry."

I am so ready for vacation.

Storm Ready

2008-11-11T11:29:00.001-08:00

Today, I had to bring my newly packed Storm Readiness (as in I'm probably being overly paranoid) Bag to work. A wind storm is supposed to be blowing through the north Oregon coast over the next 2 or 3 days. This morning when I left the house, it was blowing rain sideways. Today, I'm thinking about trees coming down and as I told the ER nurses this morning: "the rain tends to bring out the crazies."

As for my overly paranoid Storm Readiness Bag, I now carry on the unit with me:

A hard hat
Rain pants
Leather work gloves
Headlamp
Flashlight
Safety goggles

At least if I get stuck on a highway this winter, I might feel a little safer while the wind is blowing and trees are falling down around me.

Ideal Partner

2008-11-04T13:32:00.001-08:00

A comment on my last post by Michael Morse got me thinking about who my ideal partner would be--or at least the qualities that I'd be looking for.

1. Comes to work with a positive attitude. This is of utmost importance to me. I'm 25-years-old and I've been able to identify in my self that I an easily influenced by other people's attitudes. It's a flaw, I know. But if my partner comes to work with a positive attitude and keeps that attitude no matter how bad the shift gets, then we'll have a great day together.

2. Leave the ego at home. I appreciate my partner's experience, be it 10 years or 10 days on the job, paid or volunteer. I believe everyone has a different perspective they can bring to the job. That being said, I am the senior tech and with that, I'm ultimately responsible for the station, the ambulance, us (as a crew), the firemen, the scene, and the patient. I want my partner's input on things, but if I say this is how we're going to do it, then this is how we're going to do it. Check the ego and go with the flow. You keep me from having to pull the "paramedic" card and you'll save yourself some embarrassment and headache.

3. Want to be an EMT. My company works Paramedic/Basic crews, meaning that roughly 90-95% of patients are cared for by the medic, most of the time relegating the Basic to a driver. And when the Basic has patient care, typically its for the "neck-pain" c-spine patient or the belligerent drunk we (paramedics) don't want deal with. But if you have a want to be an EMT, then you should have a want to provide patient care. EMTs that are here only to be my driver don't deserve my respect. EMTs that want to ride with patients and exercise their skills will be given more opportunities to do so.

4. Have the desire to do your job. Now this goes beyond that of patient care, this encompasses everything we do in our 24-hour shifts. All the boring stuff that we don't really want to do like house chores, inventory, equipment maintenance, training, mapping, ambulance washing, and everything else that takes away from driving around with lights and sirens. I don't like doing a lot of that stuff either and would much prefer to spend my shift on the couch sleeping or watching TV--but as my boss so bluntly puts it, "you're paid to work for 24-hours." So please, take the time to help me take care of the house work and daily chores--it makes my boss happy, which in turn keeps me happy.

5. Honesty, compassion, trustworthyness, strong morals and ethics, and all the other qualities that make up a good person.

I'm still looking for that ideal partner. Oh well.

Resolution

2008-11-02T11:53:00.000-08:00

TJ and I had a falling out as partners some months back. He was moved to a night-car after it, but we were partnered again after his return to 24s. This were never the same between us. We used to laugh and joke, we had the same black sense of humour about our job. But when we started working together again, it was all professionalism, to the extent of cold shoulderness. He would hardly say hello to me in the mornings, wouldn't do a rig check with me, or would hardly say a word to the patients or firemen on scene.

I had a conversation with my supervisor last night, and it went something like this:

Supervisor: "I had a conversation with TJ the other night. He said something about you..."
Me: "Oh yeah. What was that?"
Supervisor: "He told me, 'I know that Jeramy and I have had our differences in the past, but at least I never had to worry about his abilities as a paramedic.'"

Not that I ever tried to impress TJ, but I always did wonder if he respected me as a paramedic. Now I know.

And you know, it's nice to have that resolution.

Profanity, too

2008-10-20T21:29:00.000-07:00

Thanks to Sam over at On the Clock for getting me thinking about this topic.

I curse as well at midnight-thirty in the morning when I'm being dispatched to... well... whatever. It doesn't matter what I'm dispatched to. I curse.

I'm not a sailor, so I can't curse like one. But I can curse like an irritated volunteer firefighter, which is near close to a sailor, I'd wager.

My old partner would be rolling on the floor at the string of curses (including my favorite "fuckin'-fuckity-fuck-fuck") coming from my mouth. I could hear her exploding in laughter in the next room over. And the string of profanities would continue while I walked to the ambulance, got into the driver's seat, and drove to the call, pausing only to key the mic. Only when I would open the driver's door and step out, would the cursing stop and the game face go on.

You see, I value sleep. I have an early bed time at work: 2100 hours. I like to maximize my head-to-pillow time because I never know when I'll be up, or what I'll be doing. Even with this forethought, this planning, I'm still highly irritable when I'm up after midnight.

Heaven forbid we be dispatched to an abdominal pain at three-thirty in the morning. I would diagnose it as "I can't fucking poop!" before even rolling out of bed. An unconscious male at four-thirty was "a fucking drunk dumbass!" And a male with chest pain at the jail at two-fifteen was "fucking handcuff-induced chest pain because he doesn't want to spend the night in jail! Fuck!" (For those of you that keep up with my blog, the F-bomb rule only applies when there are patient's in around.)

And Ms. Dominguez, the 79-year-old female with abdominal pain that hasn't pooped in 5-days, but is now deciding it's a problem at three-thirty in the morning--we'll be medivaning her back to the raisin ranch three hours after dropping her off in the ER, with a prescription of Milk of Magnesia in hand.

So last night, shortly after my head had hit the pillow, the tones went off.

"Medic 1, respond code 1, Raisin Estates for non-emergent transport."

The profanity started low in my stomach, accompanied by this deep, ugly feeling about wanting to do serious harm to care facility nurses.

"Medic 1 responding," my partner keyed the mic after we got into the rig.

"Copy, en route Medic 1. Be advised, patient requesting Columbia hospital. Dispatch clear at 0337."

"That's another 20 god-damn miles! For fuck's sake!"

And without missing a beat, my partner turns to me, "um... can I say that on the radio?"

I still love my job.

Screamin' Eagle

2008-10-19T14:17:00.001-07:00

On the weekends, we don't run wheelchair vans which very often means that medivans are tasked to the ambulance crews. As I sat watching a History Channel documentary about the 101st Airborne division--the Screaming Eagles--we were paged for a return medivan trip from a local nursing home. I looked over the page, seeing that we would be taking a patient home. That's a bit of a bright spot I'm thought. We don't often get to return patient's home from a nursing facility.

We arrived to find our patient, Mr. Jefferson, in his hospital bed puffing on a neb treatment with his daughter and grandson at his side. This was going to be a BLS trip so while my Basic partner began chatting up the family, I tracked down the unit nurse for a quick report and our discharge instructions. The nurse was flustered, she knew little of the patient and our paper work hadn't even been started yet. "No problem," I smiled at her, "we're in no hurry."

We situated Mr. Jefferson on our cot, made a few jokes with his daughter, and talked to Mr. Jefferson's grandson, 10-year-old Patrick. My partner wanted to know if Patrick could ride with Grandpa home. "Sure," I replied, "why not?"

After 40 minutes, we were able to fluff Mr. Jefferson's pillow, collect his discharge paperwork, and load him into the ambulance. I set little Patrick up front in the passenger seat next to me, and then off we went. Patrick told me that last year he got to ride in a firetruck with his brother, that he got to play with the siren, and the horn.

"Patrick, did you get to talk on the radio?" I ask him.

"Nope." He had a hopeful look in his eye.

"Do you want to talk on the radio?"

"Yeah!" And his face lit up. I gave him the script and had him practice it once before I held up the mic for him. He had a huge, toothy grin as a keyed up the mic.

"Medcomm, Medic 1 transporting!"

"Copy Medic 1, transporting," replied our dispatcher.

"Look at that, Patrick! Perfect!" He beemed up at me from the passenger seat. During the trip, we talked about his school sports, favorite subjects, and all 13 of his scars. We when arrived home, I let him turn on the lights and talk on the radio again.

"Medcomm, Medic 1 ending!"

We unloaded Mr. Jefferson from the ambulance and he told my partner and I what a wonderful job we were doing. "We always appreciate hearing that Mr. Jefferson, thank you."

We carried him up his front porch, then into his house. His son was there, as well as his young grand daughter. They all welcomed Grandpa home and Mr. Jefferson couldn't have been happier to see them. "This is the most comfortable I've been all day," he told us.

We rolled Mr. Jefferson into his bedroom where he had his own private hospital bed. His wife's twin bed was next to in, seperated by a small night stand in the middle. He had a homemade quilt atop his freshly made bed, and clean, comfortable looking sheets. Gently, we lowered the cot, then transfered Mr. Jefferson to his bed. Above his bed, there was a blanket hanging on the wall, like a firefighter blanket with a picture stitched into it. "You see that there?" Mr. Jefferson asked, point towards the blanket.

I inspected it then. The blanket was of a familiar white eagle head on a black shield background with the words AIRBORNE in gold letters above it. I recognized it right away. "That was my outfit," he said, "the 101st Airborne. The Screamin' Eagles." He puffed up his chest a little, obviously very proud.

And I'm sure that my jaw dropped a little. "You were a paratrooper, sir?" I asked. Mr. Jefferson nodded. "Where were you deployed?"

"Oh, Europe and Africa," he answered, almost nonchalant.

I was standing before an actual American hero and I couldn't have been more honored. If I knew how to snap off a crisp military salute, I would have right then and there. Instead, I extended my hand to him, "Mr. Jefferson, I want you to know how honored I am to have met you today, and how much respect I have for you." The look of guinine warmth and gratitude that I saw in his face was not something I will soon forget.

My partner and I spent a few more minutes on scene. Mr. Jefferson's family showed me his scrap book, with photos of Mr. Jefferson in his paratrooper uniform and journal entries and notes that he took on scraps of paper. On the wall was displayed his purple heart. We left the home that shortly after and for one of the few times in my career, I felt privalaged to be able to do my job. It left me with this thought:

Sometimes we are able to do things that make an impression on our patient's lives, sometimes are patient's do the same for us.

Minor Panic Mode

2008-10-12T20:39:00.001-07:00

I keep all of my keys together on one carabiner. One ring for car, house, and FD keys. The second ring for my narc keys for work.

My narc keys have disappeared from the carabiner, possibly on the way home from conference. I'll begin searching a 250 mile corridor from here to Bend...

I'm in minor panic mode...

Edit:
Keys located--they're only 90 miles away...

Conference Day 2

2008-10-11T22:00:00.001-07:00

So I started the day with a great lecture on "Dirty Little Secrets of EMS," all the little things we do that we don't want to admit to. A little expository and embarrassing, but very funny and insightful. I continued with an ECG class by Bob Page--another excellent class with lots of information I'll be able to use in the field. I spent a lot of time with my dad today (who attended the conference and awards dinners with me) taking some BLS classes.

At lunch today, a ton of door prizes were given out--about $10,000 worth. I walked away with a new Littman stethoscope. Boo ya!

We go home in the morning with a 6 hour drive back to the coast, so I'm headed to bed.

New Word of the Day

2008-10-11T09:36:00.000-07:00

Parapup: (par-a-pup) noun - a paramedic student or one waiting to take their paramedic certification exam

Conference Day 1

2008-10-10T21:37:00.000-07:00

First day of conference started at 0800 with a presentation by Dr Broselow (that's right, of Broselow Tape fame). He spent two one hour sessions demoing a new Color Code Kids system that is designed to provide a computer based, bedside reference for all things pediatric. He's even experimenting with syringes with color coded dose markers and bringing the color coded system to consumers (color coded car seats, OTC meds, etc.) Very interesting stuff.

I spent an hour with Bob Page in Slap the Cap! learning so many things about capnography that I didn't even know. There's an aweful lot scheduled for tomorrow that I'm looking forward to.

Tonight was our awards dinner which started with the presentation of colors, then a little-too-over-the-top rendition of the Star Spangled Banner. The food was good (much better than last years) and the program went somewhat smoothly. One of the presenters kept messing up his little speeches, skipping or changing important details about the stories. The medals weren't available as they hadn't arrived by FedEx yet. Oh, and my award plaque had me listed as an EMT-Basic. Oh well.

Long day ahead of me tomorrow, I'll be going to bed soon.

Pre-Conference

2008-10-08T22:31:00.001-07:00

The wife and I are headed off to EMS Conference in the morning. We're headed to Bend, in eastern Oregon, which is high desert country and absolutely beautiful. I'm looking forward to the trip, lots of good lectures, and maybe some golf. We'll be back on Sunday with lots of pictures.

Eliminated

2008-10-03T22:24:00.000-07:00

Overheard on the radio tonight while returning from a transfer...

Medic: "Medcom, Medic 1."
Dispatch: "Medic 1."
Medic: "We've eliminated our 3rd rider." (That's right, lots of emphasis on eliminated.)
Dispatch: "Copy medic 1, clear your 3rd rider."

Laughter ensued...

I Didn't Ask For A Lifeboat

2008-10-03T15:44:00.000-07:00

I don't blog about politics because I think there is so much of that on the internet already. Really, the most political thing I've done with this blog is slap an Obama banner up. But with the passing of the financial bail out package, I feel that it's time to rant a little.

The biggest thing I have to say is that I agree with Gov. Palin:

"Let's do what our parents told us before we probably even got that first credit card. Don't live outside of our means. We need to make sure that as individuals we're taking personal responsibility through all of this."

I understand that the country is in an economic crisis, much of which as a result of a failing mortgage industry, again as a result of lenders baiting borrowers into deals that were too good to be true. The burden for this crisis rests just as much on the American public that keeps borrowing as it does the banks that keep lending.

I have to love Gov. Schwarzenegger's quote about the bail-out:

"The federal rescue package is not a bailout of Wall Street tycoons -- it is a lifeboat for millions of Americans whose life savings, businesses, retirement plans and jobs are at stake."

I don't know about you, but I didn't ask for a lifeboat. I just bought a house--responsibly. I have a 30-year fixed mortgage. I'm able to make my payments on a monthly basis and yeah, sometimes it's tight, but my wife and I made sacrifices to make it work. And if even if I wanted a lifeboat, cut me the check.

When I see stories like this, about a woman who's debt was forgiven because she shot herself twice in the chest after sheriff's attempted to evict her, I get really upset. It doesn't matter that the woman was 90, it matters that the women took out a $46,000 dollar mortgage and an $11,000 dollar line of credit in 2004, it matters that she kept missing payments, it matters than she had been served eviction notices 30 times before this incident. Don't get me wrong, I feel for anyone who's home is taken away from them, but where was this woman's sense of personal responsibility? And where was this woman's common sense (she had 90 years of it) when she refinanced and took out a line of credit. Now she's a damn national hero.

This sort of stuff upsets me. The government has rescued the banks and now those individuals that are defaulting on their mortgages, those actually in financial need, are going to want their own bail out. The average American in mortgage trouble is now going to feel entitled to money in hand, for someone else to fix their financial problems.

I think my biggest bother about the whole bail out is that we're not looking for accountability here. The banks over-stretched themselves with the amount of money they've lent and the American people have over-stretched themselves by borrowing too much. And all that we're learning from all of this is that it doesn't matter, we'll just buy your debt, forgive what you owe, or print more money (oh wait, that's our next rescue plan).

Good News

2008-09-19T11:54:00.000-07:00

I had to stop in at headquarters on my way home from work this morning to fill out my time card and such. As I was leaving, actually pulling out of the parking lot, my boss flags me down and calls me into his office. This was unusual and he was looking pretty severe.

I stepped into his office and thankfully he didn't close the door behind me. He turned to me and said, "you remember that call in December, during the storm?"

"Yeah..." The Great Coastal Gale of 2007, not something I'll easily forget. I wrote about it here.

"Well, it sure made for a good story. I wrote it up and sent it into the state for a Meritorious Service award."

Great! I'm thinking, my partner and I are going to receive a Unit Citation.

"Turns out," my boss keeps going, "they thought it was worth a Medal of Valor."

That's right, my partner and I are receiving the highest honor for EMS uniformed service personnel in the state. According to Oregon's EMS awards handbook:

The Medal of Valor recognizes acts of personal valor or heroism in the delivery of emergency medical care, which results in the saving of a life under extreme conditions and in extraordinary circumstances.

Just as cool, the Pacific Power & Light utility worker that helped clear the highway for my partner and I will be receiving the same award. We'll all be going to the Oregon EMS Conference in October and receive our awards at a banquet dinner. I can't tell you how excited I am to be receiving this award.

What did you do tonight?

2008-09-17T23:49:00.000-07:00

I just got home from fighting a very large, fully involved structure fire.

Lots of flames, lots of hard work. I am very tired and I think I pulled a muscle in my left shoulder.

I'll write more later.

It was a good night.

Today

2008-09-11T14:20:00.000-07:00

... I didn't forget.

Seven years ago, I was asleep in the upstairs loft of my parents place. I had just graduated high school a few months before and was sleeping in late until I had to work my shift at the movie theatre later that day. There was a knock on the door, then it opened. "Jeramy, wake up," it was my mother.

"What is it, mom?"

"Hun, you need to turn on your TV. Planes just flew into the World Trade Center."

"Hmmph. Okay." I started to roll out of bed as my mom closed the door. What the hell is the World Trade Center? I thought.

By the end of the day, I knew.

***

That day, I saw my father cry, after the realization struck that 9-11 was 911. My dad to me is a stoic guy, I'd never seen him cry before. As my family sat around the TV that evening, watching CNN, and the estimate of FDNY firemen lost went to over 300, I couldn't hold it in anymore. I sobbed, shoulders shaking and tears streaming my face. Dad got up from his chair, set a hand on my shoulder and said to me, "son, it's okay. We've all got to be strong, okay?"

***

Today, I didn't forget. Never once have I forgotten, not the 343 firefighters, 23 NYPD officers, 37 NY Port Authority Officers, and K9 Sirius, 8 private EMS workers, and the 2,564 civilians and military personnel killed at the Towers and the Pentagon.

I have to say how proud I am of my fellow blogging community for the 9/11 tributes that I've read today, they have truly lifted my heart.

Everyone, take care today and keep those that were lost in your hearts and thoughts.

New Years Eve, 2005

2008-09-10T13:35:00.000-07:00

It was a Saturday evening and I had only been working in the company full time for 6 months. I was partnered with a new paramedic because I was “a strong EMT,” as my boss put it, “someone who can keep an eye on her.” She was green, but so was I, and in that way we kind of balanced each other.

Around midnight, we were dispatched to a person fallen through the roof of a downtown highrise. The buildings occupied a whole city block; an old hotel, an office building, and the old city hall. Five and six story buildings, separate, but all interconnected in strange ways. There were abandoned, condemned, and used mainly by squatters and vagrants.

We pulled up to the block, police were on scene already, so were the fire guys, both the paid and volunteer boys. My partner and I grabbed our kit and a flashlight and climbed up the front steps of the reported building. We climbed up dust covered stairs, old newspapers and trash scattered about, ascending towards the roof. I pictured walking into a room and looking up, seeing a pair of legs dangling from a hold in the ceiling.

We were met by a cop on the third floor, telling us he’d met with the reporting party and that an 18 year old had fallen into some kind of pit on the roof. We hustle up the roof access, looking across rooftops towards where a teenager is waving us over. He’s on the next building over, with a roof one story lower than we’re already on. My partner and I, followed by the fireman, make our way over to the roof edge, then clamber down to the next building using the pipes and ductwork.

We followed the teen to the edge of this building, where a ten foot wide, narrow pit separated this roof from the next. He told us he and his friend were screwing around on the roof when his friend tripped into the pit. Shining our light down, we could see another teen looking up from four stories below. He was propped in the corner of the pit, sitting in stagnant water up to his waist. He was awake and alert, but said he could move his legs.

The firemen were at our side now, and we began discussing options; setting up the ladder truck and an elaborate rope rescue sounded like the most fun. But as we examined the pit, we could see the walls were lined by the windows from the hotel we had just come up. Telling the kid to hold tight, we headed back inside.

More firemen had brought up our back board and had found the hotel room closest to the pit. The small, square window in the kitchen opened into the narrow trench between these buildings, and we could see the teen at the far end. The pit stunk, full of standing rain water, trash, and the carcasses of dead birds. All of us—the firemen, cops, and my partner and I—looked at each other, asking the question who’s going out there? And while it made the most sense for the firemen with their water proof boots and bunker pants, it was my partner and I, along with two cops, who rolled up and pant legs and waded into the knee deep fetid water.

Our backboard we floated towards the teen between us as we slogged the 30 feet towards him. The water was cold and most likely very, very unhygienic. The teen, Jay, was shivering when we got to him, with back pain, and the inability to move his legs.

We had already activated the trauma system for limb paralysis, and now we were trying to be as gentle as possible as we packaged him. My partner and I talked the cops through floating the board under the teen as we picked him up, then we strapped him in well enough to half float, half carry him out to the tiny hotel room. We passed him through to the firemen still waiting in the hotel room, and continued packaging Jay in the dark.

The evening was just starting to warm up, though.

We were still packaging Jay when we were dispatched to shots fired, possible GSW in the next town over. Our other units were busy taking other calls all over the county and we had a trauma system, paralysis patient to take care of. With cops lighting our way down the creaking grand staircase of this old hotel, we hustled to our ambulance and loaded Jay inside.

He was hypothermic, having been unable to get himself out of the water for over an hour, he had no sensation or motion in his legs, and he was lethargic. I was working on base line vitals while my partner was working on IVs, when we were dispatched to our 2nd pending 911 call, a bar fight downtown with injuries. “Screw it,” my partner told me, “lets go.”

We were only 12 blocks from the hospital and it was time for just quick patient turnovers and turnarounds. Rescue was already responding to the shooting, and now the fire guys who were giving us a hand with Jay were on their way to the bar fight a few blocks away.

I’m sure that when my partner and I rolled into the ER, we looked quite comical—both of us were leaving a trail of dirty, wet boot prints, our pant legs were still rolled up to our knees, and we were making that slurp-slurp sound with each step we took.
I had taken my uniform sweatshirt off and was only in a white t-shirt with a backwards-turned company cap. I know I looked like a fool.

We tried to be as quick as we could with the turnover, letting the staff know about the pending calls and to expect more patients. Our turnaround I was proud of, phenomenally fast considering. We rolled down our pants legs and set out he door. As it turns out though, the GSW was an unable to locate and the bar fight was some guy that pissed off the wrong person and took a punch to the face. He was fine, of course—only some hurt pride. Jay, as it turns out, wasn’t paralyzed. Just really, really cold and weak.

My boots however, didn’t fare so well. They weren’t water proof and became water logged. And oh my god, the smell. Even after soaking in a tub of disinfectant and bleach for 8 hours, the smell still wouldn’t go away. My boots didn’t survive the night of New Years Eve, 2005.

So Very Excited, Again

2008-09-08T17:22:00.001-07:00

I just found out that a third Ghostbusters movie is planned. I loved the Ghostbuster as a kid, I even dressed up as one for Halloween, complete with a jumpsuit my mom made for me and a proton pack. It was the coolest thing ever. Just thought I'd share. You can check out a short article here at SciFi.com.

iPod Woes

2008-09-04T18:43:00.000-07:00

I got off the phone with Apple Tech support a few hours ago and I'm dealing with iPod troubles again. My iPod touch dropped the right audio channel a few weeks ago. I did all the restore stuff (as if it might be a software problem) then had to send it in for service. I got it back at the end of last week and it worked fine--for about three days.

The right audio channel is out again. So I called tech support, and now they're telling me I'll be getting a replacement. But it means I have to send my current iPod back to tech services, which means I'll be without my iPod for another week.

*heavy sigh* Oh well.

Stress and a Brick Wall

2008-09-04T17:09:00.000-07:00

Last night I tried putting together an entry about how I'm really getting unhappy at work, how my partner stresses me out, how I work over half the shifts in a month at a station 35 miles from home (while the supervisors don't work there at all), and how I feel like I'm beating my head against a brick wall about this stuff. I was complaining about how working in Little Fishing Village was giving my nothing in the way of calls, how working in a station the supervisors didn't have to be at was bullshit, and how I was tired of getting up a 5:30 in the morning to make it to work on time. Then I deleted it because it was too negative, too whiny.

I put the laptop away, then rolled over to go to bed. Thirty minutes later, I was being dispatched to a baby just born, not breathing. I had never worked an infant code by myself before, and it was not a call that I was looking forward to.

The Fire guys were there ahead of us, upstairs in the second floor, rat-hole apartment. There was a definite air of calm as my partner and I lugged our gear up the stairs in into the apartment. The Fire Medic was right inside the door as we walked in and told me right away, "this is Sylvia and she's miscarrying."

Right then, I had a guilty surge of relief. I wasn't going to be working a newborn arrest, but I still had a very difficult call ahead of me. I'll say it right now though, thank God that the Fire Medic was there--he kept his newer EMTs calm as well as the cops, and I leaned on him an awful lot during this call. He's been a Medic for over 20 years and I have a lot of respect for the guy.

The Fire Medic gave me a few more notes about Sylvia before I entered the bathroom to talk with her. She was young, sitting on the toilet, anxious and upset. She was hispanic and her husband was next to me, kneeling on the bathroom floor mat, and holding a small basin between Sylvia's legs. She was 16 weeks, had a number of miscarriages in the past, and seemed to be holding herself together fairly well. She had a lost a lot of blood, though. The husband reported she had been bleeding for about two hours prior to the 911 call, at least a litre had been lost.

I tried to talk with Sylvia, using the husband and one of the police officers as translators. My partner was brining up the stair chair and I just wanted to get her out of that apartment and into my ambulance before I did anything. I had questions to ask, and after everyone I felt this sick, empty pause. Normally, I can small talk with patients and be comfortable with them, with the scene. This was different though. I knew that Sylvia and her husband felt helpless, and I admit I felt a little helpless as well.

We had to walk Sylvia to the stair chair, then carry her down the stairs. All the while, we did everything we could to keep her covered and comfortable. I called the radio report in the phone, no need to give out too many details be radio, I thought. She was tachycardic and pale, and little hypertensive. I started a line and gave her fluids, then we transported the short mile to the hospital.

For a few minutes, Sylvia and I were in the back of the ambulance alone. She was wimpering now, partly becuase of the pain, but more I suspect becuase of her loss. I felt horrible that I couldn't say anything to her, or do anything to comfort her. And I felt terrible for Sylvia, this incredible sense of sympathy.

My partner and I turned her over to the ER staff, who went to work on Sylvia right away. I spoke with the husband briefly before leaving, who thanked me for helping. We then returned to quarters and I wrote my chart.

When I was working so much time in Little Fishing Village, this was definatley not what I was looking for in the way of calls. I told my supervisor about the call this morning when he relieved me. He's a medic with 15 years experiencing, a very calm level headed person who doesn't let anything phase him. What he said summed it up for me: disturbing.

Intermission

2008-08-29T21:39:00.000-07:00

It's been over two weeks since my last post; an unexpected and unwanted hiatus. I've been working too many over time shifts at our slowest station. I'm stuck in Little Fishing Village just south of Little Beach Town with World's Longest Beach (allegedly) and I don't think they've ever heard of the internet. My company is working on getting us internet access into the station, but like all things, it will take time.

I thought that I would share some good news, though. My letter from Big Valley Fire Department arrived today and I will be advancing onto the physical ability round. I've heard through the grape vine that they've narrowed the hiring list down to 200 and are looking to hire a least half. We shall see.

As I've been stuck in Little Fishing Village, I don't have many interesting stories, but I promise I'll be back soon with some fresh material. I'm about to rotate down into the county for the next couple of weeks, so I'll have more opportunity to write and more to tell.

Angry Old Man

2008-08-13T21:56:00.000-07:00

(Or, Why I Felt It Necessary To Break Down Your Door)

Several weeks back, I responded at three in the morning to a report of smoke coming from the roof of an apartment complex. This wasn’t anything too unusual, as this apartment complex still had several wood burning fireplaces. I took my time getting out of bed, then drove lazily into the fire station. I heard the Captain getting on the air and could hear the tiredness in his voice, trying to shake the sleep out of it.

I get about a mile from the station when the Captain gets on the air again, “3105 on scene. Heavy smoke showing, call a working fire!” He was awake now.

Oh boy! I’m thinking as my foot stomps into the gas pedal. (I keep it under control; I’m not one of those volunteers that wants to wreck his care because I was doing 90 to granny fell down. But this was a fire, and there was some quickness in my driving).

The ladder (really a quint in our case) is out the door while I’m still a few blocks from the station. I arrive and see my brother and another firefighter getting into their turnouts. I sprint into the station, clamber into my gear and make my way to the officer’s seat of the truck. The Captain has reported that there is not an all clear on the building, so we roll with the three of us.

Our assignment is to supply the ladder that arrived first. As we round the corner, our strobe lights, LEDs, and wigwags bouncing off neighboring homes and business, the entire apartment complex parking lot is obscured by smoke. We pull into the thick of it, spotting on the hydrant in the parking lot. My brother gets out to take the hydrant and set the pump, while I assist the other firefighter hand stretching supply line to the ladder across from us. We’re done in less than 2 minutes.

I can hear the sirens from the mutual aid engine in the distance. Local PD had showed up, their blue lights mixing with our red. The smoke, still rolling out from under the eaves of the roof, stings my eyes a little. The pumps and diesel engines on the trucks are spun up, providing pressure on the hose lines. The complex residents are out in the parking lot in their pajamas, wrapped up in blankets, watching us go to work. It’s this whole feeling that I love about being a firefighter.

My backup firefighter and I have pulled a second line from the ladder and we’re kneeling at the bottom of the stairs leading up to the fire apartment. A resident reports that the neighbor across from the fire apartment isn’t outside yet and the Captain has told us to conduct a search. I’ve checked the nozzle on my line, and I’ve taken my helmet off to put on my SCBA mask. I’m giving instructions to my backup firefighter when I see the crew from the mutual aid engine come barreling up—and I do mean barreling up. I have never seen a group of people scream volunteer firefighter more than these six firemen that had just bumped their way up to me.

And sure enough, as my partner and I pick up the hose line to advance up the stairs, the mutual aid company barrels their way right up them. There are now six 250-pound fireman standing on a narrow apartment stairwell, blocking my access to conduct a search. While I’m frustrated at these guys, I also have a morbid desire to see the steps collapse underneath them.

I watch as one of the firemen tries the door handle to the apartment I’m supposed to search. Finding it locked, he brings up his ax to give it a blow and knock it open. But he stops short. There seems to be a conversation going on at the top of the stairs, something animated, but I can’t make it out. The ax is passed off to another firefighter, and again I see him ready to knock open the door. Again, he hesitates, stops, and conversation ensues. What the hell? I’m thinking.

“Just get the hell out of the way!” I shout up to them.

Now, all six firemen from the mutual aid company pile into the fire apartment, mind your there’s already three other firefighters operating a hoseline in there from the first in ladder company. I signal to my partner and we make our way up the stairs. Again, checking the door knob and finding it locked, I get ready to take the door. I crouch a little, bring my shoulder in, and give the door a good solid hit.

Boom! The whole door swings violently in, splinters of the doorframe scatter across the entryway. Immediately I drop to my knees as my partner comes right up behind me. “Fire department!” I shout. There’s no smoke though, so I get to my feet, only to meet the now very angry resident of the apartment.

Here I am in full fire turnouts, plugged into my SCBA, hoseline in hand, standing next to a 70 year old man in pajamas and slippers, yelling at me for breaking down his door. “What the hell do you think you’re doing?”

Oh darn. “Get your ass downstairs!” I hear from behind me, “all of you!” The Captain the followed the first hose team in, was shouting at my partner, the mutual aid company, and me.

Oh double darn. See, I had been told by command to conduct a search of the second floor apartment, that there was a report of the resident still inside. But, unbeknownst to my partner and I, the ladder company Captain had already made contact with the resident and made sure that he was okay. The resident had gone back to bed when I decided it would be a good idea to bash his door in.

I’m sure that it looked quite comical to those observing: myself looking confused and abashed, while being yelled at by an angry old man and a fire Captain.

So, angry old man, I do sincerely apologize for bashing in your door and ruining your night. But feel comforted that I did it in an effort to protect your life and property. I was just trying to do my job.

New Toys

2008-08-13T14:51:00.000-07:00

I just spent the morning in training for a couple hours at headquarters. The result of which is that we are putting into service a couple new pieces of equipment and (finally) stepping into the 21st century of treatment.

We are adding the EZ-IO and the Boussignac CPAP system. Check em out. Most of us have heard of the EZ-IO, but the CPAP system is something amazing. No moving parts, no compressors or wall mount units. Just a mask, valve, and tubing.

I do have to give credit to my OppsChief for stepping up to the plate and allowing himself to be drilled by the EZ-IO. We have it all on video and it's great. Honestly, the paramedic operating the drill was way more nervous that the OppsChief.

Aftermath

2008-08-09T14:08:00.000-07:00

I drove by the house this morning on the way in to work.

I’d driven by the house before, my wife and I had walked the dogs past it before, and I’d admired the landscaping before. I think I wanted a different memory than that of the house burning and those kids in the street. Scene tape is up all around and the investigation is still underway, but things are calm now. I don’t talk about that morning to people. My wife and I don’t talk about it to each other. Other people don’t understand. I took my wife to see her podiatrist yesterday. He knew we were from Gearhart and eventually he had to ask, “so that plane crash was right where you live, huh?”

“Yeah, I was there. I don’t want to talk about it.” That was it. I don’t want to be rude to people, but I don’t want to share details either.

I’ll write about it though. I think it’s because I’m doing it on my own terms, no one is asking the questions. I’m able to share the details that I want to share and no one is pressing for anything else. That’s comforting to me.

*****

There has been some criticism towards our local dispatch center following the plane crash and I want to stand up for them. Our south county dispatch center fields 911 calls for 3 police departments and 4 fire departments. At the time of the accident, only one dispatcher was on shift, as usual for that time of morning.

Several local people have had concerns about unanswered 911 calls after the crash, or calls that took too long to answer. The single dispatcher fielded 32 911 calls in 4 and a half minutes. The initial fire dispatch occurred 18 seconds after the second 911 call was received (the second call provided a rough location, the first apparently did not).

Per protocol, the dispatcher toned the fire department and dispatched the alarm before fielding the additional incoming 911 calls. During this 4 and a half minute time frame, the dispatcher also managed to contact her dispatch supervisor at home to request assistance in the dispatch center.

I think our dispatcher should be applauded and commended for handling such a difficult event so professionally and efficiently.

*****

Trauma counselors from the county and Red Cross have been in the area the last few days to counsel the firemen, family, and community members. I was invited (as all responders were) to the initial counseling session Monday afternoon and all following sessions. I’ve attended trauma counseling sessions before and they’ve helped, but I think doing what I’m doing right now, writing about how I feel, does so much more for me.

Seeing my brother firefighters that morning, the sadness and solemness in their eyes, I’m so grateful to know that they are getting the counseling they need. I left the scene before the body recovery began—I had a busy morning ahead of me on shift, they needed me in at work. I know the guys that carried those three kids out, most of them have families, young kids of their own. I can see in their faces and hear in their voices how this is hurting them right now. I’m grateful to know that we’re taking care of our own right now.

*****

After I got on shift that morning, I transported one of the survivors from the hospital to the airport to meet an air ambulance crew. She was going to the Oregon Burn Center for specialized care.

The tragic irony didn’t escape me, though. The helicopters couldn’t land at the hospital because the weather conditions were too poor. Now, this little girl whose life had been changed forever, was now going to fly to Portland in the same conditions that may have contributed to her tragedy.

I was so saddened and bothered by that notion, and I could only wonder how she felt. Or if she was even in a state to understand what had happened and what was happening to her right then.

But I felt a sense of fulfillment from being able to help her, even in the small way of transporting her from one place to another. I felt like I had done something good that morning.

*****

I wrote before how I wished I had been wearing my turnouts that morning and not my white button down. I’m not sure that’s really true. I don’t envy the firemen that were there.

I don’t envy any of us. I am exceptionally proud of every one of them though. Every fireman there (with the exception of a handful of paid chief officers) were volunteers. And every fireman that helped to carry the last three children out volunteered to do it—volunteers of the volunteers. No one deserves my respect more right now.

The house after the fire had been knocked down.

*****

As I drove by this morning, neighbors had set their trash cans and recycling out. Others were out walking their dogs, coffee cups in hand. Traffic on Marion had increased, as you would expect. The house is such a tragically awesome site and a large memorial has developed: flowers, candles, and balloons all along the long stone wall.

I guess it’s a sense of curiosity that brings people to the house, to leave their memorials, the same sense of curiosity that drives people to ask “what was it like?” Sometimes I feel guilty about how my emotions surround the accident. I was in the shower when the explosion occurred, I wasn’t even sure what had happened. I was only on scene for 45 minutes, didn’t taken part in suppression or recovery operations. I only assisted briefly in patient care, helping to get them packaged and transported.

Sometimes it feels like I didn’t do enough, like I didn’t have an opportunity to do enough.

Decimation and Shock

2008-08-05T09:18:00.000-07:00

A plane crashed into a beachfront home 4 blocks from my house this morning.

I was in the shower, getting ready for work when I felt something shake the house. Initially, I thought that Boomer had knocked something over upstairs—we have thin floors and walls and little things often sound very big. But Meghan began knocking on the bathroom door when I turned the shower off and I knew something wasn’t right.

“Was there an earthquake?” she asks.

“No, I don’t think so.”

“Well, I heard a loud bang, the house shook, and then I heard a lot of sirens.”

“Probably just a bad car wreck, then, “ I reply. We’re only a couple blocks from the highway, and right behind the Gearhart fire station. “Let me get dressed and I’ll turn the radio on.”

Half dressed in my uniform, hair still wet, and plodding out of the bathroom in my crocs, I turn my portable radio on.

“… 3148 responding to Gearhart.”

“48 from Command, come straight in to the scene. We’re gonna need your elevated stream.”

I’m a little disappointed at hearing this, I’m missing another fire because of work. “Just a big fire,” I tell my wife. “Probably some type of construction accident.” We’ve had those before, explosions, BLEVEs, and the rare natural gas leak gone boom. I tell her it’s no big deal, to go back to bed.

But I dress a little quicker now, I’m thinking I’ll swing by the fire station on the way into work and see how things are going. I’m half listening to the radio as I button up my uniform shirt. I start to hear third alarm units going on the air, engine and ladder companies coming in from the other side of the county.

Then I hear it—

“…Medcomm, Medic 4. Fire reports three burn patients. Requesting a second ambulance.”

Shit. I’m at high speed now, grabbing my boots, cell phone, work vest, and ball hat. I kiss my wife quickly and tell her I’m going to head up to the scene and lend a hand until the second unit arrives.

I drive two blocks west and park on Marion, out of the way of incoming fire and police vehicles. Three blocks down, I see flames shooting above the trees, grey-brown smoke rolling upwards, and what remains of a house, laying on its foundation.

I grab my stethoscope and head off at a dead sprint up the road. All of town is out here to see what’s going on: couples in pajamas, or early risers out walking their dogs. Police haven’t even set up a perimeter yet. I jog up to the command officer as firefighters are pulling lines around me. The ladder from 3148 is up and they’re getting ready to flow water on the flaming pile of debris.

“Joey, where do you need me?” He points another half block up where the Medic unit is parked. I see three people lying on the ground, covered up to the necks with blankets, with bystanders all around them. I see one of our company EMTs. “Who’s in charge?”

It’s one of our new paramedics that he points to, and she looks a little overwhelmed. “Michelle, what can I do to help you?” Right away she starts giving instructions. She plans on taking the first two patients—children—and the next arriving Medic unit can take the mother. She needs my help to get them packaged and loaded, but first she wants me to find out if the Air Ambulance was activated from Portland.

I phone dispatch, letting them know I’m on scene, and then check on the air unit. The dispatcher, a little ruffled sounding, copies that I’m on scene, but tells me she doesn’t know if the chopper's in the air. I let Michelle know and we begin to load our first patient, a young boy. His hair is singed, his legs are blistered, and his feet are cut. He tells me he had to jump from the roof.

He looked like the pictures from the text book: covered with soot, with blackened hair, and lips that were just starting to puff. But he was amazingly calm. He followed our directions, said please when he asked us for something and followed that with thank you. He was concerned about his family and my heart was going out to him. I sat with him while the cot was readied. I introduced myself, talked to him a little bit, tried to offer a comforting, older brother kind of smile. And when we loaded him into the unit and I told him that Michelle would take care of him, he almost cried. “You’re not coming with me?”

“No, I can’t. There’s others I need to help. But Michelle will take good care of you, I promise.”

Behind me, and all around me, more fire units are arriving on scene. An additional ladder company from further south, additional engines from north county. Additional chief units are also arriving and they start coordinating defensive operations. The primary house is destroyed, collapsed to its foundation, with heavy fire rolling from the debris pile. The fire has partially engulfed the neighboring homes, and the chiefs set to work on the exposure protection.

Above all of this though, I hear a father yelling, “there’s still three kids inside!” He’s standing over Michelle and I and the young boy. He’s crying, tearing at his hair, hysterical, and I feel for him. He was staying in another house, further down the block when the explosion occurred. He has no idea what’s going on, he’s only concerned about his family.

The scene is a mess. Neighbors had been the ones to render first aid to the three patients, getting them to lie down then covering them with cool blankets and bath towels. The neighbors stayed with each patient until they were loaded into each of the ambulances.

Our second Medic unit arrived, as well as the OppsChief. The MCI protocol was activated, in some ways because he was expecting three more patients. I helped to get Michelle loaded with the second child, then gave them the best directions to get themselves out of the scene that was quickly bogging down with fire apparatus. The second medic unit had their patient loaded and was pulling around now, too. The OppsChief wanted me to stay on scene with him, at least until a third unit arrived to provide standby coverage.

Scene tape was going up now as the Sherrifs worked to control and move the crowds back. The OppsChief and I turned our backs to them and walked towards the command post. I took the time now to really study the scene. Something big had happened here, enough to literally blow the house apart. Glass had been blown into and across the street. The roof of the garage, still completely intact, had been blown up, then landed upright. Walls had been blown out, and debris piled the center of the house. The back side of the house was obscured by smoke and steam.

I watched the firefighters work hoselines through the debris pile. The ladder pipe was raining down a gentle fog. Steam was billowing out through the burned out home next door. I listed to the radio chatter as additional companies arrived and received assignments or were told to stage. Trauma Intervention Counselors were requested to the scene for the family members. I was watching all of this, wishing I was in my fire turnouts, not by white button down, when I heard the OppsChief ask, “so the plane came in from the west?”

I interrupt. “Wait, what plane?”

The command officer looks at me, dumbfounded like I should already know this. “A plane crashed right into the house.”

Holy shit. I was shocked and in disbelief. A plane? I couldn’t figure out how this was possible. It had come in from the west, over the beach, and that didn’t make any sense. This was the only house hit in the impact, and that didn’t make any sense either.

Bystanders had reported seeing the plane come in very low, strike a tree, then crash into the house. A secondary explosion, the one the shook my house, occurred just moments after the initial impact. Upon really inspecting the scene, a plane door was leaning against a tree in the front yard.

Oh my god. Three kids are dead, and three more are critical because a plane crashed into their house.

The house was decimated like nothing I’d ever seen before. And as I looked around at the firemen on scene, really looked at them, I could see the same look of shock, horror, frustration, and sadness that I knew was on my face. Three kids dead in an instant from a plane that had crashed into their house.

*****

I still had to go into work and the OppsChief cleared me from the scene as the third medic unit arrived. I went home, hugged and kissed my wife, cuddled my dog for a few minutes, then grabbed my day bag and headed out the door. It was going to be a busy morning.

My first assignment coming on shift was to transport one of the burn patients from the trauma hospital to the air station, and transfer them to an air ambulance crew for her trip to the burn center.

Both children had been taken to the same hospital and both were in relatively the same condition. They both had extensive first and second degree burns, both had been sedated and intubated in the ER (to protect their airways and provide for their comfort). My patient, whom I’d seen at the scene, looked far worse than when I’d last seen her. Blisters had formed all over her face, and her skin was starting to swell. Patches on her arms were sloughing off and we had to be careful as we moved her. She was transferred to my gurney, then quickly transported to the air station where the helicopter crew was waiting for us.

We turned the patient over, then returned to the ER where the nurses there told us what a fantastic job that our crews did. All the typical high-fiving and back slapping that goes on after a “good call.” But I can’t get the image of the kids’ faces out of my mind. I just can’t believe how destroyed this family is now, how such a freak accident has decimated their lives. All I want to do right now is go home and hug my wife.

*****

This was written the evening following these events (8/4/08), however I could not post this until today. Numerous news stations covered the accident and a report can be found here.

Back to Testing

2008-08-02T15:54:00.001-07:00

I took the firefigher/paramedic test for Big Valley Fire Department yesterday and I'm feeling pretty good about it. It was the FireTEAM video test by ErgoMetrics which is a terrible test to take. Very long and very cheesy. I have been on a test-taking hiatus since I got my medic last year, so I'm a little rusty at the whole testing taking process. But I'm pretty hopeful as Big Valley is giving paramedic preference this year--a first for them. I've also taken the FireTEAM test before, so I knew what I was getting into. I'll find out in mid-August how I did. Fingers crossed.

Little Victories

2008-07-27T19:34:00.000-07:00

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

2008-07-24T15:22:00.000-07:00

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

2008-07-24T12:04:00.000-07:00

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

2008-07-22T13:56:00.000-07:00

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

Just thought I'd share.

Tragic

2008-07-21T10:35:00.001-07:00

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

2008-07-15T22:14:00.000-07:00

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.

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
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

2008-07-12T18:53:00.000-07:00

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)

2008-07-06T21:07:00.000-07:00

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:

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.
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.
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

2008-07-06T21:02:00.001-07:00

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.

Outcomes

2008-06-30T13:08:00.000-07:00

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

*****

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

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

*****

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

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

*****

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

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

*****

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

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

*****

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

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

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

My Respects to Air Medicine

2008-06-30T11:01:00.000-07:00

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

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

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

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

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

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

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

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

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

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

Shaky Hands, A Follow Up

2008-06-26T16:58:00.001-07:00

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

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

I have never felt better about being a paramedic.

Shaky Hands, Part 3

2008-06-25T22:18:00.000-07:00

Shaky Hands, Part 1
Shaky Hands, Part 2

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Shaky Hands, Part 2

2008-06-25T02:02:00.000-07:00

Shaky Hands, Part 1

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

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

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

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

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

"Fire dispatch, medic 4." No response.

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

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

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

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

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

to be continued...

Shaky Hands, Part 1

2008-06-24T20:43:00.000-07:00

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

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

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

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

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

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

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

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

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

Oh shit has turned into oh fuck.

to be continued...

At Home EMT 2

2008-06-24T10:20:00.000-07:00

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

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

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

Helmet Education--The Traumatic Way

2008-06-20T19:40:00.000-07:00

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

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

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

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

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

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

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

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

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

At Home EMT

2008-06-13T11:19:00.000-07:00

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

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

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

Thanks

My Tolerance

2008-06-06T10:18:00.000-07:00

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

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

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

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

"What happened, sir?" I ask.

"I hit a power pole."

"I see that. Are you hurt?"

"No." He responds.

"Does you neck hurt?"

He shakes his head no.

"How about your back?"

Again he responds, "no."

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

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

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

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

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

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

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

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

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

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

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

My Pockets

2008-06-03T16:35:00.000-07:00

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

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

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

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

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

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

Difficult Arrests

2008-06-03T16:13:00.001-07:00

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

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

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

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

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

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

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

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

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

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

My Relief

2008-05-29T12:25:00.000-07:00

I live in a small town, part of a small county. I know most of the firemen and EMTs in the county by first name. I'm familiar with dozens of frequent patients, care center staff members, and nurses. Because of the closeness of it all, I've also run calls on family members and friends.

I've run on my uncle when he had a massive heart attack, I took my brother to Portland for an appendicitis, I've been on friends of my wife and parents, and just last shift, I transported my sister in law.

I was on the phone with my mom last shift while my mom and dad were driving back from Portland over highway 26. We had to cut our conversation short because cell phone reception tends to cut in and out over the pass. About 10 minutes after hanging up, my partner and I are dispatched to an MVA on highway 26 at milepost 26, a very common milepost for accidents. Now, it took a moment or two, but then I realized that milepost 26 would be right where my parents would have been.

Code 3 out to accident, I couldn't shake the terrible feeling in the pit of my stomach that I would be seeing my parent's crumpled car off the side of the road. I thought about terrible scenarios like having to intubate my own mother. I prayed the entire drive out that the size-up we'd get from fire would be a positive on. One vehicle, two injuries is all that we heard.

We rounded the last corner approaching the scene, numerous fire and police cars parked along the shoulder, next to a steep embankment. We slowed to park and I saw my parent's car parked on the shoulder between a state police cruiser and a rescue truck, but it didn't look damaged. Still, I was fearing the worst. The firemen had two patients c-spined on the shoulder of the road, but I couldn't see the patients because the firemen were crowding around them. I placed us on scene, then exited the ambulance and approached the commanding officer.

He began giving my a brief report as I surveyed the scene. There were skid marks on the highway, crossing both lanes. I saw flashlights a hundred feet down the embankment where a car had landed. Then I start looking over towards the patients and I see a familiar white haired head suddenly look up, a stethoscope draped around his neck. There was my dad, a First Responder with Seaside, directing patient care. The relief that I immediately felt took over completely and for a few moments, I wasn't even listening to the firefighter. But I recovered quickly and went to work on the patients.

Looking over to the second patient, there was my mom, no medical training whatsoever but wearing a pair of medical gloves and holding c-spine on the second patient. Relief again as I walked over, touched mom gently on the shoulder to let her know I was there, then continued to work. We transported both patients, minor injuries that had self extricated from the vehicle, back to Providence Seaside.

I talked to my dad the next day and he told me they came across the accident just minutes after it occurred, before police or fire had arrived. He always carries a small jump kit in his car and he grabbed it and went to work assessing patients. He said when he turned, my mom had a pair of gloves on and was asking how she could help. Right then, I couldn't have been more proud of my mom and dad, or more relieved that they were okay.

My second biggest fear in this job is running a call on family member or friend (my first biggest fear is not being able to find the address). I live in such a small place that there is no paramedic back-up, no one to take over when I find myself caring for a loved one. It's a difficult thing and one of the things that makes working in a small system so unique.

Paramedic Pedal Power

2008-05-26T20:03:00.001-07:00

This Memorial Day weekend, I got to see a personal project of mine take off with a very satisfying start. Following discussions with my fire department's EMS Officer, I put together a pilot program for a EMS Bike response team.

Bike response teams are in use by multiple fire and EMS agencies nationwide and provide an alternate (and often times faster) response time in pedestrian crowded areas such as special events, large parks, and promenades. Seaside is a very tourist friendly town with a 1.5 mile promenade and downtown core area. During holiday and summer weekends, the population can increase to 20,000 or more. During certain events, the downtown area can be closed completely to vehicle traffic and turned into a pedestrian parkway. Access to 911 calls during peak summer activity is extremely difficult by ambulance and often, we have to park a block or more away before reaching the patient.

This weekend was the program's pilot weekend and I worked the first two 6 hour shifts. My partner and I staffed a pair of bike's equipped with an AED, oxygen, IV supplies, BLS equipment, and ACLS drugs and patrolled the downtown area and prom. The response from the community and visitors was astonishingly positive. It was our goal to provide EMS service but we acted more as public relations than anything else. We gave out directions, answered questions, assisted the Seaside Police, and even helped to promote a neighboring fire department's annual fund raiser.

Unfortunately, the weekend overall was slower than anticipated and the bike team was not kept very busy. However, during the single 911 call in thier response area, they did arrive ahead of both the transporting ambulance and the fire department's rescue on a chest pain call.

Support from the police department, business owners, Seaside lifeguards, and local ambulance service has been very positive and it made for a very promising and bright weekend. Our next operational event will be the June 14th Muscle Beach Cruz car show, an event where downtown is closed to vehicle traffic.

I'm looking forward to a fantastic program this summer. I'll post more on this soon, or check on the Seaside Fire Department's website in the next week for a page to go live with all the details.

My Storm Story, Part III

2008-05-17T21:22:00.000-07:00

My Storm Story, Part I
My Storm Story, Part II

The entire drive home was like watching clips from CNN storm coverage. There were very few houses that were spared any kind of damage. The highway was clear but I could look down side roads and see them carpeted in green and brown. I would learn later that in some parts of the county, it would take over a week for some people just to get off of their property because of trees down in their driveways.

Turning onto my street and pulling up to the house, I was relieved to see there was no storm damage to my house or any of my neighbors. I was weary as I headed up the front steps and let myself in. Meghan's mom, who lives alone, had driven over before the worst of the storm to spend the evening with Meghan and keep her company while I was at work. They were both sound asleep in bed as I let myself into the bedroom. Lilly gave a slight woof when she saw me, then settled into sleep again. I changed quietly, putting on a fire department sweatshirt and jeans, then kissed Meghan on the forehead before driving down to the fire station. There was still plenty of work to be done.

Weather forecasts said we were only in a break and that more high winds were expected that evening. The city was doing its best to mitigate damage and help the community. The community center had set up a soup kitchen and shelter, which we checked in with throughout the day and resupplied. The Fire Marshall was handing out assignments to fireman as they trickled in that morning and when I reported, I was put on a debris crew and also put in charge of home oxygen needs. It was anticipated that power would be out for at least a week and numerous citizens on home oxygen would be in need in the coming days.

Before going to work that morning, I headed upstairs to the department's kitchen where a few of the firemen's wives had put together and soup kitchen for us. Breakfast was up and they were starting to set out sandwich fixings for lunch. During the week, these wives would cook, feed, and take care of the department's 40 volunteers.

My crew set out shortly after lunch to help a resident clear a tree that had partially fallen and was now threatening his house. The tree hadn't caused damage to the house yet, but if left, it would surely blow over that night into the gentleman's living room. It would be dangerous to fall the tree as the winds were picking up, but we were dealing with each tree on a case by case, risk assessment type system. Using the rescue truck's winch, we pulled the tree away from the house to direct its fall then set to work cutting. In a little less than an hour, the operation was done and we were recalled to the station. Upon returning, I began doing oxygen checks and visited one of our frequent patient's who had called into the station earlier about his oxygen.

The second night of the storm was nothing like to first. It was comparable to our normal winter storms and therefore tolerable. We wouldn't be getting up that night for down trees or lines--we figured the work could wait until morning.

All week was like this; fireman reporting to the station in the morning, receiving assignments and working all day. In the 3 day period of the storm, we responded to over 40 alarms, over 10 times our daily average. In the 5 day period of the storm and clean up, we responded to 65 alarms, enough to set a new monthly and yearly record.

As for myself, I went in to work after having only one day off as I picked up an extra shift. All day long we responded to calls and had to take alternate routes because of road closures, or wait for fireman to clear a driveway. Several elderly patient's called because of oxygen problems, others called because of general illness associated with having no electric heat in their homes. On a county wide level, several people died as a result of storm related injury or accident, including carbon monoxide poisonings due to using gas grills inside as heat.

I keep a mental note of the worst shifts I've ever worked and the winter storm of 2007 certainly takes top honors for me. In a strange way, it also made my partner and I local, strange celebrities. Everyone in town had heard of the ambulance crew that was stuck on 202 during the worst of the storm and wanted to hear our story. Really, there wasn't anything too exciting or heroic about it. It's just a story of a couple of EMTs doing their jobs.

-----

The History Channel show "Ax Men" just aired an episode that covered the Great Coastal Gale of 2007. Ax Men, Episode 11: "The Storm of the Century" has many great clips of how highway 202 looked the first morning after the storm hit. Darrel's property is out on 202 the the footage of driving back into Astoria is the devastation my partner and I faced that night on the highway. Ax Men can be downloaded on iTunes here.

Exposure

2008-05-13T14:28:00.000-07:00

Sunday evening while my wife and I were catching up on Battlestar, I received a phone call from the south station crew who had just transported a patient to Providence. The crew member wanted to inform me that the hospital was putting together a contact list of all health care workers who had come into contact with a certain patient because this certain patient was positive for meningitis. Not only did I have contact with this patient, but I also spent two hours in the back of an ambulance with her on a transport to Portland.

So I paused Battlestar, got out my little contact book and started making phone calls. First I called the ER to speak with the doctor directly. Sure enough, I'd been exposed to meningococcal meningitis and they want me to come in and start cipro right away. Great I'm thinking. Next phone call is to my shift supervisor to let her know about the exposure. Third phone call is to the supervisor who was working the day of the exposure as it was an extra shift for me. The fourth phone call was to my partner for that particular shift, who would now have to drive an hour into town to the ER.

Now, I understand that paramedics (and all health care workers) run the risk of exposure and I can run down a short list of recent ones.

A hepatitis patient had explosive, bloody vomiting in an ambulance and the ER, contaminating a number of nurses and EMTs.
An ambulance crew transported a confirmed pneumonic plague to Portland.
A fire lieutenant was recently splashed in the face by contaminated IV fluid after the catheter was pulled from the patient's arm and subsequently sprayed around the scene until it was clamped.
An EMT Basic received a needle stick after being in the wrong place as an EMT Intermediate was handling the IV catheter.
I was splashed in the face by potentially contaminated IV fluid after the spike was pulled from the bottom of the bag and the sprayed all over my partner and I.

All these have occurred in the last 4 months between my ambulance company and my fire department. Thankfully, there have been no confirmed cases of any hepatitis, or plague, or meningitis in any of the exposed responders. It really makes me worry about the odds though. One day, my partner, or myself, or one of my coworkers may get more than just a scare.

By the way, Sunday was my birthday. What a hell of a thing to have to deal with...

What I Get for Taking Vacation

2008-05-10T19:06:00.000-07:00

It's been a hell of a week. I took a shift off on Tuesday to spend a few days away with my wife celebrating our 4th anniversary. I paid for it though, before and after.

The shift before my anni-vacation, my partner and I ran 5 calls before noon. One of which required cardioversion for SVT after two unsuccessful rounds of adenosine. In the middle of all this, dispatch is paging us that there are return medivans waiting at providence ER. We made three round trips to Portland that shift.

I had to paralyze and intubate a stroke patient while nervously waiting for additional personnel from rescue. We took him to Portland on a vent.

Upon returning from my anni-vacation, I had a first ever experience as a patient went from a 3rd degree block to cardiac arrest in front of me. I was setting up an oxygen mask and not looking at teh patient when a fireman said "I think he just went out on you!"

"No he didn't." I replied as I double checked the monitor leads (one of them had fallen off). It was then the patient went from pale to purple in 10 seconds. Fuck I thought.

"Code 99." My partner calls into the radio. Immediately this is followed by the FTO sitting at post "Medcom from Medic 3, does 1 need our assistance?"

In the middle of applying defib pads, setting up for the intubation, and IV, I grab the handset. "Negative 3, fire is already on scene." I don't need another medic to drive 15 minutes from post to 'assist' me on a code when I'll be off scene in less than 10. (I have a problem with second ambulances responding as "back up," something I'll rant about later.)

That shift was rounded out with a transfer for gall stones at midnight. Something I truly considered a valuable use of my emergency medical skills.

Today, it continued with a trauma system entry from the memory ward at one of the local adult care facility. The patient fell outside and was in the rain for 10-20 minutes before the caretakers found him. He had a huge hematoma on the back of his head and was supposedly altered from his normal state of dementia. Turns out he had a subdural bleed as was a trauma transfer 30 minutes after arriving at the hospital.

And this afternoon, I took my second vent transfer of the week, an acute MI with complications. I just took a vacation, but really, I need another one.

Love and Loyalty

2008-04-25T17:03:00.000-07:00

I just finished reading Marley and Me by John Grogan, and while I'm not going to write a review like I typically do (there are already thousands out there and by the way, it's a fantastic book) I'd like to share how it's affected me.

I've written a few times before about me own lab puppy, Boomer. She's a handful, as most puppies are. Destructive, playfully rambunctious, and fully of life. I love that dog, sometimes against my better judgment. I was working the office a few days ago and Boomer was in the hall chewing on something. Now, I should know better by now that more than half the time, she's chewing on something she shouldn't be. When I got up to go downstairs, there Boomer is, happily thumping her tail against the carpet while she is shredding my uniform hat to pieces. The bill was completely shredded, the sweat band gnawed on, and the plastic snap adjuster was gone all together.

Boomer looked up at me, those puppy eyes of hers saying "hi dad! Look what I found!" I was upset, but only a little because obviously I'd left the hat someplace it shouldn't have been and she found it. But now I have to take the shredded evidence into my boss and explain to him how my dog ate my ball cap and I need a new one.

The point though, by reading Marley and Me about John Grogan's struggle with his ill behaved lab, I've come to accept that this is how Boomer is. She's a lab with tons of pent up energy and usually no place to channel it. I love that dog no matter what she does. And I see that love and loyalty reflected in her eyes every time she looks at me.

I'm a dog person, and as a whole, we have a place in our hearts for dogs in need. Several years ago, shortly after I became an EMT, I responded with my fire department to a fast moving grass fire on the beach with at least one injury. The fire itself turned out to be small and fairly slow, so I was tasked with taking care of the gentleman who had tried to put it out--and was consequently responsible for setting it in the first place.

After lighting a cigarette, the man had carelessly dropped the match into the dry beach grass, setting it ablaze instantly. Alarmed, the man tried to stamp out the fire, but the fire jumped to his denim jeans and began burning at his lower legs. Running out from the immediate area of the fire, he tried patting out the flames on his jeans with his hands and was eventually successful.

As we arrived on the scene, the patient was on the promenade, smoking another nervous cigarette, with scorched and tattered jeans and burns to his hands and lower legs. What struck me the most though, was how he tended to his 3 month old black lab puppy. There was no doubt this little pup was this man's whole world, in a very literal sense. He was a transient, without insurance, and unwilling to go to the hospital to be treated. It wasn't the inability to pay that was keeping him from going though, it was his unwillingness to leave his pup behind. This man's love and loyalty for his pup was so great that he would put up with the pain of 1st and 2nd degree burns rather than leave his pup behind. We made a rare exception for the man, transporting him and his pup to the hospital, as he was in urgent need of medical care.

For me, a dog inspires such a rare type of love and loyalty between master and pet. In reading Marley and Me, in my interactions with my other volunteers, coworkers, and patients, I've come to learn that I'm not the only one that feels this way. I love my pup for who she is and I look forward to her growing up, and her ever present love and loyalty.

My Storm Story, Part II

2008-04-13T20:00:00.000-07:00

My Storm Story, Part I

“What?” was my immediate response. Stopping cutting operations was just not an option. “Who ordered it?”

“Chief says we get off the highway until morning. We won’t be cutting until then.” The district’s fire chief, who’d I’d seen and talked to when we picked the patient up, were ordering his men off the highway. The plan was to park us at the nearest fire station about a mile back, and wait out the worst of the storm.

The cell towers were still operational so I placed a call to my supervisor at the other end of the county and gave her a report: the fire department had stopped cutting and we were returning to their station.

My supervisor, for her part, would do her best to put together a plan for us. For me, my priority was my patient. I advised the receiving trauma hospital that we were delayed indefinitely and that they could release their trauma team until we radioed another update.

My partner turned the ambulance around and followed the fire department’s brush unit down the highway. We turned down a short gravel drive and approached the little 3-bay station. They would leave the brush unit out so we could occupy the bay. The three firemen followed us into the bay and then closed the door behind us. It was the first break we’d had from the storm since we’d pulled the patient out of the house almost an hour before.

The supervisor called shortly after and told me that a plan had come together. The paid firefighters from the west end of the highway (the other side of the downed trees) would be working with a number of Pacific Power crews to clear the road and get us home. The work would be slow as Pacific Power estimated over 50 trees down in just the few miles back into town.

So we waited. The patient was stable and resting comfortably with the morphine. The supervisor was calling every twenty minutes to give me updates, check on the patient, and try to keep our morale up.

We spent over two hours at that little station, during which time a tree came down on the brush unit that was parked outside and the battery on the ambulance died, requiring a jump. Eventually though, the bay door rolled up and there stood the Pacific Power crew and the crew sent from Astoria Fire, decked out in storm gear and helmets. While there was only one Pacific Power truck outside, I would later learn that they had diverted numerous crews from repair work to come cut us out.

My partner made the radio call to dispatch that we were continuing and I called in to the receiving hospital with another update. By this time, the storm had reached a slight lull and the trip into town, lead by Pacific Power and Astoria FD, was easy going. Power was out throughout the city and the hospital was running by generator when we pulled in. The entire trauma team had been released and we were met only by the ER physician and nurse. Uneventfully, we turned the patient over and returned to quarters.

For the rest of the shift, we listened to the wind batter the station. 911 service in the county was sketchy so we had to scan with portable radios for calls coming from our dispatch and fire dispatch. If there were other calls that night, I don’t remember them.

I was off shift on time at 0800 the next morning, relieved by a crew who had slept the whole night in their own beds. The storm had calmed, but I didn’t have to drive more than a block away from the station to see the damage.

Tree debris covered the roads, houses were missing whole sections of roof, and trees still blocked side roads. I made the usual twenty minute commute in double that time. I was concerned about my wife whom I hadn’t spoken with in 12 hours. I was worried about our house. And I was worried about the guys on my fire department and how they’d survived the night.

More to come…

A Perfect Morning

2008-04-13T19:59:00.000-07:00

I awoke this morning to the first perfect spring morning of the year. The sun was rising over the hills, casting a wonderful pink-purple glow. It was already warming outside, 60 degrees or better at seven in the morning. The air had a fresh, warm, clean smell to it, just like my favorite summer mornings always do.

Boomer was following me through the house during my morning routine. She waited outside the bathroom door while I was in the shower, sat and gazed up at me with quizzical brown eyes as I packed my lunch, happily wagged her whole body when I took her outside, then bounded up onto the bed when I kissed my wife goodbye.

With my uniform on and day bag packed, I grabbed my Oakleys and got into my car. Driving to work this morning, the 45-minute commute to Station 1, didn’t seem so bad this morning. I had a smile on my face for the first time in months when I walked into the station to relieve the previous shift.

My Mistakes

2008-04-06T17:18:00.000-07:00

I'm a new paramedic, still in my first year in the field. I've made mistakes, some big and some small. I misdiagnosed a failing pneumonia patient as CHF and gave lasix, further worsening the problem. I've asked stupid questions in front and patients and firemen. I've rolled into the ER with cardiac patients that aren't on oxygen.

Today, I've had a difficult shift. I can't start an IV to save a life. I forgot to check a blood sugar on a fallen diabetic. My partner and I (with the fire department) had to inadequately c-spine a 300 pound patient strictly because of his size.

I've been reflecting on my mistakes today because I've been feeling down. My favorite ER nurse told me that I'm just being too hard on myself--and maybe that's all it is. Sometimes it's easier to focus on the mistakes than the times when I "got it right."

Seaside Fire Rescues One

2008-04-06T17:15:00.000-07:00

I'm so proud of my fire department. Yesterday morning at 0430, the Seaside Fire Department was dispatched for a structure fire with victims trapped. The first arriving truck company effected a rescue of a woman from a second floor window. Check out the full story here.

The 10/90 Theory

2008-04-01T17:38:00.000-07:00

I have this theory about EMS that we respond to 10% of the population for 90% of our calls. While I have no statistical data to back up the actual numbers, I do believe that we respond to a narrow margin of system abusers, frequent callers, and high-risk patients for a majority of the calls that we run.

A perfect example of this is an adult care facility, one that we respond to on a daily basis. Almost every patient living at one of these facilities is high-risk due to their medical history. We know many of these patients by name because we run on them so often, we know their medical histories, their primary care physicians, and their dog's name. This small population accounts for a high margin of calls.

System abusers and frequent callers are just as bad. I grew up in a household where I never went to the hospital. The thought of calling an ambulance for anything was just unheard of. But I can't tell you how many times I go to a frequent caller's home because they believe they are having a medication reaction (they aren't) or that their blood pressure is too high (it's not).

It is not unusual for me to run half a dozen calls in a shift and have 5 out of the 6 be patients I have seen before... frequently. 10% percent of the population 90% of the time. The other 90% of the population is too healthy to need an ambulance, will drive themselves to the ER in a crisis, or understands what the purpose of an ambulance truly is: a means of emergent transport.

My paramedic preceptor and I had talked about this during my internship and it continues to be a topic of conversation when we help Ms. Jones back into bed for the fourth time in a week.

My Storm Story, Part I

2008-03-29T17:23:00.000-07:00

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"We've got a big tree down!"

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

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

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

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

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

more to be posted soon...

My Storm Story, Part II