Tuesday, February 28

Standby to copy code 3 traffic

I recently had the opportunity to attend a great seminar at the local trauma center.  Monthly, the trauma docs get all the trauma residents together to talk through a case from the previous month.  It sounds pretty dry until you realize how they present the case.

It starts with the Doctor playing the initial radio report recording.  Then he looks to his residents and asks "So, what positions are you assigning, who do you page, what are your chief concerns?"

I always knew the thousands of people in the trauma room when we arrive are important, but I never thought through that there was one person in charge of that room that asked them all to be there based on my report.  It makes perfect sense in retrospect.

In this particular case our medic made a near textbook MVIT truama radio report and had an ETA of 8-10 minutes.  A lot can happen in 8-10 minutes.

The Doctors discussed different concerns for maybe 5 minutes, then they went to the video.

In the corner of all the trauma rooms are cameras.  I always thought they were security cameras, but how great to be able to critique in real time referring to video!  The room is packed with gowns and masks, all awaiting the patient and the Doc stopped the video again.  "Who is missing?" He asked and the residents began to identify all the persons and departments in the room.  No one was missing.  Trick question, but I was impressed that everyone knew everyone else by sight.  a good sign of a team that works well together.

The video started back up and here comes the moment of truth for me, the CQI guy sitting on the side of the room:  The medics have arrived.

His tone was clear and even and he began his report with "Hello everyone this is Erma..."  My favorite way to start a report.  Put the team at ease and calmly describe your findings.  He went on to multi-task, describing the patient's mechanism, vitals, his interventions and treatments, as well as his reassessment after the interventions.  As the patient was transferred and the swarm of gowns came in, the video stopped again and I was beaming with pride.  I know because the person next to me asked "How come all the reports aren't like that?"

The Doc went on the quiz the residents about what their first assessments should be and he finished that discussion with "What else do you want to know before EMS leaves the room?"  his laser pointer now shows my guy standing in the doorway out of the way and removing his gloves.  They had nothing more to ask, he had covered it all. 22 seconds.  22 seconds was the length of his in person trauma report.  As the video picked back up he states over the heads of the crowd "you have access left AC 16g TKO on transfer and we put her back on the NRB at 15, I'll be outside."

I wanted to do the slow clap until I realized that this should be happening each and every time and, judging by the reaction of the room, it doesn't.

 

The seminar continued to show the entire time this patient was in the trauma room, including the chest X-ray (then we all looked at it on the big screen), the abdominal and chest ultrasounds (interpreted by the residents) and even to the results of the CT.

 

Near the end of the discussion the presenter asked why no one was so quick to intervene on what they were finding.  Their answer?

 

"EMS is calm, we can take our time and see things through.  When the patients are bad these guys start to sweat.  This guy is calm."

 

Awesome.

Sunday, February 26

Patient kidnapping - The cowtipping of EMS

Kidnapping!

I've been sitting on this post for months and recent discussions on the facebook and around the interwebs are leading me to revisit it.

 

In an old You Make the Call we discussed when to take people to a  certain medical facility versus another and, sure enough, the topic of kidnapping came up.

It was reinforced in a (not so) recent story out of Florida about a man who claims to have been transported against his will.

 

Much in the same way Country kids sell the legend of cow tipping to City kids, I believe kidnapping of patients is an urban legend perpetuated by EMS managers and Chiefs alike to keep us from making waves and doing the right thing.  They need transport dollars to survive and taking people to their hospital of choice is an easier bill than not.

Are you confused with the definition, both of the word and the action?

 
kidnapping n. the taking of a person against his/her will (or from the control of a parent or guardian) from one place to another under circumstances in which the person so taken does not have freedom of movement, will, or decision through violence, force, threat or intimidation. Although it is not necessary that the purpose be criminal (since all kidnapping is a criminal felony) the capture usually involves some related criminal act such as holding the person for ransom, sexual and/or sadistic abuse, or rape. It includes taking due to irresistible impulse and a parent taking and hiding a child in violation of court order. An included crime is false imprisonment. Any harm to the victim coupled with kidnapping can raise the degree of felony for the injury and can result in a capital (death penalty) offense in some states, even though the victim survives. Originally it meant the stealing of children, since "kid" is child in Scandinavian languages, but now applies to adults as well.

Gerald N. Hill and Kathleen T. Hill.

Hmmm...

Taking someone to a hospital where they will receive medical care is not kidnapping as far as I can tell.  I've been looking at many different definitions of kidnapping over the week and keep coming back to the same definitions at heart.

If you do it for the right reasons, how can it be the wrong thing to do?

If you are doing it to get back to dinner, get off duty on time, or because your manager tells you to, THEN we have an issue since your position of authority could be interpreted as intimidation, but taking someone having an MI to a proper facility instead of local band aid ER is not kidnapping as far as I can find.

This discussion started when we discussed a patient who did not want to be taken to the appropriate medical facility for his presentation.  The discussion that followed revolved around him being "alert and oriented" "not intoxicated" and "I'm not going to kidnap him."

In that situation YOU AREN'T!

You may do some research and find a term called "simple kidnapping" which appears to cover a slew of false imprisonments, holding without permission, and similar crimes, but in no definition do I find an example of a kidnapping being taking someone to the hospital.

Keep in mind your jurisdiction may have their own definition and you need to be familiar with it, but let me extend this one hypothetical step further.  If a person claims they need a transport and take me against my will, since I don't think they need to go, is THAT kidnapping?  I'm being forced to go somewhere by fraud and could suffer harm as a result.

That more closely fits the definition of kidnap than taking a person to an appropriate medical facility, conscious & alert or not.

 

We are told not to disobey the patient and do what they say, take them where they want, and 95% of the time that works out just fine.  Your stomach hurts?  Sure we can goto St Farthest.  Your leg itches again? Kaiser patient, not a problem.  Trauma patient wants to goto St Farthest?  Aren't we supposed to be patient advocates and do everything we can for them?

Isn't EMS supposed to be patient centric?  So why aren't we teaching EMTs and Paramedics what the definition of kidnap really is?  Probably the same reason we avoid teaching them what liability really means.

There are a lot of problems that will come bubbling to the surface if we started acting in our patients' best interests and none of them are ours OR theirs.

A common practice in my jurisdiction is the art of hospital shopping.  A person will identify as a member of a hospital they rarely attend because they believe the doctors there to be superior, or that the nurses are prettier, or the other place "kicked me out" but in actuality they are simply trying to get someplace new, or clean, or where lunch is served at 1 and it's 12:45.

In the pilot episode of Beyond the Lights & Sirens, I had a conversation with a regular named Val.  She presented with chest pain, 10/10, radiating, with history, a mere 10 blocks from an appropriate facility.  Her requested facility, 2 hospitals and 25 minutes away was on saturation divert, or no longer accepting patients by ambulance.  I transported her, per chest pain protocol, to a hospital that was not her requested facility.  No kidnapping charges were filed.

Many of you would argue I kidnapped her.  I moved her from one place to another without her consent using intimidation (My position of authority).  But looking at the situation unfold, I did not kidnap her, but get her to the appropriate facility for her chief complaint, as defined by my Medical Director, County EMSA, State EMSA, Chiefs and Captains.

Don't default to the stories the Anchors tell you about kidnapping charges being brought against a long lost co-worker for taking Erma to the wrong hospital.  That case likely had a different, more shady reason for leading to termination, not kidnapping.

Perhaps we should spend less time worrying about vague definitions that don't apply and spend more time in the airway lab?

 
And I hate that I have to remind you of all this, but these words are my opinion and are not those of my employer, a lawyer, an expert, my daughter, the crossing guard or the guy at Sears who stocks the vacuum bags.  Before you act on these words, consult with your local system administrators for the rules and laws applicable in your area.

 

Saturday, February 25

The Pup - Part I

Taking a line from our buddy MC, I've decided to try a little fiction.  Instead of changing so many details to protect privacy, let's try making it up!  Comments encouraged.

Pup - Noun. A young, green, unsure paramedic.

The engine is sent code 2 to the quiet neighborhood and has trouble finding a spot to park.  The narrow street is littered with patrol cars and the decision is made to circle the block and walk in from a ways back.  As they get closer what they thought was a waft from the nearby sewer gets stronger and they're covering their noses with their hands from 2 houses away.

The house they approach  seems a bit run down, with paint chipping away, stairs out front warped and rotting and the car in the driveway looks like it was parked in 1983 and left to rust.  Back in the 1930s this would be a gleaming new single family home.  Those days have long passed but the rest of the neighborhood seems to be keeping up alright.

The first indication of what was going on was in the side yard where a young police officer was gagging, then vomited in the bushes.  As the engine crew got to the steps another officer came out of the building covering his mouth only to vomit on the way down the stairs.

"How many more are in there?" the Pup asked, uniform neatly pressed while the other members of the crew were in untucked navy blue T-shirts listing their membership in a variety of departments no where near them.

"Judging by the street, at least 5 or 6 more officers unaccounted for. No idea why they're in there,"  Said the engine boss, a tall rough skinned man in his late 40's who the crew referred to as Jims.  He went on to to explain that their uniforms will never get the smell out and with much more exposure their skin will smell like this for a week.

"Alright kid, this is why you get the big bucks." The officer says as he motions towards the door.  The young Paramedic grabs his monitor and sees the EMT has wrapped it in a wool blanket with a chux pad taped to the bottom.  Clearly he has seen this before.  The Pup has no idea what he's getting into.  Suddenly his mind flashes back to the day he spent in the Medical Examiner's office and the foul odor that arose when they opened the stomach and intestines.  That raw gut wrenching stench of a thousand portable toilets on a one hundred degree day at the chili cook off caused his stomach to do a back flip as he mounted the staircase.

Whatever was making this smell had to be confirmed dead using his little machine.  That was the protocol.

'You can do this' he told himself.

'No I can't' he told himself back.

Another police officer emerged, a sergeant by the looks of the stripes, and motioned to Jims, the engine boss. "You guys can go Jims, this is a CLEAR 802."  802 was the code for a DOA, Pup knew all the codes from fire college.

"Let the Pup have a look, needs his bubbler cherry broken." Jims grinned when he said bubbler and Pup suddenly realized the other 2 members of the engine company had gone back up the street towards the engine.

'Bubbler?' Pup heard his inner voice cry, 'what the hell is a bubbler?'

From the side of the monitor bag Pup pulled an N95 mask and placed it over his mouth and nose, suddenly realizing this is why the nurses in the ICU carried small tubes of toothpaste.  A dab of wintermint sure would be nice right in front of his nose.

The front door of the rotting house is slightly open, just enough for Pup to slip inside.  With a sigh and a quick moment of quiet reflection he steps into the house.

 

Thursday, February 23

I finally answered the age old question...

...how many Fire Chiefs does it take to turn off a toilet?

3.

 

Doing my usual work up on the third floor of FD HQ, our new Deputy Chief of Operations starts digging through a small tool box near the door to my office.  Not one to let a gold badge do something someone else could do, I offer to help locate the tools he needs.  He's in a hurry and needs a wrench.  I know where some are.

"Give me those...and come downstairs, we might need you," he says as he almost runs for the stairs.  My sleeves are rolled up as I exit the second floor stairwell and see a small wave of water exiting the men's room as the door closes ahead of me where the Deputy just went in.

As I opened the door I learned the answer.

To turn off an overflowing toilet takes 1 Deputy Chief, 1 Assistant Deputy Chief and 1 Division Chief.

Before I could open my mouth to offer help I hear the Division Chief say, "Hey, get out of here, gold badges only."

Damn executive washroom.

Monday, February 20

the Difficult Airway App - Review

Awhile back, actually right before I stopped treating patients on a regular basis, I was asked to take a look at an airway app.  My initial thought was probably the same as yours, "I barely have time to bag, get the tube and see the cords and now there's an app for that?"

Kind of, yes.

 

I'm not a big fan of field guides, cheat sheets, crutches or other devices that give you a false sense of security in not having to know everything you need to know.  We've discussed this before boys and girls.  If you refer to a guide on scene perhaps you need to spend more down time studying.

The Difficult Airway App was designed to be user friendly in the field to assist with difficult situations.  With the doses for many meds, especially RSI, dependent on a number of factors it could prove very helpful in a tight spot.  If you have the resources for someone to access this app during a call it is a perfect resource.

But I wanted to focus on the benefits for those of us who may not have enough people to use this app on scene.  This app is an excellent tool for as soon as the ambulance is in park on post or back in the station.  I installed it on my iPad and began to look through it immediately realizing it was a resource, not a tool.

The app opens to a screen with 7 basic parts, Airway Anatomy, Airway Algorithms, Predicting the Difficult Airway, RSI calculator, Pearls of Wisdom, Video Clips and Additional Resources.

The anatomical notations are what you'd expect and are a great refresher for the salty dog medic who claims to have seen it all as well as the green medic student or EMT wondering why it's so hard to put the little tube in the mouth.

The algorithm section is the only draw back of this app in my opinion, because it is an over simplification and vague guide to the other algorithms which are again over simplifications that can't really be studied.  For example, one asks "Intubation successful?" and if "No" we are instructed to keep bagging and try again.  I see the reason to lay out every step of the process, but like many of the algorithms in EMS, the patients have trouble sticking to them most times.

But this minor issue is made up for with the Predicting the Difficult Airway and RSI calculator.

Predicting the difficult airway is a group of mnemonics that can be used to reinforce proper techniques when encountering a difficult airway.  When appropriate, they also include pictures to reference things like the 3-3-2 and Mallampati scales.  These were a welcome refresher to the usual dry text at refreshers.

One feature I see used over and over again in the front seat of the ambulance is the RSI calculator.  The guide opens asking the general weight of the patient and immediately has a link to the 7 Ps Preparation, Preoxygenation, Pretreatment, Paralysis, Positioning, Placement, and Post Management.  This screen is a welcome reminder that there are a great many steps to securing and maintaining a patent airway.

The calculator also takes into account variables such as obesity, blood pressure and possible asthma or ICP and calculates a dose for a variety of medications used for rapid sequence intubation.  I imagine two medics challenging one another to calculate the proper dose, then using this app to check their work so that on the scene of a difficult airway they're not removing their gloves to reach for their pockets to get their phones and actually use the app.

 

In review I like the app and am glad I took a look at it.  I recommend it to new and student paramedics as well as the dinosaurs who could use a bit of a refresher sometimes.  The app is easy to use and read and has no annoying music, sounds or cheesy animations, just good solid airway information.

 

The price of $14.99 (at the time of posting) seems a bit steep at first but considering you likely spent half that on a game at one point you should grab it before you have an airway go south and wish you had it ahead of time.

I give it a 6.5 on the 8.0 ETT scale.

You can learn more and purchase your app HERE or on itunes, just search difficult airway app.

Friday, February 17

New AHA CPR Guidelines leaked!

An AHA employee is in hot water today after the discovery of his lost laptop containing controversial recommendations for new CPR guidelines was found in a coffee shop in Atlanta.
Authorities were quick to deny claims that patient data had been compromised, but new guidelines had already been leaked.

 

HMHQ has obtained a link to the data.  This is going to change everything.

 

Monday, February 13

The Ultimate Lifesaver - EMS in the Wall Street Journal

I got a strange voice mail from the Secretary of the Chief of Department asking if I could talk to a reporter about our advancements in cardiac arrest survival.

Um...yes please?

 

Laura Landro from the Wall Street Journal asked the kind of questions I wish more reporters asked.  Not just asking for our survival rate, but the more important question:

"Why is your number improving?"

We discussed continuous chest compressions, training the entire department to AHA standards and ensuring our BLS fleet can anticipate ALS interventions.  We discussed esophogeal airways, CPAP, see through CPR (from ZOLL), end tidal capnography, so many different tools that come together to make a 9% into a 23%.  And that was all before I got my job at HQ.  It's nice to highlight the work of those who came before including Jeff Myers, Seb Wong, Brett Powell, Pete Howes.

Hopefully this is just the beginning of a conversation with the public about how EMS impacts their daily lives, not just when they, for lack of a better term, drop dead.

 

The Ultimate Lifesaver

 

Wednesday, February 8

the Prosthetic Medic

There has been scuttle around the EMS interwebs as of late and I've linked to this little blog from my little blog but have been having trouble finding the right words to describe what Joe Riffe is going through.

I'll link to his site in a minute, but he's been in the sidebar for a few weeks.

Joe can better tell you about his past, I'm more interested in Joe's present.

You see, Joe is recovering from the amputation of his left leg above the knee.  Had this been me, I would just curl up in a ball on the floor and ask for water occasionally.

But not Joe. Joe smiles, gives a double thumbs up and asks the Universe, "Is that all you've got!?"

To say that his spirit to overcome this tiny lifestyle change is an inspiration does not do justice to how I feel when reading his day by day accounts of living with and around having only one leg.

Recently a child began to ask what happened to his leg and the child's parent whisked them away without an answer.  He's been called a cripple.

I call him brave.  There isn't another word to describe someone who faces this kind of setback and charges forward, guns blazing, kicking ass and taking names.

When life seems rough at HMHQ I often think back to the days before kids, or maybe when we lived in the City, perhaps even before this staff job finds me in traffic 5 of 7 days, but I can get up, walk somewhere else and change my life if I want to.

That is what Joe is teaching me as I read his accounts of life with one leg.  Sure there are awkward moments like,

How do I pee without falling down?

Do I need a wheelchair?

Will I wear shorts again?

 

But it makes me step back and wonder what in my life is really bothering me.  Joe didn't set out to inspire me to reevaluate what's important in my life, but he is.  My take on his story is a selfish one for sure, that's just who I am, but this story has really set into my mind to make me think more about what I have, and less about what I think I want.

Joe is about to walk into a whole new chapter in his life with his head held high and I'm honored he's letting me come along.  You should too.

 

Tuesday, February 7

On the doorstep

It was a crisp morning, I remember that much.

There were three of us assigned that day, the Medic, me the EMT and the firefighter who happened to also be an EMT.  We had decided to ro-sham-bo to see wwho took the day on the ambulance and who got to man the tender.

I lost and began to check out the ambulance, having no idea that by the end of the day I would thank the heavens I had chosen scissors instead of rock.

 

The medic and I had decided breakfast burritos from the gas station were in order and loaded up in 91 and away we went.  Wandering the tribal roads was always interesting, dirt to gravel, gravel to pavement and finally to the highway to loop around to the border and the gas station.  As we listened to some Alan Jackson song I've learned to forget we heard a panicked voice come over the air.

"Isleta, Station 1, I need 91 back here code 3 and  launch Launch Lifeguard!"  Lifeguard is the one and only helicopter in the entire state.

In the movie version of this story I scream "hold on!" and execute a perfect skid turn and peel out in the opposite direction.  But in the real world we're in between exits on the freeway, 4.5 miles to go until a safe place to turn around.  Then back.  We're at least 10 minutes away.

"Station 1, Isleta, Lifeguard is not available "  maybe 30 seconds pass.

"Station 1 10-99! 10-99!" Our code for officer down.  One of 2 things has happened.  Either there is an officer down or our firefighter back home needs help so bad he'll take anything.

Minutes pass with no transmissions, we've started an intercept from the north, they'll arrive in about 20-30 minutes.  With an unknown situation and no cavalry, we tended to err on the side of getting help on the way.

As we finally hit the exit to get to the station I'm varying the siren to let him know we're coming.  On the PD channel an officer states he's on scene and there has been a shooting.

Oh fuck.

"Our guy is OK, but we need that ambulance ASAP!"

Another movie perfect skid into the dirt lot of the station would send a cloud of dirt past the Chevy extended cab awkwardly parked almost infront of the ambulance door.  Had we been in quarters, we'd be stuck.

In the front passenger seat, covered in blood of varying ages and degrees of clotting, is the patient, shot in the stomach with a shotgun at close range.  My friend tending to the patient had him on oxygen and was applying pressure, about all he could do.  It didn't do much.

The weapon has been secured, and is in the back of the truck, by the patient's 12 year old son.  And now we understand why the truck is parked so awkwardly.  In a community where middle school aged boys are expected to work in the fields, it is not uncommon for boys as young as this to be comfortable driving on the farm roads.

While mending fences on the eastern border of their land, dad always carries a shotgun for defense from animals mainly.  On this day Dad set the shotgun down against the fence barrel up.  It was a simple thing to do, perhaps he always did it that way, maybe it was just this once, but when he reached over from the other side of the fence to carry it back to the truck it discharged.

A 12 year old boy took off his shirt, dragged his father into the pickup, stuffed his shirt over his father's wounds and drove a good 20 minutes to our ambulance station.

The transport was a fast one, understanding what little we could do in the back of the ambulance would help this man.  He needed "bright lights and cold steel" as we used to say.

The look on the face of that boy has been burned into my memory.  I hope I'm that brave one day.

Street Box only

Why yes, all of our antique street boxes do still work...flickr image credit will scullin

...and here's why.

 

Thursday, February 2

No autographs please

Early on the morning of January 1st I was flexed out as an additional ALS single resource and jumped a call at one of our regular spots.

I made patient contact, completed my assessment and cancelled the ALS ambulance instead opting for the more appropriate BLS ambulance.  We don't usually have this kind of flexibility, but the system was so overwhelmed, the local EMS Agency brought in additional cars from additional companies in the area.

The BLS unit arrived from a company I had seen, but never worked with.  The EMTs seemed a bit excited to be responding to a scene instead of a facility, and I was trying my best to a)stay awake and b) keep my patient in good spirits.

I completed my hand off and helped walk the patient to the back of the ambulance and after double checking they were OK accepting the patient I said good morning and began to walk back to the buggy.

"You're that blogger aren't you?" she asked.  I turned.

"First time anyone's called me that while at work," I cryptically answered.

"Yeah, I read your stuff. I used to think you made it up but," she motioned towards the ambulance, "you can't make this stuff up."

"The blog seems to write itself most days.  Be safe."