Occupational Hazards

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

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

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

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

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

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

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

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

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

AMA

Overheard on the dispatch:

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

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

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

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

Ouch.

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

It begs the question: WTF?

Modest Recognition

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

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

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

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

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

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

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

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

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

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

***

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

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

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

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

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

"Free" Health Care

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

Here's my problem:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Happy Milestone!

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

The Science Of It All

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

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

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

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

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

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

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

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

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

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

Unethical Decision Making

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

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

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

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

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

***

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

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

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

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

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

***

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

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

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

Jaws Training

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

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

My older brother, Gordon, and the Supervisor.

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

More to come soon, I promise.

Protocols

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

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

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

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

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

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

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

To Die at the Beach

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

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

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

*****

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

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

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

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