Tuesday, March 31

Attention "Closet Medics"

This post refers to the "closet medics" out there employed in a public safety profession but current on their Paramedic license.

My tip to them is to get promoted or be quiet.

A few nights back we were working on one of the rare folks who actually needed us in a hurry. We were able to start getting the picture and deciding on a plan when the person who keeps their license in the dark, for whatever reason, questions my treatment.

In most circumstances I want to know if something I'm about to do may be harmful or wrong, but in this case the three paramedics on the scene had verbally decided a course of treatment and suddenly this EMT has an issue.

He slows down the IV fluid I asked for wide open so I could administer my medications in an efficient manner and he refused, stating I was 'doing it wrong.'

Oh I loved that little moment. He was above me, holding the IV bag, refusing to open it up.
"He's hypertensive, you can't bolus him." I was told. He was not.
"He should go code 3." I was told. He did not.

Back at the firehouse I asked him why, if he was such an accomplished care giver, he was only serving as an EMT. His answer said it all.

"I don't like working on an ambulance."

Gag me. Use your license or shut up. This was almost a letter in your file.

Monday, March 30

...for the seizure/active/multiple...

Ah criteria based dispatch, how do I love thee? Let me count the ways.


Caller states a man with a heart condition is unable to get out of bed.


Somewhere, somehow this was coded as an emergent seizure. How, you ask? Because the public knows all the code words.

I have told you all many times that you could not make this stuff up, yet when I think back on this run, even later in the day, I can't believe it wasn't on a TV show.

Rent is past due, almost a full month. Our "patient" is convinced that if he tells his landlord he can't get out of bed that he won't have to pay rent.

Landlord decides that if deadbeat can't get out of bed he must need an ambulance (moving crew) to get his tenant moving.

As we arrive the engine company is in the hallway of the third floor apartment barely holding in their laughter. We see the engine paramedic trying to interject herself into the discussion the tenant and landlord are having.

We present ourselves and send them along when we see this is a battle of the stubborn stoics. Tenant tells us he shouldn't have to pay rent because he is on disability and can't work. (Later described as a foot injury, seems data entry was far too below his abilities.) Landlord tells us that he can't have a tenant who won't pay rent just laying around all day long.

I had to do my signature look around the room. I looked behind a dresser, moved the landlord to take a peek in the closet, asked the patient if I could look under his pillow.
Finally they asked what I was doing.

*I think I have a bite, let's reel it in*

"I could have sworn someone called 911 because someone was having a seizure but darn it, they lied."
"Well he told me he has seizures and I can't be waiting here all day." Says the landlord with a stance that says this statement is not negotiable.
"Actually, you can and you will." I turn to the man in the bed,"Can you stand up? If you stand up we can let you go about your day, Sir."

He looks from me to the landlord and back. "I better go and get checked out."

I wonder, what do folks expect the hospital to find when they get "checked out?" Mister Johnson, you have a troll in your ear, no wait, you just have the sniffles, go home.

So down the stairs we go, man unable to get out of bed walking beside us, all the while yelling to the landlord that his disability entitles him to free rent. For all the talk of disability he was quite nimble on both feet I must say.

At the hospital he thanked us, not for giving him a ride to a physician, but for getting him out of a "tough spot with the landlord, I owe you one."

He now owes the taxpayers about 650.

Still Alarm Medical Aid

A 17 year old boy presents to the front door of the firehouse with quite the anterior dislocated shoulder and deformity to his clavicle. FROM YESTERDAY. He needs us, but his mother has other priorities.


While wrestling with his uncles, our patient was tackled and his shoulder has been in pain since last night.


We get radio to put us out and issue a number while my partner slides down the pole to help out. That startled our patient who apparently assumed the brass pole was for something else entirely.
He's hurt, no doubt about it. One of the guys is calling his mom who informs us she's only a few blocks away and will come and "get him."

I assumed, and I'm sure you did too, that she would arrive in some sort of conveyance, perhaps a car or light SUV. But since you're reading this and saw my quotes around "get him" you know she is on foot. How is he supposed to get home I wonder? And where was she when he decided to come here, and, and, oh forget it.

Their hospital of choice, Saint Closest, is diverting ambulance traffic so we're on the way to Saint Farthest when Mom asks if there is a fee for the ambulance.
"Yes there is," I tell her, trying to make the ride smooth for our injured new friend.
"How much, like, a lot?" She asks and I judge she was not much older than our patient when she became his mother.
"We'll worry about the fees when the Physicians make his shoulder better, OK?"

She pondered this for a few minutes and, out of nowhere asked the following:
"Can you drive us real close to the ER, then let us out without a bill."
I had to blink. I usually have a smart ass answer for most questions in the front seat, but this one took the cheese.
"Oh, of course!" I said, "We'll just give you a ride most of the way and pretend nothing happened."

I have been told on more than one occasion that my subtle sarcasm often goes unnoticed and is taken as fact.

She smiled and I realized that was again the case.

"Of course not, we have to take him to the hospital. Vans that take people most of the way to the ER are called taxis and are remarkably less expensive."

We got him into the ER at St Farthest with Mom in tow without any other mind blowing questions. As we were leaving my partner asked, "Did she really ask you to drop them off near St Closest?"

"Yup, and I reeeeealy wanted to."

Sunday, March 29

Sunday Fun - Welcome Firefighters

Whenever I travel I try to at least get a shot of a firehouse or fire engine. I'm sure all of us are curious to see how things are done in other countries or regions of our own country.

With that in mind I wanted to extend a warm welcome to our expanding international audience.

Welcome Firefighters

American Firefighters are often compared to the Fire Department of New York by international travelers as they are often in the news. They carry on the traditional red with white cab but I think most departments long for the days they can have 5-7 FFs on a single engine.

Celebramos Los Bomberos

Rio Grande, Argentinia Firefighters celebrate a day for Volunteers on June 2nd. Rio Grande is a suburb or the capital city Buenos Aires.

Vigili del Fuoco di Benvenuto

This sharp looking Mercedes is in service as unit 14 in Milan, Italy. Ambrosiana, who posted this picture on flickr, has a series including unit 14's accompanying ladder truck. Take a look.

Willkommen Feuerwehr

, Germany has an interesting orange paint scheme. This link also has a neat video, in German, about what appears to be their new aerial device. If you've never seen a Metz ladder go from road to work, check it out.

ترحيب رجال الاطفاء

Member Bomba Boy at Fire Engine Photos shows us the As-Shubaikah fire station located just aside of the Masjidil Haram Mosque,Makkah. Happy wonders if those folks will move when the bells ring.

Добро пожаловать пожарных

Firefighter Nation member RUS fire 86.10 posted this shot of two similar Russian engines with the familiar white door. Most of the units over there appear to be very heavy duty.

Bienvenue Pompiers

The Pompiers of Paris, with their distinctive shiny helmets and hose carts have a variety of specialized apparatus for the old narrow streets. Engines de Pompiers shows us Paris Rescue 6.

Saturday, March 28

Egads! 200?

Holy Lidocaine!

This week will include the 200th post to my little therapy project called the Happy Medic.

It started as a way to scream, only not out loud, and has grown into an obsession of sorts, wanting to check comments every 30 seconds, just to see what everyone is saying/thinking/doing out there.

Thank you for stopping by and taking a look around, I do appreciate your time and hope I could put at least a smile on your face, if not a chuckle in your heart. (Does that get Amiodarone 300mg or no?)

For number 200 I'll drum up somethin'...real nice.


Friday, March 27

The Handover Blog Carnival - Volume 2

Alright class settle down, settle down.

Over the past month you all had a homework assignment to bring me a tale of "A lesson learned." Many of you took this to mean a number of different things. Some of you submitted a list of advice for new Paramedics, others a tale of a mentor teaching through experience and one of you turned in a spam advertisement for a breathing technique. Very funny Motorcop, now sit down and pay attention class!

Let's start where this whole idea started and follow some lists of suggestions for New Paramedics and EMTs. The founder of The Handover, UK Paramedic Mark Glencorse, (Third row, green jumpsuit), is better known on the playset as MedicBlog999. He has a list of 20 quick tips for every new practitioner, my favorite being #16, trust your instincts.

Another list of great suggestions I found under the desk of AD or Ambulance Driver, (Fourth row, Borg drone, cleaning his handguns) over at A Day in the Life of an Ambulance Driver. Less about patient care, he gives great advice for the new Paramedic dealing with the person sitting next to you in the rig, who used to be you. His list is to ward off "New Medic Syndrome." AD...those aren't loaded...are they?

As an example of a learning moment, I offer up a call I went on with my early mentor Mr Bill, which taught me more in 2 hours than I had learned in the first year jocking a box. I won't include my submission's grade in the curve.

Where is Erin? Erin! Oh, I'm misreading my attendance sheet. There you are ER RN (First row, paisley scrubs and fresh coffee). I know you need to get back to your crowded ER but thank you for your paper about drug seekers and that appearances can be deceiving. We should all learn a lesson from Erin. ER RN, sorry. No extra points for scenting it by the way.

Some appearances hide nothing. Spence Kennedy from Siren Voices (Second row, elegant style and handwriting) writes of a time when a hidden weapon made an appearance at a call, not once, but twice. Scene safety is always a big points getter in this classroom.

Michael. Michael Morse! (Fourth row, Lieutenant's badge) Please stop writing your next book and pay attention. Your submission titled "Fairy Tale" had better not be another story about trolls and princesses. I hope it was a moment when you saw the real person underneath the shell she had built around herself simply because you cared. What? Oh. It is? OK then, back to writing "Happy Rescuing Providence." Oh, that's not the title? Then you fail.

, who calls them as she sees them over at callitasIseefit(Third row, PJ pants and pager), got a bit emotional at a scene that would cause any rescuer to take a few moments and rethink what a bad day really is. The learning moment isn't spelled out, but it's in there, you just have to feel for it instead of look for it. Great paper Bernice, keep them coming. Now please go change into your proper school uniform.

Here's a letter written to all of you from Peter Canning's Street Watch Blog. It is titled Letter to a new Preceptee and has valuable information for you folks new on the street.
And Peter, you did extra credit by adding to the letter in a separate post. Well done. Your days as a speech writer in the Governor's Office have served you well. Now please leave the podium and take your seat this is not an oral report.

All right class, time for our music lesson. Oddly enough, that's the theme of our next report from Impacted Nurse(Back row, giggling and rubbing hands together). Often it is difficult to explain to new folks on the job the way the ER can flow like a symphony if you just listen to it. Everyone raise their instruments and...ready? Play.

Great music lesson Impacted, let's go outside for recess and enjoy the spring weather. I'll grade these papers while you play. Oh Motorcop and AD, the firing range is open now, knock yourselves out.

When we come back your History Lesson will be covered by Kim from Emergiblog who asks us to form our next submissions around the theme of "Emergency!" the influential and fun to watch 1970s TV show. Submissions should be sent to Kim no later than April 20th for consideration. Now go and play while you can and, above all else, BE SAFE!


Blog Carnival Index - browse the archives

Thursday, March 26

A tip from me to them

paramedic school www.pct.edu
"Them" in this post refers to anyone attending Paramedic school so they can "get hired" with the Fire Department.

I would like to let them in on a little known secret. At least a good deal of medics I work with now didn't know this nugget of truth. When you get a Paramedic license just to get on with the Fire Department...


More than once I have been approached by persons who are looking for a way to drop their Paramedic license, yet keep their jobs. I've been known to actually read the rule book and they expect me to know some magic loophole. Many of these folks took abbreviated courses designed to "get them in and get them out" so they could apply with the local FD and have a better chance of getting hired.

Turns out the FD is hiring Paramedics because they need Paramedics. I know it's hard to understand right now, but patient care will actually be an important part of your new job as a firefighter.

A Firefighter/Paramedic is a firefighter who has been specially trained to deal with the ever growing 80+% of our call volume. You are not just a firefighter.

Your brain needs to be all in on this decision, not just to get to the top of the applications pile. When I started down the road in this business I always knew I would end up as a Paramedic, I just never expected I would fight so hard to get the license and so proud to keep it. They don't call me "the Happy Fireman."

When I take an intern I try to find a philosophical match to myself. My last intern, when asked why he got into EMS, told me exactly the kind of thing I want to hear. He was in the Coast Guard and when they were going to board a ship everyone else would grab a gun and he would grab the first aid kit. He figured that curiosity about first aid could grow into something he could love, and it did. He wanted to be a Paramedic because he enjoyed being an EMT but got frustrated he couldn't do enough for his patients.

He is now a competent, confident Paramedic and we meet often to discuss his new career and interesting calls we both go on.

Another intern candidate told me he was in Paramedic school for the extra money at his firefighter job. I told him to get a side job doing something else, that the role of a Paramedic isn't just an extra salary, you have to want to be there. Nothing drives me crazy more than a Paramedic who wants to be something else.

So if you're considering taking a Paramedic course so you can get hired, think again. You just might save yourself and someone who needs a Paramedic a lot of time and effort.


Wednesday, March 25

...for the medical alert/smoke detector...

Well which one is it? With ambulances closing, I'm getting more engine time and these building alarms are just as monotonous as the drunks. This dispatch is confusing, not sure which hat to wear, Medic or Fireman. Turns out all I needed was my common sense hat. I carry it with me.


Life Alert Home Ambulance summoning company has called stating a resident's smoke detectors are alerting.


Great, now they monitor smoke detectors. At least now we know what hat to wear.
Nothing showing on arrival at the 2 story type 5, just a man holding a smoke detector, wires and all, in the front yard.
"Sorry, guys. These things are all screwed up."
The house is familiar and so is the frail old woman at the front door, but this guy is new.

"What happened? Is there a fire?" Our boss asks as we gear up just in case.
"The life alert people called and told me to change the batteries in the smoke detectors (Go Life Alert! Imagine that.) but they won't shut off." He hands me the detector and I take a cursory look, pretending to know more than I do.

That's when the smell on his clothes made me wonder...
"Sir, you smell like smoke, and not like cigarette smoke, was something burning in here?"
We're making our way towards the house and the little old woman sees us coming and has ducked back inside like a shy child.

"I used a paper to test the detectors. It smells in there."
We enter the house to the odor of burnt paper and can see small pieces of black paper scattered down the hallway.

"Sir, did you use the paper to test both detectors or did you use the 'test' button?"
I hold it up to his face, finger on the button.

His face turned the shade of the engine.

We went through every area he had walked with the burning papers and checked to make sure everything was OK. I quick lesson on how to test smoke detectors and we were back in service.

...building alarm box...

The alarm machine called us, so this isn't a funny call story, but a notice to other firefighters to think about WHY alarms go off.

And to let you know that one person actually evacuated when the alarm went off a the 10 story apartment building. A clear sign people are learning what that loud buzzing means.


Automatic alarm activation in 10 story multi-residential type 1. Alarm panel indicates single smoke detector on the third floor.


We're the first engine in and up to the third floor we go. There is only one person standing out in the cold, wrapped in a blanket, asking if she can go back in yet. Clearly she's from out of town, likely a new student at the nearby college.

Roaming the hallways we see no signs of smoke or fire, only the flashing strobes and blaring buzzer. We can barely communicate it is so loud.
Looking from detector to detector for the indicator light showing it is the one tripped, we see nothing. The ladder company finally silences the alarm but the system will not reset.
Assuming the alarm is confused, we search the floor above and below finding nothing. There has been some wall refinishing in one area of the third floor, but the areas smell of paint instead of dust.

Downstairs, the alarm will not reset and the Chief wants us back up to take another look around just to be sure. No one will answer their door, but all the doors on the floor are cool to touch and have no odor coming from them.

I decided to slowly walk looking for anything out of the ordinary, not just signs of fire.

It was on this walk I noticed a faint over spray near one of the detectors. Looking closer and reaching up I felt the reason...wet paint. Someone spray painted only the sensor part of the detector, including the light that indicates it is faulty. We called up the building engineer who said he'd get to it whenever.

After picking our jaws back up off the floor we explained that the giant building's alarm system was not working and he doesn't want to wait on this repair, but get to it immediately.

On the ride down (elevator down of course) we could only think of 2 reasons to spray paint a smoke detector:
  1. You like to smoke in the hallway.
  2. You plan on burning the building down and are testing response times.
We're hoping for the former.
Although when it really is a fire, more folks might leave the building when the alarm sounds.

Some things are funnier than others

I can't stop giggling about this. Why? What in my messed up brain thinks this is so funny?

Special thanks to cakewrecks for adding this to my day.

Tuesday, March 24

A Letter in the File

Heroism. What does it mean to you? Webster's lists many definitions, most notably, "showing extreme courage; especially of actions courageously undertaken in desperation as a last resort."

At my department there are occasions when certain persons meet this definition and they are recognized with an award for heroism.
These are often the result of a rescue at the scene of the fire.

But what about when you are not the hero, but just happened to be at the top of the stairs at the right time?

A few years back an engine company made a fantastic lead down a narrow hallway on the second floor encountering heavy smoke and immense heat. They found the seat of the fire and began attacking it when they came across a woman and a young child, alive, in an adjacent room, both unconscious. Many companies may have withdrawn and made the rescue, leaving the fire to expand, but these heroes chose to remove the victims one at a time.

The last man on the line pulled the child back along the hose line to the stairs where he encountered another team making their way to the fire floor. There were no words to exchange in the heavy smoke as one firefighter handed the limp body to the next who quickly turned back down the stairs and carried the boy out. By the time the confusion in the stairwell had become clear, that there was an active rescue in progress, the original company, still eating heat at the seat of the fire had now removed an elderly woman to the stairwell to be removed by another member of that team in the hallway. Both victims survived.

You may be saying to yourself, "Happy, sounds like a great story of true heroism, what's the problem?"

The guys fighting the fire, the ones who effected the removal of the victims from a life threatening hazard, all the while still fighting the fire and as a result saving the other floors from involvement, weren't recognized by the award.

The team on the stairs not only was nominated for the award, but accepted it. It sits on the wall at their station. I know the real story because I relieved the company that fought that fire the next day and you could see the light in their eyes when they talked about how good it felt to drag the victims out to a safer area, then get back to work. I knew these men well and trust what they say.

When what really happened came to light the engine company was given a certificate of bravery from the Mayor's office...by mail.

The reason I'm putting this letter in their files now is because last week, at the dinner table, someone from the stairway team at that fire told a yarn about how he had been the one to remove the victims, not the engine. When pressed for details on what room they were in he changed the subject.

It's not about awards in this business. If you need a shiny plaque to replace your own feelings of inadequacy or feel the need to lie in order to sound "cool," quit now before you get someone killed actually trying these things on your own.

That is all.

Monday, March 23

You Make the Call...Opposing Engine Companies...What Should Happen

The question on Friday was THIS

Given the scenario, you are first due and would be first on scene, but Engine 2 has turned the wrong way down a one way street.

The important thing to keep in mind in this situation is apparatus placement. The first priority in this scenario will be ladder placement. We engine folk can forget that the engine should NEVER be in front of the fire building, but pulled past it. Lines can be stretched and extended if necessary, but ladders have a set range and angle and blocking them means no ladder access whatsoever. In a narrow street like this, even a 35', 45' or 50' ladder will need to be footed in the street to make the angle to the third floor.

That in mind, Engine 2 should be given the right of way to advance towards the fire building. Since you heard Engine 2 and Truck 2 were at the same location when the call came out, we must assume they are responding together and that the truck is following the engine. If Engine 1 advances and drops lines, Truck 2 will have to go around the block and come in the other way behind Engine 1.

When engine 2 pulls PAST the fire building, the truck will have the full fire building to ladder or place the aerial device should the officer make that decision.

As officer of Engine 1, you should advise your driver to pull past the intersection and back down to Engine 2, drop a supply line and reverse out to the hydrant to supply Engine 2.

This will solve the access, water supply and traffic control issues in one maneuver.

If you said let Engine 2 take the fire building to let the truck in, you made the right call.

If you said, "Screw Engine 2 this is our fire" you need to grow up and work as a team.

Sunday, March 22

Sunday Fun - Get Motivated

Here are some motivational posters I'd like to see.

Saturday, March 21

A moment of reflection, officers have fallen

Our thoughts are with our brother Motorcop and his extended motor family.

He says it better in the linked post than I ever could.

Strange the connections you can make through a machine these days.

Stay safe Motorcop.

...for the abdominal pain...

What's that old saying? Fool me once shame on you, fool me twice...can't get fooled again?
See, I say it and I'm an idiot. The President of the United States says it and...well...I'm still an idiot.
Ever been on a call when you told your driver, "Turn off the lights and sirens and pull over, this is not an emergency"?


A caller states she is experiencing severe lower abdominal pain.


We arrive as a dual paramedic unit to find a mid 20s patient doubled over, guarding the lower abdomen on the left side. As we always say, "...a sexually active female experiencing lower quadrant abdominal pain is experiencing an ectopic pregnancy until a physician proves otherwise."

Not a bad base for a treatment plan, but let's make sure to follow up on everything.

I'm going with the treatment plan of "acute abdomen" which allows us to transport to the nearest facility. In questioning our patient she meets all the criteria for an ectopic pregnancy except one.
Sexually active with boyfriend - check
Abdominal pain LLQ 10/10 with guarding - check
Pale, diaphoretic - check
Low BP - check

Female - ...wait a minute...

The question that made me take notice was as I was taping up the IV.
"When was your last cycle?" I asked.

From most female patients I get a response in days or weeks or a look of dread when they realize they're late.

This patient simply looks up with a blank stare. I repeated the question and got a faint shrug of the shoulders and I began to take better notice of the features of my new client. They're doing marvelous things with plastics these days but other features don't add up, the hyoid for one.

"Are you male or female?" I asked bluntly, straightening up my shoulders on the bench.
"Why do you need to know?" was the answer that came back.

"Turn off the lights and siren and pull over, this is not an emergency." I told my driver. With the IV in place a borderline low BP, this was looking more like a "standard" abdominal pain rather than a possibly rupturing fallopian tube. We were only minutes out and I had already given a glowing code 3 acute abdomen radio report.

At the ER I advised the staff that since my radio report certain new facts had changed the course of my treatment and they just smiled and giggled.

Our friend was only weeks away from surgery and had completed all the tests and treatments and psych evals and now, apparently, the hormones.

By now she is living happily in her new role and I learned a valuable lesson to always ask bluntly that which needs to be.

Fool me twice, shame on me.

...for the headache...

Sometimes the truth leaks through all the fancy dispatch criteria and triage devices we have in place. And sometimes when you get there you say out loud, "Are you kidding me?"


A caller states she has a severe headache


Responding, I notice we have been dispatched to a street corner instead of a street address. Since I know the location of most the few remaining working pay phones (this location is not one of them) I assume a cell phone caller.
What I didn't assume was that we would be flagged down at the main entrance to the local hospital. The woman is upset because the doctors want her to wait to be seen. I explain to her that sometimes all the gunshot wounds, car accidents and pregnant women go first and those of us with headaches, if we choose to go to the hospital, wait our turn.
That set her off.

She began screaming to anyone passing by that we were harassing her and leaving her for dead instead of doing our jobs.

"Do you want to be seen by a doctor?" I asked her, carefully recalling the EMTALA laws.
"Yes I do!" She shouts in return clearly standing on hospital property.
"Then by law I am required to take you."

EMTALA (Emergency Medical Transport and Labor Act) says that if you have been triaged, I can not legally transport you away until a physician has deemed you "stable." She is not in my opinion "stable."

I took her by the arm and began to walk around the city block to the emergency room entrance.

"Where are you taking me? I want a different hospital! This one ignored me!"

We walked through the ER entrance and up to the triage nurse who glanced up and pointed towards the door to the waiting room.
"She can go back in line or go home." The nurse exhaled almost without emotion.
"Will do." and I turned to leave.

Back on the street I see the ambulance crew walking towards me with a confused look on their faces.
"The engine boss said you were waiting for us around the corner." One of them said. I replied, "Do I have to do your job too? I already completed the transport guys, you're in service."

I tried to explain the law to the other guys but they cocked their heads when I got into the details. And I'm pretty sure that woman's headache didn't get better as mine just keept on keepin' on.

Friday, March 20

You Make the Call...Opposing Engine Companies

This topic came up at the dinner table a few watches back and was the cause of much the heated debate. I wanted to pass along the scenario to you and see what you think or what your department dictates.

The Dispatch

You are the Captain of Engine 1, a 3 person engine dispatched first due to a report of a structure fire. You know the area is mixed residential, mostly 2-5 floors, varying types of construction. You are first due of a three engine response, there are 2 truck companies also responding along with other units from farther out.

Your neighboring district, district 2, was in the area on a building alarm not long ago and they go en route over the air before you leave the station.

Refer to the picture below.
Special thanks to Oak Park, Illinois
As you make the left turn down the one way narrow street, you see Engine 2 making the turn and opposing the opposite direction, against the one way sign. You see fire mid-block blowing out the third floor.

There are no other cars on the street between the 2 engines.

You are first due and your driver wants to know where to go. If you advance you will reach the fire building before Engine 2.
There is a hydrant on both corners, near the current position of both engines.
What do you tell your driver, and why?

You Make the Call

Wednesday, March 18

...for the psych eval...

Always amazes me when we get called to evaluate possible psychiatric patients. Reading a recent post by Medicblog999 reminded me of a fellow who not only has psychological issues, but had math issues as well.


A man has called from a payphone stating he is a threat to himself and requires an ambulance.


The police have "cleared" the scene. In this situation, they were waving us in while standing away from a man dressed mostly in denim lying in the bus stop shelter next to the phone off the hook. He is motioning towards his left arm which strikes me as possibly an injury.
Off the ambulance we make contact and our scraggly beard patient has that distinct odor of week old urine. A smell so thick and so penetrating I hesitate to even breathe near him, let alone put him in my office.

Throughout the course of our assessment we find he is complaining that no one will listen to him at the VA and get him a complicated hip surgery necessary due to injuries he received in battle. His pointing is to the Airborne patch on his dirty denim sleeve.

Our patient identifies as a veteran.

A quick aside from the tale before someone gets upset when I describe what happens next. No person who served in uniform deserves to be put or find themselves in the situation I found this man in. These men and women are serving in a field I am not cut out to do. I admire anyone who chooses to stand and fight for me and my family.

Our veteran friend has a valid VA card, which the staff almost requires for evaluation in the ER. We get him loaded and covered in a blanket to cover the smell and get underway. Gathering his information I ask about his living conditions and situation in an effort to guide him towards other veteran's services in the area.

When I asked what branch he served in he rattled off the division, unit and details I didn't completely understand. When he answered after I asked where he served, my ears perked up and I scratched my head.

"I did 2 tours in 'Nam, man." Was his response. According to his VA card, he was 51 years old.
"When did you get sent over? Were you drafted?" I wondered aloud, more curious than accusatory.
"I don't have to tell you anything kid, but I'm a veteran." he grumbles.
"If you don't mind sharing, how were you hurt?" I thought was non-threatening, he did not. He began to scream that my generation had no idea what service meant and that he and his brothers in the service in the 60's knew more about everything than I ever will. I can't challenge that statement, so I'm back on the bench finishing my report.

I never doubted my new friend had served his country, but I now doubted where he served. By my math he would have been 12/13 at the height of the conflict and just turning 17 when combat was winding down.

At the VA facility the staff was upset our patient had the aroma he did and spent very little time talking to him while we were there. Last I saw him he was falling asleep in the bed in the corner, likely to be kicked out when he awoke, no better off than when he came in.

Tuesday, March 17

...for the reported fire in a building...

We take this kind of thing very seriously. Fire, that is. I remember a visit to New Orleans a few years back and seeing all the old gas lamps still flickering in some of the older parts of town, yet I never called 911.


A cell phone caller states she can see flames in the apartment building across the street.


We are first due and first on scene to a multi-story type 3 (Masonry over heavy timber) high rise apartment building. Nothing showing from 3 sides, no alarm ringing, no one has exited the building on fire, or panicked, heck there's no one outside.

We check the lobby, sure enough, no trouble and no alarm. Wandering around as other units arrive we can't see anything remotely resembling a fire. The truckmen recently onto the roof have no findings on their secondary search upstairs and have walked down the central stairs, finding nothing on the way down.

Our caller comes out from the hotel across the street and points to the 100 year old gas lamps, which still burn on either side of the front entrance. They are great old lamps, heavy iron and original glass, a small flame still flickering. A great reminder of the history of our old city.

"That can't be safe, will you put it out?" She asked wrapping her sweater around herself in the chilly air.
"No ma'am that's supposed to do that." And we cleaned up and left. Driving back to the firehouse I noted at least a dozen other buildings with working gas lamps and wondered why this call has never come in before.

I'm glad it hasn't come in since.

Monday, March 16

That does it, I'm changing this thing

In the end it wasn't the homeless beggar or the drug crazed whacko throwing his poop that cracked my "go with the flow" mentality, it was an elderly woman who frowned when her daughter spoke about her.

Early this morning, while helping a cancer patient back into bed I had to listen to her adult daughter complain about how difficult it is to help her mom all the time.

Our patient felt weak, from all the chemotherapy, and got up to use the restroom. Her legs felt weak and she plopped down to the floor. When she needed help she did what every self respecting person does, she called her family for help.

10 minutes away with her own family the daughter didn't help mom back into bed, but called 911 so we could, "Get her admitted, she can't stay here alone."

The woman with the end stage, painful, slowly vomiting her life away, cancer simply wanted to stay in her home. A more and more common tale these days.

The family saw fit to rent out a few rooms in mom's house to help cover the costs of, well...I'm not sure because there is no caregiver at the house and judging by the daughter's reactions and words, there never will be.

Our hands were tied. We couldn't leave a woman in bed with no way to ambulate in case of fire and no one there to help her. The family refused to step in and without access to other options, a dying woman is now in the most disease infested, uncomfortable place the current system allows. The emergency room. And taking a bed out of rotation for emergencies no less.

Well, not anymore. I'm young in this business but I see a need and I see a solution and I'm going to do something about it.

Studying the Advanced Paramedic Programs I can find I see an awesome opportunity to reach out to the community in a way they demand but we can not provide currently. A fluid response that can be dialed up or dialed down to address specific issues in specific communities.

I spent over 3 hours this morning reading through state EMS documents, training requirements, Licensure and re-certification demands as well as a number of position papers describing similar problems. Usually a task like that spills the wind from my sails on page 2.

I am fired up, energized and ready for a fight. I can hear the Medical Directors already shaking their heads, but with the training I've outlined, the skills needed and the limited persons who will perform them, there is no way it can't at least get to a trial phase.

I feel my time here playing at Happy Medic Headquarters will decrease quite a bit in the coming months as I prepare this proposal. You're not rid of me, but the posts will be fewer, and perhaps as a result, more pertinent to the original purpose of this place.

Wish me luck gentle readers, I'm taking on the entrenched Old Ways and I intend to win!

Your Happy Medic

You Make the Call...Trauma Room...What Happened

You should know by now to read THIS first.

Not yet a Paramedic, my understanding of anatomy and physiology was still at a basic level, but I knew that a sudden change in sensation after movement was never good.
I spoke up repeatedly that the numbness developed only after the spine board had been removed, finally assuring that the nurse taking the notes in the corner had written it down.

Rest assured that my incomplete written report now had an additional paragraph under "Condition on arrival."

The gentleman later had a full recovery.

Don't let folks who are above you in training or licensure ignore you if you have a pertinent issue. Make sure your concern is heard and understood before you leave.

If you said do whatever it takes to get the MD to listen, you made the right call.

Sunday, March 15

Sunday Fun - To the Shops

Turns out the Chief wasn't too happy about us going out of service for fine art last week.
But we need to head into the shops and get the Engine looked at. I thought we'd have a look through the reserve fleet and see if we can get a nice rig in the interim.

They recently replaced the stout valves on this engine Firegeezer linked to awhile back.

It's got the beer keg taps and the pizza oven ready to go. I think Engine 3 had this last, so it might need a cleaning.

I don't think we'll be able to indulge in the finer aspects of the upgrades, but at least we know dinner won't get cold.

With the weather still a bit cold and winter not quite gone, we could ask for Engine Sub-Zero.

The treads might cause some trouble on the recently waxed bay floors, so we can park it out back. Now that I think about it, Alan Robock might need to get this rig back down to Antarctica. That reminds me, your detail is to Antarctica tomorrow, sorry.

Our response times have been lacking lately, so let's consider Engine 6. You remember, the one with the jet engine?

We'll need to carry the hose in the cab, but imagine how quick we can go get a cup of coffee!

This isn't the first jet powered Engine in the yard, but it is the prettiest.

Rumors of budget cuts have been circling and the cost of large flashy rigs is being taken into account.

I think that's why this Dr Seuss Rig is still down at the yard.

When the flashy rigs do come back into style, I have my eye on Engine '42.

We can finally listen to the Jan and Dean Tape I made us last year.

But I have a feeling we'll get stuck with the oldest rig in the yard. And we all know the clean up is the worst!
This fantastic image is from James Gurney, illustrator and author of the popular books Dinotopia. According to Mr Gurney's personal blog the Gurney Journey, this image is the result of a discussion with a friend as to what a fire engine would look like in a society that closely included dinosaurs, as the Dinotopia books do.
Follow the link to his personal blog and read the posts in order, there are 5 in the series. It was interesting how his original concept was changed when he consulted a friend in the fire service who considered the physics of firefighting and applied them to a dinosaur.

The idea that the animal pumps the water with a bellows type foot pump is just great. Wander around Mr Gurney's blog a bit and see some fantastic fantasy art, then get back here in time to feed our relief engine. Looks like we'll need about 400lbs of conifer and ferns for our brachiosaur.

Saturday, March 14

If it's broke...how do we fix it?

Follower Dantarius recently commented on a post I put up about how I was frustrated about the limits of care offered by private companies. Then those companies turn to the "Socialized" Fire Department for help.

I too often forget that I live in a microcosm where I am and likely have a different view about what is broken and what is working.

Anyone who has even glanced at this site knows I don't have all the answers, but I know what would work better where I am. Terms like Socialized, profit, care etc are used differently in different parts of the world, so my using them here could be interpreted differently by others.

So that got me wondering, what would work better where you are?

I'm asking readers to give a quick thought to what doesn't work where you are and give a solution.

Kind of like this:
We have a great deal of folks who use the Ambulance as a free taxi ride. I think a good solution would be to have a kind of little school bus that wanders the city giving them the rides they want. Not point to point, but on a set route. No commuters or kids going to school. That would reduce the strain on ambulances and ERs.

If you know of a system that solved a problem someone lists or know of a solution already working, drop that person a link.

Let's learn from each other what is broken and how to fix it. Together we, the care providers, might be able to fix this thing from the bottom up.

Friday, March 13

Pegging the Board

as recalled by my probationary officer just prior to his retirement.

My Department, 1968

Day Watch in the fire department had a single responsibility and that was to monitor the bells. The bells were sent out from the central dispatch station to all stations via telegraph. Each series of bells had a meaning and it was necessary to pay careful attention or the company would miss a call.

Ding….ding..ding rang over the bells and the teletype rattled out a short message: 135. Alarm Box 135, a reported fire. The tickertape nearby had a corresponding alarm code along with other dots in sequence. These were translated into a complex code system.
The day watchman reached for the large cabinet under the telegraph which stores the cards which will let him identify which companies are due to that fire. He fumbles at first, not sure if he’ll find the right card but does. Card in hand, he quickly places a clothespin on the ticker tape at number 135, the purpose of which will become obvious in a moment.

Over on a large board on what would pass for an architect’s desk is a series of labeled holes. The holes are arranged horizontally in columns three wide, then two wide, then one and then three more. There are 10 rows from top to bottom, a good 90 or so in all. There are also pegs with tops the size of quarters on another section of the board, each with a letter and a number. Some say engine, some say truck, and there are about a dozen random others, including chiefs of course.

The card labeled 135 lists all units due to that particular area as well as subsequent alarms due. In other words, if you needed a 14th alarm, this card tells you who is due.

Scanning the card, he reads that engines 1, 2 and 3 are due to this fire and moves their pegs into position on the first row on the board. All the while bells are ringing, the ticker tape keeps coming, and the clothespin is now hanging from the desk, dangling. Referring back, trucks 1 and 3 as well as battalions 1 and 2 are due and he places their pegs as well. With a piece of chalk he writes on the far left of the column the number 135 and returns the card to the drawer.

Finished “pegging the board” he returns to the ticker tape which is now on the floor. The clothespin is still in place at the last alarm pegged. Scanning up the tape he is able to read a code that only a few firemen still recall.
The tape reads, among other things 1-1-5-5, which means Engine 1 is out of service, 2-1-2-2 records that truck 2 is back in quarters. All these transmissions must be updated on the board in order to know when your company is due to a fire.

Today alarms from central dispatch alert the station when there is an alarm. In this system it is the day watchman who must track the movements of the rest of the department and ring the bell in his own house to announce when his units are to respond. There is no automatic alarm, no lights coming on automatically, just the bells.
It can be very confusing for a person new to such a system to be able to understand not only what each code means, but to begin to anticipate that because one unit is out of service, the next unit on the card is due. Then in the next fire, because the other was out and the other went another is due. You can see how easy it is to get lost.

After 7 hours on the watch the rookie is relieved and another member takes over pegging the board. As he walks away he notices something that would become the most amazing thing he has ever seen until one hour from now.
The man who relieved him at the ticker was not looking at the ticker tape as the bells rang or opening the card drawer to see which units were due. He was doing it all from memory. The bells began to come quickly, almost overlapping each other and the new watchman simply kept moving pegs from the “in service” area to the rows of box alarms and back. All while still reading the newspaper.
“How do you do that?” He wondered out loud.
“Take a hike, kid.” Was the only explanation offered.

An hour later, upstairs laying down for bed there was an odd excitement in the air. This was his third night in the firehouse and he always waited for the main bell to ring. You see, even upstairs in the dorm you could hear the bells from the ticker constantly ringing, but without seeing the board to know what companies were in service or seeing the card to know who’s due, there was an anticipation for each series of bells. The nightwatch was easier because it was often slower. The trick was staying awake, often with the help of strong coffee and cigarettes.

While laying wide awake, there was a rustle from the senior firefighter sleeping nearby who suddenly sat bolt upright and began to dress.
“Let’s go kid, that one is ours.”
“I didn’t hear the bells.” He apologized prematurely as the main bell began to ring.
“Box 113, engine, truck” was shouted and the whole dorm came alive. For a second everything froze and the rookie was able to scan the dorm and notice something interesting.

All the experienced fireman were already standing up when the bell rang.

They had heard the bells from below and tracked the status in their heads, and while asleep at that.

Down the pole he went and off to the fire they were.

This is the first of a number of memories passed along to me that I will be sharing as the times allow, I've tagged them as "Tales."
The image shown is labeled as the New Orleans Fire Department in 1957.

...for the cardiac eval...

If the private market place can handle patient care, why am I constantly being sent at tax payer expense to do the job of their care givers?


A woman has called reporting an elderly woman has chest pain.


As the fire engine winds through the residential streets, narrow and difficult at normal speed, we're now blaring the siren and blowing the horn hoping to shave seconds off of the critical cardiac care clock.
We arrive at the house and are out focusing on quick evaluation and confident treatment. We're met at the door by a care taker from a private health care company who removes her reading glasses and looks around us at the fire engine, lights still flashing.
"Do you have an emergency?"
"I need help getting my patient back into bed."

Are you kidding me? All this to help someone into bed?
Upstairs our patient is an apologetic elderly woman telling us how sorry she is she can't get up on her own. A quick check confirms she has no injury or complaint other than being on the floor.

The caretaker hasn't said a word.

After getting her back into bed I ask the caretaker for a business card so I can contact her agency and advise them of the conditions at the house. If she is unable to care for her client, shouldn't someone from her agency come by to help her lift the woman back into bed?

No, she tells us, she was told by the office to call 911.

I looked back through the dispatch information and the caretaker told quite a yarn to get the call classified as an urgent dispatch. Each question was classified as most urgent. Our actual 26A1 was called in as a 6D1.

Once again we're picking up the slack the "free market" supposedly has a handle on.

You Make the Call...Trauma room

As an EMT-Intermediate with an EMT partner, I am responding to a possible entrapment out on the desert. A utility company has been digging up and replacing large diameter concrete tubing a good 10 minutes off the main road up a dirt sideway.

We arrive to a work truck, pickup style, and a good half mile of pipes, each 40" in diameter and up on 12-16" of cribbing, except the one nearest the truck. The pipe is on the cribbing at one end, but the other end of the 20 foot long section is resting against the back side of the truck and on the ground.

Our patient is conscious, alert and is complaining of vague "hip" pain. Turns out he saw the cribbing fail and barely escaped being pinned against the truck. He states the large pipe struck his hip and pushed him against the truck, then he was able to spin away towards the rear and escape entrapment.

We take full C-spine precautions and do everything within our protocols en route to the trauma center.
As we arrived, I gave my report and they began to remove the long spine board almost as soon as we moved him over. I had just finished stating he had good motor and sensory response distal to the injury when the patient began to grimace and groan as the board was removed. The common chaos in the trauma room was drowning him out so I moved towards his head to calm him when he told me his right leg, the one connected to the hip that got hit, was now "numb and tingly."

I told the physician closest to me of this and I was told it was "common" for this type of injury. I thought the timing of the new symptoms with the removal of the board could not be coincidence.

I need to do something...You Make the Call.

Thursday, March 12

Ambulance driver asks, "What do you do?"

Ambulance Driver (AD) over at A Day in the Life of an Ambulance Driver has posted a great situation I think we should all think about.

It asks what would you do if a large security guard, who is armed, has a seizure. The employer wants him disarmed. What do you do?

Click over HERE to read the exact situation and the responses so far. Quite a range of answers, but what do you do?

Treating Trauma with Mr. Bill

Trying to think of a "learning moment" recently, I remembered a single call I went on that taught me almost as much as I have learned since then. Some Medics are book smart, some are street smart and a rare few straddle both easily.

Early on I got a job with a local Federal Department that mainly ran an ambulance and water tender to cover a population of about 3000. It was there that I learned the basis of what it means to be a good care provider.

My mentor there, I'll call him Bill, was a relaxed Paramedic who always talked about everything but the job. You know the type. Sports, family, anything, but when the bells rang he was all business and I soaked it up like a sponge.

Bill was the one who taught me that driving an ambulance isn't a race, but instead a challenge to see how little you can make the box move from side to side. He instructed me to drive with my back slightly forward from the seat back to better feel the motions of the box I was dragging along. One night when we had 2 trauma patients in the back alone with Bill, one near death and the other considering it, I slammed down the accelerator hoping to cut down the 35 minute drive to the trauma center. Bill calmly came to the pass through and said, "Can you just do my a favor and take it easy up there, you're driving, not playing paramedic pinball." As smooth as if he was asking a waitress for extra napkins.
I now tell my patients not to panic until I panic, just like he did.

I listened in to his radio reports, always trying to learn something new. On this call, even after starting IVs on both patients and asking me to call and see if we could get an intercept to take the more critical patient the rest of the way (there was none available) his radio report sounded like a magazine review of a new restaurant. I recall parts of it all these years later:
"Medic 99 to base, we will be arriving at your front door, ETA 15 minutes, with 2 trauma patients. Standby for patient one. Patient one 25 year old female, restrained driver small sedan rear ended at high speed, positive loss of consciousness, GCS 8, head, neck and left shoulder trauma, full C-spine precautions, (vital signs I can't recall), and high flow O2, without questions standby for patient 2. Patient 2, approximately 40 year old male, unrestrained driver of truck which struck stopped vehicle at speed, unconscious, unresponsive, Multi-systems trauma - he meets all criteria, BP 90, full c-spine precautions and high flow O2. Unless you have questions base, we'll see you in about 10-15, 99 clear."
Even typing this again I can picture the part of highway we were on and I was wondering why he wasn't in panic mode. I was in panic mode and I was only driving.
I still keep my reports to the MVIT format and try to make the person on the other side of the radio understand what is going on before I arrive.

Then we hit the ER.
Because he called so early, they were able to clear out both of the trauma rooms and have all necessary personnel waiting in the parking area. As I parked the Doctors opened the doors and asked a question I later realized Bill had prepared for.
"We'll take the unresponsive first. Which one?"
"He's on the cot, take him right away."
Bill knew the man was more serious and would be taken out first.

Later we moved the woman onto a hospital stretcher and into the second trauma room. He answered questions from both rooms without referencing his charts, which were both partially completed and without a drop of blood on them I might add. I cleaned that rig, it was a disaster area, but he and everything he touched was clean. I, again, later discover how he did that.

He wore two pairs of gloves the whole time. One pair always remained on and he worked on his patients with a second set pulled over them. When it was time to use the radio or make notes, he removed the outer gloves and completed his task with clean gloves, but still protected his hands. I had never thought of that and people who see me using the same technique today say the same thing.

Then, on the drive back to the single wide mobile home that served as our station he literally picked up our conversation where it had left off when the bells rang.

"How do you do it so easily?" I remember asking him.
"Do what?" He replied with a smile. I worked a great many shifts with Bill and learned a great many tricks of the trade, but none had such an impact as that single call did.

I will never forget the look in my interns' eyes when they see me do something Bill taught me and say, "Where did you learn that?" and I feel Bill's smile on my face.

Wednesday, March 11

On the lighter side from The Angry Captain

Decades ago, as an engineer on a busy truck company, we got to handle all the "service" calls for our station. These included resetting alarms, smoke checks, cats in trees, all the stuff that didn't rate an engine company being tied up. Of course the engine pukes (an industry term) always cheered us on when we got one of these important calls.

We also got sent on calls that did not fit in any other category. On this particular afternoon, we were toned out for a rescue call not requiring medics. The caller had access to a phone but nothing else and had her big toe stuck in the bath tub spigot. Immediately, we had all sorts of assistance being offered by the other 2 engines in the house as well as the medic unit. We graciously declined their help, as this was undoubtedly a call requiring the specialized training of our extrication team.

On arrival, the front door was unlocked. (A good thing since both firefighters were ready to make the fastest forcible entry in history.) Being the knowledgeable Engineer, I immediately applied 'try before you pry' and opened the door. While they were still in shock, I moved through the house calling out for the party trapped and followed the voice to the bathroom. On entering I grabbed a towel off the rack and tossed it to the very embarrassed lady of the house. Once covered, we were able to squeeze enough soapy water into the spigot to release her toe. Those firemen still hate me to this day!

The Angry Captain

Glossary of Terms

I'll try to keep this current, but probably won't. Updated 3/2009

Jedi Vitals - When you know the patient is fine, but still need to record something, you pass your hand in front of them just like Obi Wan Kenobi and poof! the vitals come into your mind.

Mr Fishbiscuit - Husband of the ill fated Mrs Fishbiscuit, a rarity, but can be seen in the wild.

Saint Closest - The nearest hospital.

Saint Farthest - The farthest possible hospital we can legally transport to. This haul always ruins dinner.

F&B - Private ambulance company.

Erma Fish Biscuit - The elderly woman who needed a Doctor a year ago, but never went, and who's symptoms don't seem to match anything treatable, yet not in the green zone for signing a refusal. She's often slightly altered, but good humored and has a list of meds longer than my...clipboard.

Fella - A person of the non-heterosexual community.

Bob, Bubba, Billy - The type of gentleman who wears a 3XL T-shirt and wonders why he is in such bad health. Also seen living in Erma's basement well into his 40s.

Engine 99, Medic 99, anything 99 - If I tell you what unit I work on, then you'll look me up on the busiest Ambulance list from Firehouse magazine and all is lost. Seems one rig keeps making the top 25 and it has a unique number. I've said too much already.

Steph - My BS Medic name. A name used by responders to communicate to one another that the incident they are working is, in fact, a no merit call. The names are used to avoid actually saying, "This is BS" in front of the patient. Other BS names I work with include: Johnny Ampersand, Fred Garvin, Ricardo Montecarlo, Woo Kie (Asian fellow who makes a dead on Chewbacca noise)

the Brass - Command Staff. The folks in charge. Many have been off the streets a little too long.

Tuesday, March 10

...for the choking infant/FMS response...

In all honesty when I hear this call go out I very rarely get worried. Reason being I've seen not even a handful of choking babies and it never comes in as a choking baby, always a recuscitation or unresponsive. I still take it seriously, but I also take a deep breath.


Mom called saying the infant is choking


It's always comforting to climb off the ambulance to the choking and hear the baby crying.

We make your way past the new expensive stroller, past all the unused baby toys in the living room into the well apportioned baby's room where the cries are coming from and are met by our patient and our patient's...DAUGHTER.

According to mom the baby was feeding, leaned her head back and she stopped breathing for "at least 5 minutes." Applying the FMS scale of time (more on FMS in a moment) that converts to about 10-15 seconds. Sounds like she either fell asleep or as is normally the case, got too big of a gulp and went bradycardic for a short time, mimicing apnea. We do a full check on baby and everything looks great. Good color, scared of fireman, clean breath sounds, scared of firemen, O2 sat of 100 on room air, scared of firemen. Everything is checking out when we offer our transport she of course accepts.
Nothing wrong with that. I can't confirm the baby didn't aspirate food, so why not go see the general practitioner in the ER who doesn't handle Peds cases except in the ER. Sure, let's go.

The mother, my real patient, is shaking and nervous, acting much like her husband likely did the day baby was born.
I call this condition First Mother Syndrome or FMS.
This affliction is noted by a strong desire to disinfect anything and everything baby has or will touch. FMS sufferers see every sneeze as the flu, every spit up as cholic (which has nothing to do with vomit, but oh well) and every cry as an earache.
They are dedicated parents who are much better to their children than most parents I meet on the job. The Fellas (see glossary of terms) are even starting to become afflicted with FMS, which is hard to explain to folks who don't live near Fellas.

The entire transport was simple and baby eventaully calmed to rest on mom's shoulder, but mom never clamed, or stopped asking questions about why we weren't using the sirens, whether her Pediatrician will be able to make it in, will there be shots involved, just about every question you could imagine I had an answer for, but not the one she wanted.

So look out for the FMS sufferers, but make sure you have the right person, because mom's with sick kids are immune from FMS, they are in a panic for a good reason.

Mutual Aid updates

Two mutual aid companies are up and posting again.

Siren Voices, another of our UK EMT friends, has a style like a novel and great tales from the streets. Every time I see an update I get a fresh cup of coffee and sit in a quiet room to set the mood.

In stark contrast is the matter of fact style of firefighter/paramedic over at i love my job. His (I assume it is he since the only image on the site says 'Daddy drinks because you cry') posts are scattered but he saves them for the strange calls he gets, which seem to focus on drunks doing stupid things. And the address of the site, seofaswtown, puts him somewhere between Dallas and San Diego.

And don't forget to send me your link for the March Blog Carnival "A learning moment" about when you learned something you'd like to pass along. Especially you ER and A&E readers. Drop a link or a story to thehappymedic@gmail.com.

Until the bells ring again,
the Happy Medic

Monday, March 9

...for the PD eval...

I love my cop buddies, always looking to punt a disagreeable patient to me. Not because they want to, but because that's just the way the system works. They catch the bad guy and I deal with the bad guy's BS complaint. For once it wasn't the bad guy. And behold, this call was another 2-fer!


PD is requesting a Code 3 Medic.


Every time I've asked for PD code three I get a response from radio of, "Why do you need them code 3?" I'm sure they're not second guessing me, they just want to give the responding officers a headsup as to the situation. Makes perfect sense, now let's apply the standard both ways.

We're responding to the big box corner drug store that rhymes with Ballgreen's and we see the car out front with the yellow lights flashing slowly.
As we pull into the parking lot we hear another dispatch to this location for the unconscious. they're sending an engine and another ambulance.
"Control this is Medic Van 99, cancel those other units, we'll advise." Is my response and I hear both units cheerily go back in service.

The boys, and girl, in blue advise their person in custody bit a clerk while trying to rob the store. Apparently in this bad economy, thieves are reduced to holding up stores using only their pearly (not in his case) whites (also, not so much in this case.) The clerk is embarrassed more than anything and says he was just leaving for the local clinic to get it cleaned out.
Here's a guy that knows how the system is supposed to work.
"Don't even touch me, I'm not your patient, I didn't call you." He knows the law as well. Sounds like this guy got stuck with a bill when someone else called for him and now he knows how to avoid one in the future. Kudos. I took off my glove and shook his hand.

Oh, that's right, you're wondering where the unconscious person is? She is sitting in the parking lot, in the driver's seat, conscious. Her friends have called demanding she been taken in at once and "given something for the pain."
"Slow down there, she has to take me to dinner first..."


Tough parking lot. My opening line is met with tears from a woman clearly in discomfort. She describes her ovarian fibroids and it sounds like kidney stones times 3. I'm thinking of different options to help her, O2, position of comfort, etc when the answer to my next question confirmed she would get nothing.

"Have you seen a doctor for this recently?"
"Yes, I just came from there to get my prescription filled." She's holding up a full bottle of hydrocodone.
"Do you want to go see another doctor?" With only a hint of 'What the hell do you expect now?' in my voice.
"I need to do something, the pain is too much." She's crying and clearly in pain, hence the prescription.
"Hang on a minute," I rise up from the car and look at the crowd of people who have gathered. "Who called us?"
"I did," A woman comes forward, blue flash from her ear.
"Do you know her? Can you give her a ride home?" Seemed like a fair question to me.
"That's your job honey. Just give her a pain shot or some antibiotics or somethin', then she'll feel better." Was her unreasonable answer.
"Is there anyone who can come get you and take you home so you can take the medicine the doctor's think will make you better?"
"I just want to go home!" She cries.

From the other side of the parking lot appears the husband, who she called prior to the passerby calling 911.
"Thank you so much for checking on her, I just got the message she was out of the doctor's" He's tearing up as well.
"Can you take her home?"
"I will right now, thank you." And he parked his own car and helped her into the passenger side of the car and began to drive off.

The woman who called us just gave a sneer and walked down the street, completely unaware of the chaos she had caused.

You Make the Call...Structure Fire...What Happened

The initial report is HERE, along with comments.

Needless to say, I was simply stuck. I had exhausted all my options at that time and felt since I notified the IC on a recorded line my butt was covered should anything go down, but I don't want anyone hurt, no matter how foolish they are.

As soon as my team exited the building I was on my way to find the Chief Officer. He was around the back of the building, still in tennis shoes and blue jeans and the coat still unbuttoned.

I made a comment along the lines of the building still being a hazard and recommended to him that he at least put on turn out pants, boots and button his coat.

He ignored me and told me to return to my pump panel, so I did.

At the post fire analysis we gathered in the driveway and each person discussed what went well and what did not. When it got to me I went into what was later described to me as a very sarcastic monologue.

I told the group about the importance of PPE. I went and showed everyone how the entry crew's coats were buttoned and touched the fabric of their pants describing how they protect us from heat and flame. I reminded everyone that safety is #1 on the fire ground and that no one is immune. I then looked directly at the Chief Officer and said, "The fire doesn't know what rank we are, we all need to be careful."

He looked at me and, I could not make this up, pointed at his helmet and said, "See this? This means I'm right and you're wrong."

It was this incident that had me applying at the local private ambulance company the very next day. I ended up staying a bit longer, but we learned to do our jobs around this particular supervisor.

If you said get that man in full PPE or off the fire ground, you made the right call.

Sunday, March 8

The way EMS...works?

A few days back our friend Mark over at Medicblog999 responded to a request to explain how the NHS system categorizes and responds to calls for service.

Although many of you reading this may shudder at the idea of "socialized" or state run healthcare, if you draw a paycheck from a public agency for supplying healthcare, you already perform a socialized state run service.

Let's put all the political labels and bias aside for a few moments and really look at the options and services available to the persons served by the NorthEast Ambulance Service.

Start by reading Mark's entire post HERE, then return and let's have an honest discussion about this system and some of it's components.

Welcome back, let's begin. I'll post snippets from Mark's post in NeeNaw blue and my comments in black.

999-In September of 2007, NHS pathways, a new triage and assessment tool for emergency and urgent calls to the ambulance service went live for it’s pilot trials. This replaced the US system that was in use previously called CBD (Criteria Based Dispatch).The call is taken by one of our services EMSOs (Emergency Medical Services Operator). These are staff that have undergone an intensive 6 week course to familiarize themselves with the systems, triage, basic medical terminology and understanding of basic emergency medical conditions. The course now also focuses on using the pathways system to assist in getting the right patient to the right services at the right time, and also various prompts for the EMSOs to give out some prudent medical advice as scripted from the system, such as advising the patient to take 300mg of aspirin if a cardiac chest pain is suspected.

911-This looks like a good place to start indeed. The CBD places calls into categories by severity based on criteria given by the caller, then recorded by the call taker. In my system, which I believe is very similar to most US systems, the call taker and dispatcher have limited, if any, medical training and are experts at asking and recording questions and answers. The new 999 system has calls adressed by persons who can "see through the crap" and actually triage a call based on their training and not what a group of lawyers decide. Already the 999 system is ahead of us and all they've done is answer the phone.

999-Once the allocator recieves that information, they have 45 seconds to dispatch a vehicle to the detail. The computer system automatically shows a list of the nearest vehicles in order of distance from the job but it still remains the responsibility of the allocator to choose a vehicle depending on various service demands such as meal breaks, start/finish times etc.

911-This allocator position seems similar to what is carrie dout in our service by a "fleet seat" who monitors the status of medic units, fire engines, trucks with AEDs and police cars with AEDs. One drawback is that not all the vehicles have GPS locators so there is usually confusion when closer units are not activated simply because they can not be seen on the screen. I do see a conflict in the allocator judging a resource based on meal breaks but that reason becomes clear later in the system explanation.

The goal of pathways is that at the end of the triage and assessment process, the end disposition will be displayed to the EMSO.

Some of these are :
  1. Ambulance response within 8 mins
  2. Ambulance response within 19 mins
  3. Ambulance response within 1 hour
  4. Refer to GP services (or out of hours service)
  5. Refer to clinical nurse adviser (more about them in a minute)
  6. Patient to make own way to hospital
  7. No vehicle required
911-Here is where the 999 system breaks away from just being a glorified taxi service and actually starts to give medical care. Let's address the obvious glaring red flag many of you will scream about. Number 3: Ambulance response within 1 hour. Before everyone goes crazy about waiting for an ambulance for an hour and repeating the horror stories we've all read about old ladies left on the floor for an hour waiting for an ambulance, think about it. The last time you went on the BS "my foot hurts, I want to goto the hospital" you took that person in, by law. In the 999 system, it seems the call taker can give that caller a choice to seek alternate appropriate care or wait their turn.
This is no different than the way the hospital triages patients in the ER. Their baseline is established and regardless of complaint or protest they often wait hours for a physician to see them. Did they need that 911 red lights and siren paramedic for a non emergency call the ER won't see them right away for? Of course not.
Numbers 1 and 2 seem very similar to our current system, except that there is a blanket response priority for "emergency" calls. Our call center upgrades calls to get them out of the system faster, padding numbers and making more calls appear to be "emergent." I would like to see an evaluation system where someone compares the recorded call, the call taker's notes, the dispatch code, the paramedic's judgment at the scene and the final disposition at end of total care.

Numbers 4 and 5 will never exist in a for profit, pass the buck, health care system. Imagine a 911 call taker calling a physician and asking them to talk to a patient on the phone, or even VISIT THEM AT HOME? Every physician I've ever met would say, "sorry they're not in my group" laugh and hang up. Not to say there aren't patient driven physicians out there, far from it, but most are overloaded with patients as it is.
But the idea that a call taker can be trained, and legally allowed to tell a caller they do not need an ambulance and that they should speak to a doctor is mind blowingly simple and makes perfect sense.

Why wouldn't we want to get the proper resources to the proper people?

With dozens of for profit companies fighting for market share, none of them will allow a civil service employee with a telephone tell their patients what to do.
Obviously there are items on this list that simply will not work with the current system in place. It would take at least a decade for people to realize the ambulance is an assessment and treatment tool that happens to be mobile, instead of a free taxi.

999-The whole purpose of pathways was to reduce the number of Cat A calls (which have to be responded to in less than 8 minutes from connection of the call to the contact centre), Reduce the number of Cat B calls (response times of less than 19 minutes),increase the number of Cat C calls (response in less than 1 hour), and overall decrease the amount of ambulance journeys required

911-And that makes perfect sense to me. Getting the resources to those who need them and withholding them from those who don't. What could be simpler? As with any system, there are exceptions. For every story of a UK medic unit arriving late to a fall victim, we can find another from the US. Each NHS rig that gets lost has a US counterpart as well, often myself. I work in a big place and even after all the time I've been there I still get turned around and lost sometimes. It happens.

Often in our system an ambulance will be sent code 3 to a "sick eval" which the CBD considers a low priority. In fact, in my understanding, the CBD doesn't even recommend a dispatch for such a low criteria call. Sometimes the call takers will misinterpret a caller's history as part of their chief complaint and upgrade the call so the computer will create a priority dispatch and they can send the call out the door, keeping their numbers strong. Then I arrive lights and sirens to the patient who has an infected laceration, has for weeks, but mentioned they also have asthma.

That's why the "sick eval" turned into the "shortness of breath/asthma."

I think the 911 system needs a major overhaul to get medically trained people answering the telephone and triaging calls. Just like an MCI we need to help the ones who need it and tell the ones who don't they'll have to wait their turn.
It will cost more in a time when budgets are razor thin as it is, but if we can take some of the profit from health insurance companies who instruct their customers to call the government run ambulance service at the first sign of a fever, we could afford to do it no problem. I'm not for "redistribution", the cause dejour, but they're making a profit while providers outside their circle pick up their slack, at tax payer's expense. Maybe they should start up their own ambulance services if they have all that extra money. Government bureauocracy is better than private profit beurocracy in my opinion, but rereading this, that's obvious.

Thank you Mark for the detailed explanation of the new system in place at NorthEast Ambulance Service and keep the blog going!

Hiding from the bells,
the Happy Medic

We're really not all that different when the bells won't ring...

Sorry, I had to.