Thursday, December 10, 2009

The Job ALWAYS has new Twists

I haven’t posted in several days because I have had little time and that time has been devoted to reading and absorbing the best That Justin and Mark have to offer, and they are satisfying the requirement and expectations. Go read their stuff if you haven’t yet. The Happy Medic and 999Medic have links over in the right column.
I have also spent a lot of time thinking about my co-worker that my last post was about. I don’t usually get wrapped up in my patients and their problems unless I can be of some concrete help to them, which isn’t very often, considering my training level. I am a good hand-holder though, or at least that’s what I have been told. Still, this was my first serious call for a co-worker on the job and there are a lot of dynamics I had never considered.
Of course, everybody in the plant expects me to know the details of George’s condition and readily share that information. I repeat what is public knowledge and tell them I don’t know anymore, which is mostly true. I don’t speculate. Anything I have learned this week has come to me through the company grapevine (read as “public knowledge”) and it isn’t sounding too good.
George made it to the hospital OK, but it got worse as time went on for him. They told his wife that he probably would not survive the night, they flew him to a Cardiac Hospital and admitted him to ICU after they put a intra-aortic balloon pump in him (goggle it, it’s pretty cool). They said he needs a transplant, it’s the only option. The guys and gals in the shop pretty much think it’s over for him and keep asking me what I think will happen.
I blew off the question the first time it was asked by saying that I had no idea what the details were, and that I lacked enough training to even rate having an opinion. But I DID think about it.
I’ve been pretty bummed that I could not do more for George and I beat myself up over it a little bit. I ran the job over and over in my head and came to realize that I did everything right, didn’t miss anything, and chose the correct priorities. I reviewed the job at length with my respected partner and he emphatically stood by the fact that I did all I could do and should feel good about the job, it was a ‘clean call’. Still I felt bad until I figured out that I was not bummed about my actions or abilities, I was bummed because it was a co-worker and friend. This is a totally different thing, and I am “OK” with feeling bad about that.
All week long people have been catching me alone and saying how impressed they were with my coolness and professionalism and how George was lucky to have me around. If they only knew what was going on in my head.
This afternoon, I got a call from George. He is in ICU, and can’t do anything until they find a donor and ‘do the deed’. He is totally upbeat, sounds great and cheerful and wanted to thank me for what I did for him. He says he doesn’t remember much of the whole ordeal (which confirmed for me that I was right when I thought he was dropping off on the ‘alertness scale’ even thought he could answer my questions). He does not remember the chopper flight or much of what happened after he left the plant, He does remember a lot of people coming around when he didn’t feel well.
I will pray for George tonight and hope he comes back to us even if he doesn’t come back to work. He is a good man and that is enough for me.
So as I said, I’ve been thinking about how to answer the question of what I think will happen to George and I’ve changed my tune because I realize that just maybe I have seen more than most of my co-workers have. Now I tell them this: “I don’t know enough about medicine to render an opinion on George’s situation, but in my experience as an EMT, I have learned to NEVER give up hope because I have seen people I did not expect to live all the way to the hospital, go on to recover and live long fruitful lives against all odds. It isn’t over until it’s over and tomorrow is always a new day.”
I hope George proves me right.

Saturday, December 5, 2009

They're BAAAACK!

I’ve been a reader of The Happy Medic and Medic 999 for a long time now. I mentioned in an earlier post that it was partly because of their blogs that I decided to give this a try. So you won’t be amazed to learn that I have been missing them during their well deserved rest period. This morning, during the 6 spare minutes I have before leaving for work I was contemplating doing a “You Make The Call” piece to fill in for Justin.
That is a moot point now, and in addition to coming back ‘on the air’ Justin had broken the break with a piece about his trip AND a “You Make The Call” piece. Mark has also come back with some very nice writing and it whets my lips for the coming few weeks of posts from both “Johnny and Roy” as I like to call them. Mark, if you don’t ‘get’ this reference, ask Justin. It’s a compliment.
Their posts are a welcome relief for me, because I was driving to work and trying to pick a call out of my memory and figure out how to put it into words. It wasn't going well in my head and I knew it would look worse on the screen.
So I'll jut tell you about my routine day instead.
Once I got to work, the job overtook my thoughts and although I can usually steal a little ‘think time’ for myself near the end of the day, today that was not to happen. I was interrupted by a cardiac call for one of my co-workers. Volunteers are always on duty, right? I was in a meeting when they were trying to find me, finally they called the conference room and I knew it was an internal call so I answered the call (which interrupted the meeting flow) with something humorous like “Crisis Management Office, how may I direct your crisis please?” It was an HR person and she said: We NEED you out in George’s area right now” I said “OK, tell me what’s going on” so she started to give me a long litany of symptoms “Well he’s sweating like mad and can’t breath and he’s really tired and he says…”, “OK, I cut her off, I get the picture, I’m on my way.” I only asked her because ‘needing me there NOW’ doesn’t tell me what I will be dealing with and what gear I might need. I have been called with the same urgency to a minor finger laceration.
I am the only person in the building with any training beyond ‘first aid/CPR’ and we run a very safe company. We are anal about safety and I can tell you that a year with 3 finger cuts is a really bad year. I kid you not. It is not a place where an EMT would go to practice his skills. So getting this call was something I expected to get someday, but certainly not something that is common.
So out I go and grab the trauma bag out of the First Aid room on the way. “Hey George, tell me what’s going on man” I asked as I approached. George is almost 60 and a former Police Officer and EMT. He knows the drill and we communicate on a level that nobody in the surrounding group even comprehends, which is fine for both of us. It leaves them out of the conversation even as they are listening to everything we say. “OK George, any diff breathing?”, “yup, bigtime” he says. “Hows the lungs?” I ask. “Probably clear in all fields, no sounds that I can feel, but give a listen anyway”. I wrap the cuff on his bulky arm while I yank the cheapo steth out of the company trauma bag and also turn over my shoulder and throw my car keys to the HR manager and ask her to go to my truck, grab the ‘big red bag and the round green bag behind the driver’s seat and get them in here’. I get the cuff pumped up to around 100 and check for pulse sounds….nothing. I reposition the arm, tell him to relax and search for the magic BUMP-BUMP-BUMP. Nothing. I can’t find the artery. Damn cheap stethoscopes. OK fine, what next. Well I think, I need a pulse to see how hard he’s working because I already see short rapid respirations. Feeling for a pulse, but this guy has thick wrists and again I’m having trouble. My O2 shows up, well hell, I know that no matter what’s going on here the O2 is going to fit into the hit parade of treatments, so lets get it going. Then I realize I screwed up. I always like to know what the O2 sats are prior to administering the O2. It tells me how the patient was doing prior to treatment and if the treatment helped. But I don’t have my pulse ox, it’s out in the truck in my little holster right next to my Littmann Stethescope. I send the HR manager back out for it. (I always knew that these managers were good for something!) I go through all the questions on meds, blood sugar, recent history and George spills it all out like a pro, he knows what his sugar was at 7am this morning and again at an hour ago, he tells me how it tracks with his normal history. He doesn’t spell it out for me, he knows I am putting it all together. His sugar level is 224, but that doesn’t quite wash with his other symptoms and George came to that conclusion 10 minutes before I did, that he had a cardiac issue. He never told me that, he knew I’d reach my own conclusions. The pulse ox shows up and George is feeling better with the O2. I’ve made another attempt at the B/P with my own cuff and steth, still no joy. Fire shows up, an engine with 2 EMT’s. They have no monitor, which is all I want to get on my patient at this point. They start taking a history and I am happy to let others work on that while I continue to think this through. The one EMT takes a shot at the B/P and has no luck either. I have been giving directions to others while this is going on as to where to bring in the ambulance (we bring it right in the building) and I sent somebody to meet the rig and tell them to come in with a stretcher and a monitor. They brought the monitor but the driver went back for the stretcher. The medic was not only somebody I knew, but a neighbor from down my road. “Hey Bill” I said in my usual ‘on-scene, everything is under control’ voice. “This is my friend George, George had a sudden onset of difficulty breathing and is diaphoretic. He says he has no specific chest pain, but I am seeing that his respirations are about 30 and shallow, I had no luck getting a B/P due to my poor ears, sorry, but his O2 sats are now 98 percent on 15 liters and the NRB and his pulse is holding around 76 but weak. I’d really like to get a monitor on George to see if we can identify what is going on.”. Bill went into his deal and I shut up and changed to support mode. Bill had a new partner I have not yet met and I could tell by some of the basic questions about ‘what do you want, and where do you keep it’ that they were new at working together. Hell I had only worked 3 calls with Bill in the past 2 years and I knew the answers. So I played support guy and anticipated what he would want to do and what he would need so that I could try to get ahead of him and have what he wanted ready when he asked for it falling easily into the routine I have done a thousand times when we run a call that is properly deemed as ALS. We packed the patient and got him in the rig about the time the O2 in my bottle ran out and we switched bottles and I got mine back. I was closing the doors on the back of the rig and just asked the Medic one last time if there was anything else he needed (his EMT had just asked for the third time which hospital they were going to), and he looked up and said, “Yeah, call my Father-in-law and tell him that you’ve managed to work a call with me before he did.” Small Towns, you gotta love them. Bill has been a medic for about 2 years now, and he was a career EMT before that, but lost his way in his paramedic classes. 2 Years ago, he married the daughter of a member in my volley squad, and with kids on the way, started to see a bigger picture and had no problem finishing his classes and clinical time. I guess he has yet to work a call with his father-in-law.
Monday, things will be normal at work but I will be requesting an informal meeting to do a call review and see if we can streamline the way we do things. When people don’t see what can happen and understand that having a plan is important, they avoid it. I have been telling them for 3 years that this incident would happen and they all blew me off. Now it has happened and they have an opportunity to make things a little safer for those involved, including the patient. For me it’s just another cardiac call, routine stuff, for them it should be a wake up call. Do you think that maybe perhaps, I can finally get an O2 bottle in the building?

Thursday, December 3, 2009

Unscheduled Hours…..

I’m just back from a call. Two hours standing on a frozen road watching a tree that may, or may not succeed in it’s attempt to take the 13KV primary line completely to the road surface, completing the circuit to ground and offering up a spectacular reward for those few of us that stood there for so long watching it, protecting the public, and awaiting the arrival of ‘our heroes’ the power company folks, to fix the problem. We do a lot of these calls in our part of the world during the spring and fall when the weather gets blustery. We have many hundreds of miles of power lines and millions of trees. They do not always ‘get along’. So who you gonna call? Us. We actually had 2 of these calls working in different parts of town at the same time tonight. I was en route to the first one with an engine and got diverted to handle the second one. That happens a lot here when the weather kicks up. One night a few years ago we had 14 calls in 20 minutes. We don’t have those kinds of resources, but we handled it with creative thinking and covered them all by priority and severity. It was a long evening and one in which I almost lost a man on my Engine. I’ll tell you about that sometime soon.
The point I’m trying to make here is that we never know what we will get called for, or when. Unlike the career service where you are “on” when you are “on duty”, and you are “off” at other times, we in the Volunteer service are always “ON”. (I know there are thousands of the ‘Paid On Call types’ out there, but again, you know when you are on.) Not that there is anything special about that, it’s just part of the job. It can make things hard at times, and you certainly need to find a way to deal with it in your mind, as well as with your family and friends.
Every time I go to a family event at my sister’s house one of the first things she asks me is “are you on tonight?” I am always on, I tell her. Usually we meet at her place on Holidays (when we are not at our place) and holidays are the times when EVERYBODY is with family or close friends. I know this means relaxing, family time, perhaps a few beers, and that means you are out of action. So although I REALLY enjoy kicking back and having a couple of beers (maybe a few more if I don’t have to drive) I also know if we get a major call, we need all the help we can get. So contrary to the rest of the sane world, I generally don’t drink on holidays. If I do, it’s very late in the evening when the motoring public is home and all the older folks are in bed. I’m working the statistics into my social habits. I am not alone and I know several other people in my department as well as many other departments that surround us, that do the same as I do. We even have one Officer that gave up drinking completely because he missed a few big fires. Hasn’t had a drop in over 15 years. It’s a good thing to have: Dedicated people who not only see, but focus on the big picture.
On the other hand, there are some that I just can’t understand. They take assignments and are ‘unable’ to respond. If you don’t want a job, why volunteer for it? If you do volunteer for it, why not just do it?
Right now I am assigned to EMS and have a few dozen people in my Company (I still do Fire when the pieces fall into place for me). We organize these folks into duty groups, they pick the night they can respond. Yes, sometimes we bend a few arms to get things evenly distributed, of course, but each individual does ONE NIGHT (12 hours). For the life of me, I do not see why this is so hard. The rules are simple: if ‘something comes up’, you need to find somebody to cover for you and notify your crew who it is, otherwise we (and the state laws) expect you to be there when the tones drop. Almost every week we have a call and I get a phone call or email the next day that “so and so didn’t show up at the 3am call”. I then have to follow up. I hate this with a passion. I know that I will get the excuses and I have heard them all, some good and reasonable, some poor, some unbelievable, and some just downright unacceptable. Some folks ‘get it’ and are sick to learn that they missed a call, usually because their pager never tripped. (We have hills around here and atmospherics can affect radio propagation in strange ways.) I also get the excuses like “I had a big meeting in the morning” (so you were willing to let Mrs. O’Grady die?), “I thought it was a BS call” (so you were OK with blowing your crew off to handle it?), “That was a Fire call, you didn’t need me” (OH, and you are saying that our Fire personnel are not worthy of an EMS presence to back them up? Not to mention that our POLICY is that EMS rolls on EVERY fire call to care for victims or our own people.) You the reader, should understand that we are backed up by an ALS unit (commercial service) on every call, but our goal is to turn them around before they get too far down the road if we can handle it without ALS interventions. Our primary concern is the patients we serve, but it sure would be nice if we could serve them without mutual aid. Why is this so hard?
I am guessing that we are not the only service that experiences these problems. Does anybody out there have any magic bullets?


Wednesday, December 2, 2009

I am NOT 911

So it’s about 3 am on a ‘work night’, meaning I have to get up for the regular job in about 3 hours. This is the worst time for me because it is right in the middle of my deep sleep period, assuming it is one of the rare nights when I can sleep normally. It’s hard to wake up and become alert at this hour.
The phone rings with it’s little ‘TWITTLY-DITTLY-BEEP” which at that hour and in my state of sleep, can sound an awful lot like my pager which sits right next to it on the shelf. I sat up getting ready to grab my socks and hear the call and location while I dressed. ‘TWITTLY-DITTLY-BEEP” it goes again and I realize through my stupor that it is the PHONE and not the pager. I pick it up expecting the usual wrong number. As I grunt out a “Hello?” a very grumbly low voice on the other end grunts out “I think she’s having a heart attack!”. The voice was excited and I am still not awake, I asked for a repeat: “I think she’s having a heart attack!” Now I’ve got it and I’m waking up. “Who is this?” I ask. “It’s Mary and I think Susie is having a heart attack!”. “OK, Mary, listen carefully, I want you to hang up the phone and call ‘911’, OK? I am on my way.” “OK” she says, “But hurry, PLEASE”.
So now I am awake enough to function and dressing quickly. It’s not my ‘on duty’ night but I always run on cardiac calls especially ones where I might make a difference. It is one of the true emergencies, and certainly worthy of ‘all hands on deck’. I know that the elderly woman who called lives in a retirement trailer just down the road from me and I can be there in quick order. I am halfway there when the page goes out for a patient with ‘severe chest pain, possible cardiac emergency at 119 WINDING MOUNTAIN RD.’ HUH? That’s 3 miles from here?! Well, what do I know? So I change gears and head to the new address, sliding up the hill and arriving at a mostly dark trailer home. We had to use mild force to gain entry because the patient was in too much distress to move. The dog barking, the patient yelling to us, firefighters and EMT’s walking around the premises looking for an entry point made the scene a little confusing as the snow fell to complete the effect.
As it turned out, the patient was experiencing crippling arthritic pain because she was non-compliant with her pain meds (“they make me all wobbly in the head”). We worked with ALS to do an assessment, get her packaged and out the door. Routine call, except for how it started.
I talked to Mary a couple of days later and found out that her best friend Susie had called her in the middle of the night to ask for advice about her pain. You know the rest. I told Mary that the next time something like this happens, please call 911 first, and then she is welcome to call me if she feels the need.
You would THINK this is a rare situation, but it happens a lot. Some folks mistakenly think I am their solution to all problems medical. Some folks think they can evade intrusive treatment if they just call me. I get calls for ‘lifting assistance’ and find a broken hip. I always tell them the same thing, “hang up, call 911, I’m on the way”.
I don’t mind helping, that’s why I’m here. I am happy to stop by and do a B/P on a patient to help them monitor their ongoing care or look up medication sheets and explain to patients what they say and mean. Things that others in the healthcare system SHOULD have done, but failed. But it’s hard to explain to people that when it’s an emergency, they need to call 911 and get the system in motion. It is equally hard to explain that if you can walk, and have transportation to take you to definitive care, it MAY not be an EMERGENCY. There is nothing more frustrating than being called to a residence at oh-dark-thirty for a belly ache. You assess the patient, they say they can walk fine, but want to go to the hospital. You walk them to the ambulance and the spouse/father/mother/boyfriend/girlfriend says “OK Honey, I’ll follow you to the hospital”. So I’m thinking “OK, so you called 911 and snatched 3 people out of bed (the BLS Crew, and of course you awakened many more that that when all those pagers went off), 3 people who have to go to work in a few hours, got an ALS crew on the road from Big City based on your chief complaint, PD rolled on the call because he knew we would have trouble finding your house (you never bothered to replace the numbers that fell of the tree at the end of your 200 foot driveway), and all the time, you have a perfectly good car in the driveway, complete with driver, and you want to walk to the ambulance anyway. Did it ever occur to you that if you had just gotten in the car, you would have seen a Doctor about 20 minutes sooner?” I’m a firm believer in EMS 2.0, and I would love to be able to make ‘house calls’ within the parameters of the system. Unfortunately, the system is not designed to always do what is best for the patient. Protocols are protocols and we need to follow the protocols. You call, we come, you get a free ride, even if you already have one in the driveway.

Monday, November 30, 2009

A Culture of Safety, Suppression, or Stupidity?

At the last FDIC Lt. Ray McCormick of the FDNY gave an absolutely wonderful presentation on the current ‘Culture of Safety’. His presentation was so thought provoking and ‘out of the box’ that it caused a bit of an uproar and Fire Engineering pulled the video off the FDIC site within a day and the FDNY had a lot to say about how the good Lt. does not represent the views of the FDNY. Therefore I can not offer you a link to the video, although I wish every Chief Officer would be forced to watch it 3 times. I watched it 3 times before it was pulled. I should have grabbed a copy. Great stuff.
So I will give you the Cliff Notes version. The Lt. brought up the point that we have swung so far in the direction of being safe that perhaps we have forgotten why we are here in the first place. That is ‘TO PUT OUT THE FIRE’. He suggested that perhaps, we might consider taking a little more risk, early in a fire event, to actually extinguish the fire, and we just might in effect, make the scene safer for everyone. In other words, he was challenging our current effort to make the scene as safe as possible, and interjecting the thought that we just MIGHT have gone a little too far.
I am all with the good Lt. and having an open mind. I am also fully in favor of keeping our people alive and put a LOT of effort into getting NFPA 1584 widely used in our area. Rehab is where we SHOULD find problems before they become a fatality. Some day I’ll do a thoughtful and well footnoted post on rehab. Right now I’m pissed off and don’t have time for all the good teaching moment stuff.
Each year in the United States Fire Service we loose around 100 people in the line of duty. About half are due to stress induced by the demands of the job which lead to cardiac arrest. Check the sidebar for the USAF Fallen Firefighters in 2009 on the right of this page and read the causes of death for the fine men and women we have lost this year. Among the names you will find two of my friends.
So it is with no small interest that I do my best every week to carry the message and reduce the number of wakes and funerals I attend each year.
By now you are wondering where I am going with this rambling line of thought.
We are running a recruit class in our volley department this fall. It is being taught by a State Fire Instructor with help from other State Fire Instructors for the evolutions and classroom sessions. Lately they have been getting a lot of work done on the actual evolutions. The lead Instructor is a Deputy Chief in a career department in the adjacent small city. In addition, he spends a lot of time working at the Stat Fire Academy. He believes in the persona of the firefighter of the 60’s. He thinks most volunteers are sissies and he needs to ‘break them down so he can build them back up’. I call him the ‘Drill Sargent’. The last live burn they did with the class, our Department supplied an Engine with a Pump Operator and a Rehab Crew. When the Rehab crew showed up and asked where to set up, the Sargent said, “out there in the woods, I don’t want any of these guys to even see you. They’ll keep running over for water and bullshit every 5 minutes.” Now I ask you, the reader, is this what we expect from a Nationally Certified Fire Service Instructor? I am trying to keep these people alive, not make it easy to die. This particular class had two individuals pulled before completing all the evolutions because their pulses never dropped below 125 and their B/P’s remained elevated after about 10 minutes in the burn building. The Sargent got ticked off. I spoke with one of the other instructors who let it be known that he clearly did not agree with the lead instructor and had grave concerns about putting people in the building that had medical issues.
Now we finally get to why I am pissed of, and spent the evening typing this instead of (just for once) being able to watch ‘TRAUMA” on TV instead of the little web screen.
This coming weekend is another live burn for the class and the lead instructor asked our Department liaison to the class for an Engine and an Operator, but he told him to “keep the damn EMS people away, all my instructors are EMTs and one is a medic”. Now besides the obvious point that Instructors who are involved in the evolution are NOT doing any medical oversight, and having EMTs on the ground does not mean that you are MONITORING the condition of the students. In addition, they will not have the tools with them anyway, no rig, no toys, no tools.
As an Instructor myself, I can tell you that the Instructors themselves usually take the brunt of the physical abuse. They are in gear ALL day long while the student crews rotate through and get some breaks. The instructors only stop when they need a bottle change. I have stood at my post during a recruit class on a hot August day for over four hours at a clip, pushing students through, pulling those out who had issues, watching every one of them, and at the end of the evolution just pouring water out of my mask. No way could I start tending to a patient at that point.
There are reasons most States have very strict checklists for running live burns. This guy is one of them.
The only question is, do I put the guy out of business, or defer to those who say ‘hey, we need the classes, and this guy puts on the classes..’?

Dear Probie.....

(The reader will have to parse this out on their own, This letter can take a number of paths, but in the end, it should all come out the same. It reflects what I say now, or should have said in the past, to all the new members that pass before my eyes. Perhaps it is what you should say to yours? Just pick the option from the [bracketed text] to suit your needs.)

Dear Probie,
Welcome to our Department, and thank you for volunteering your time in what is to be both a rewarding and trying experience. You are [16], [17], [18], [19], [half my age], [about my age], [older than I], [good God, WAY too old to be doing this!] but I think I can easily relate to your situation and it is my job to make sure you survive your probationary period and become a functioning and valuable part of our team. I am [an old fart], [twice your age], [just a couple of years older than you], [about your age] and have been in this Department [longer than I can remember], [since we had horses], [for xx years], [for several years], [well over a year now] and have gained a lot of experience and knowledge that I would like to pass along.
Part of being a probie means that you will be asked to do the most menial and meaningless tasks, slowly working your way up to less menial and meaningless tasks. You should understand that we all do these tasks and you, as a valuable member need to know how to do them also, and do them well. You may think we are ‘picking on you’ and ‘having fun with you’, and that, of course is true. But you should understand that this is our way of feeling you out. We need to know where you are strong and where you are weak. We will, in time, take advantage of your strengths, and help you overcome your weaknesses.
At times you will be [screamed at], [yelled at], [ass reamed], [kicked in the ass], [counseled], [spoken to sternly], [corrected with extreme prejudice] when you don’t do what is expected. This is normal, and we all go through it. This is how we learn, and keep from getting hurt.
Your parents [raised a fine child], [didn’t do you right], [left a lot to be desired], [would like to see you come home each night], [said they would send their new address when they settle in] and we are now a new part of your family, as you have become part of ours.
My job, as your Line Officer is to [teach you the ropes (and knots)], [make sure you don’t die], [keep you safe], [ease your transition into the Department], [make sure you get off to a good start], [keep you from getting any of us killed], [be your mentor and friend], as I have done for many others before you.
I just want you to understand ahead of time that when I [lose my flippin’ mind], [yell at you], [kick you in the ass really hard], [grab you by the back of your helmet and drag you to where you should be], [speak to you in a forceful and stern manner] it is only because I am concerned for your safety. The same can be said for any other member of our Department, we all want you to succeed and be proficient.
You can expect to see my face at your recruit class on a regular basis. Your instructor is an old friend of mine. I will be checking in regularly to make sure [he is giving you an ass beating on a regular basis], [the training you receive is up to our high standards], [you don’t embarrass the Department], [your needs are being met], [you are not in need of remediation or further training]. Between the two of us, we will make a Firefighter out of you.
So, as you enter the Fire Service, one of the oldest and greatest traditions in this Great Nation, I want you to know that if you have [any questions], [any whiny assed needs], [any hurt feelings you need to share], [a hand to hold], [needs that are not being met], [any piss-ant complaints] you can bring them to me and I will see that they get [the attention they deserve], [tossed in the bucket with all the other complaints], [made public so we can all make fun of you], [treated with the utmost sensitivity and attention].
Volunteering your time is one of the greatest things a person can do. We want to make sure this is [as easy as possible], [as difficult as possible], [a pleasurable experience], [an experience you will always remember fondly], so if there is anything I do can do make that happen, you just let me know.
In service of others,
[Your Line Officer]

Sunday, November 29, 2009

Hear Here!!!

I just finished reading an excellent piece over on the Rogue Medic that every EMT, RN, and ED Physician should study carefully. Such was the value of this piece that I wanted to run and scream it from the rooftops for everyone to hear. Unfortunately I live in the woods and nobody would get the message except for some random wildlife. So I am doing the next best thing and posting here to perhaps get some others to pay attention to this excellent and well written post.
For too long the protocol fairies have been out there second guessing those of us who deal with patients in their native environment and ‘as found’ condition. Spinal Immobilization is one of the worst problems we have to deal with as specified in our protocols. To ‘do no harm’ should be way up the ladder of commandments. Tim brings this point clearly to light with his ETOH patient and an equally unpleasant Medical Control physician.
We are taught to do things in a certain way, and we expect that this is what’s best for the patient. Once we learn, sometimes repeatedly, that this MAY NOT be what’s best, we are left without any alternatives. I have seen Medics and EMTs threaten patients with the fear of severe crippling injuries should they not submit to a backboard and collar for no better reason than ‘it’s protocol’.
Sometimes, the protocol is not always best for the patient in a given set of circumstances. I recently did a PED job where the child, less than a year old, had fallen about 4 feet and landed on her forehead. The child was reported to be dazed on impact but slowly came around and was alert and oriented on our arrival (6 minutes from dispatch). Head to toe and front to back exam revealed nothing, no sensitivities, no complaints (guarding, withdrawal, etc). PEARL was positive as was cap refill. The only thing we observed was a slight red mark over the left temple. The child was animated and followed colored toys with her eyes. When I took her from her Mom and laid her on the coach, she began to fuss during the physical exam. Putting her back in Mom’s arm calmed her right back down. In consultation with the ALS crew, we decided to do a BLS transport for a further exam and observation at the E/D. My partner said he'd go get a PED board and collar, but I told him to hold up a sec. I turned to the Medic and said “I’m thinking that tying this child to a board is gonna be scary and upsetting for her. Based on the way she fussed when we layed her down, I’m thinking we don’t want to do that again, what do you think?" The Medic looked at me, looked at the child, then looked back at me and said “Do no harm”, the she turned to the parents and asked if they had a car seat that fit this child properly. Yes, in fact they did. So we secured the car seat to the stretcher with the back fully raised on the stretcher and put the child in the seat, we didn’t even need a headroll, the seat already had one.
Is this the protocol? No. Was it the right thing to do? In my opinion, Yes and I would do it again.
Our State’s protocols demand that every suspected hip fracture be transported on a long board in the supine position. Have you ever tried to pull the overweight little old lady out of her bathroom at 2am and make her straighten that leg out? You can’t even ask her to roll on her back. If you try to make this happen she will probably grab your lower lip and pull it up over your eyes, at least I hope she does. Elderly hip patients are very delicate and need to be moved as little as possible. My weapon of choice is the scoop stretcher so that we can lift them while keeping them in whatever is the most comfortable position. Lots of pillow padding in the proper places and everybody is happy. Leave the scoop in place on the stretcher if it doesn’t cause discomfort and you have eased their transition to the hospital bed. But again, this is contrary to our protocol and another reason why this is an anonymous blog. I will not increase my patient's pain. If they fight to avoid a treatment, I get them to sign a refusal after I explain why I want to do the treatment. Informed consent works both ways.
Why is this so hard to get included in our protocols!?
So go read Tim’s article and spread the word. Maybe if enough of us keep talking about it, it will get fixed.

Therapy or Another Job?

OK, so I’m several posts into this blog thing and I’m beginning to wonder if I made the right decision. I started doing this for a couple of reasons. First, I have been reading a few blogs for a couple of years now like the Firegeezer, The Happy Medic, and 999Medic to name a few. I also read the blogs they list in their side bars when I get time on the weekends. Mostly it is to stay current with stories, news, and attitudes in the fire service for the students I teach. In my mind there is nothing worse than an instructor who does not know what is happening TODAY, and prefers to teach what he learned 10 or 20 years ago.
So lately, things for me have been wearing me out. Job pressures (have you heard there was a major downturn in the economy?) have cost me some income, personnel issues in our Department continue to distract me from the primary mission of serving as an effective Officer, Rules, Regs, Standards, and protocols coming down on us from every direction and level imaginable, and all falling on my skinny old shoulders. Not to mention the plan of the week that comes down from the Chief. It all gives me plenty of reason to look for an outlet or a vent portal. This was supposed to be it. Maybe not.
All my close friends say they are amazed at the load of stuff I take on and pull off. My wife says I take on too much. My wife is right because I neglect the house and home in favor of the commitments I take on. I serve as an Officer because many have asked me to. I look forward to the day I can pass the position off, as leadership has never been my goal. The welfare of my community is always the goal. My Chief EXPECTS that someday I will move up and take an Assistant Chief’s slot. Again, not my goal (remember an earlier post? I’m an ‘old guy’.). Responsibility such as that bears a heavy burden to those who are led. I am a firm believer in the concept of ‘servant leadership’. If you are not familiar with the concept, it is the belief that those of us who lead are actually servants to the needs of those who are led. That is, if we are the leader, our primary concern is to serve those who are under us. That translates, in the Fire Service, to giving your people a leader who is: Well trained, very skilled, maintains the safety of all as THE primary concern, treats everyone with respect, respects the skill and opinions of all his/her people, and does his best to let his people do their jobs and look good while doing it.
So the original question was: is this blog the right thing for me? Well, let’s see: I work about 45-50 hours a week at my paying job. I am out at meetings, training sessions (teaching), classes (learning), and meetings on an average of about 4 nights a week. I spend 1 night a week answering emails from my people. I spend about 2/3 of my weekend on Fire Department issues such as doing the newsletter and collecting the information for same, supply orders, helping with other classes (like rehab for a firefighter one class or serving as a Safety Officer), working on my own lesson plans, doing orientation for new members (I do this on a ‘one on one’ basis and it usually takes 4-5 hours), and sometimes it includes running a major drill such as a 2-4 hours extrication drill, low angle rescue. I also work on projects the Chief has handed down that need to get done. So how much time do I really have left for a blog?
Maybe I’m nuts (my best friends have been telling me this for years) but I’m going to give this a run and see how it goes. I like to write and I’m usually not too bad at it. This stuff I’ve been putting out so far has been mostly drivel, IMHO. Once I get the introductory stuff out of the way I’m hoping an issue pops up that I can get my teeth into and then we will see.
In the mean time, drivel it is.

Saturday, November 28, 2009

Dear Neighbor….

Dear Neighbor,
We’ve know each other for what… 25 years now? We moved into this neighborhood within a year of each other and our kids, all grown now, were all around the same age. The played pee-wee sports together and we saw you quite often in those days. Later we would se each other occasionally at school plays, concerts, and the rare church events when one of us wasn’t working. I remember that time I passed your house and saw you struggling to place all those stones your wife made you buy to make the garden “pretty”. I thought twice before stopping to offer you a hand, but it turned into a fun afternoon sweating our butts off. Those long necks and steaks sure did taste good that night.
We were never what you might call good friends, but I think we both agree we are close acquaintances. I truly do like you and you are a fine neighbor. You loaned me some pipe fittings on a cold windy Sunday night in February that allowed me to fix our heat and keep the kids warm. Boy, that was huge for me.
So dear neighbor I hope you will be understanding when I tell you that no, I will not tell you what happened at your friend’s car accident last night. Of course I was there and I did take a hand in the job but that does not mean that I will share everything, or even anything that transpired last night with you about your friend.
I am very sorry that your friend did not survive. I can assure you that everything that could have been done, was done for your friend. That is all I can or will tell you. If as you say, you two were very close, then perhaps you can get the information you seek from his family.
Because you are my neighbor of so many years and we have shared many conversations over the fence I think I can also tell you this: I would appreciate it very much if you would respect the confidence in which I hold all information about the jobs I work with the Fire Department. I am sure if it were your family, you would not want me spreading that information around town. Please understand that I never discuss these incidents with anyone who was not on my crew. Please don’t be mad at me. If you consider that by just asking me the questions you pose, you have forced me to re-live the moments and experiences which I am still trying to process. You saw the article and pictures in this morning’s paper and have to know how horrific that scene must have been. Why would you want me to go through that again by relating what happened to you?
I know you probably did not consider that these type incidents have an effect on me, after all, I do this all the time, right? Well my friend, I can tell you that for me at least it never gets easier. I got in this business, as a volunteer, to help and hopefully save people if at all possible. We all train very hard to keep our skills up, which can be tough when we also have jobs, kids, spouses, and homes we try to maintain to look as nice as yours. When we fail to make a save, it affects us deeply and each in his own way. For myself, I take it as a personal failure. It takes me many days or weeks, and on rare occasions, years, to sort out the feelings and get on with life.
So when you ask me to ‘tell you what happened’, you have in effect just ripped the wound open again. I know that you didn’t think about this, but I am asking you to think about it now. You’ve asked me questions like this before, but just in passing and you probably didn’t notice that I changed the subject or gave you an answer that included only the information that was in the newspaper.
I know for you, it is harmless small town chit-chat, but for me it is somebody’s life, death, or health information. On the other side, I am sure that you have never considered that what I might tell you would overload your senses. In other words, I doubt that you could handle, or even understand the things I have seen and had to deal with. There is no way I would burden you with the mental pictures I carry. I have training and understand the ‘why’ part of the equation, which helps me parse it all out; you do not and will only see something you don’t have a clue as to how to deal with it. Telling you all might take you down a dark road indeed, with no map home.
Neighbor, I like you and we have been friends for a long time, but I’m asking you to respect my position and please do not ask me these questions again.
I hope we are still friends.
Your Neighbor,

I am NOT a Hero, but thank you.....

One of the points of this blog is that as volunteer responders, we are ‘on call’ all the time and never know when or what we will be called to do. Hours and days of boredom interrupted by seconds or minutes of extreme stress and testing to see if we can do it right, not get hurt, and mitigate the problem. No stress there, right?
As I’ve mentioned, we are a small town with lots of little roads, and a couple of State and County roads passing through. Most of us join to be a help to our neighbors. You get to be known by many in town as one of ‘the good guys’. They see you in the convenience store grabbing coffee and ask how you are with a big genuine smile, sometimes they even pay for your coffee. They see your personal vehicle going down the road with the blue light and FD plate on the front and they give you a big wave. I don’t even know most of the people I wave back to. Apparently they know me. On rare occasions they embarrass me in public. I’ll stop in a store and there is ‘Mom’ just leaving with her purchase, she spies me, gets this big smile and gets into my comfort zone quickly, lest I might escape. She says in a voice loud enough for everybody to hear around her, but not loud enough to seem like an announcement . “OH! It’s so good to see you again. I wanted to thank you one more time. My little Johnny is doing just fine and is fully recovered. I don’t know WHAT we would have done if you hadn’t come. You really saved his life and we are SO grateful. God Bless you and the others in the Department.” If she is with a friend, she will then relate the story of how I ‘saved’ her son’s life. If I am lucky, there will be enough detail so that I can remember which boy is hers, and what call she is talking about. In this particular case I didn’t do anything to save her son. My job on that call was getting medical info from the Mom, keeping her calm, and explaining what was being done and why. I also explained how she could expect things to go once they arrived at the hospital. Of course you try to tell them “It’s a team effort, I was just doing my job. I’m glad your son is fine. “He’s a good kid, but tell him for me; ‘No more rock climbing without a rope, OK?’ ”.
You collect a few dozen of these incidents and people start talking about you behind your back. It’s not the usual nasty small town gossip stuff, quite the contrary; they talk you up into hero status. I hate that word hero, it is SO overused. I have never, single handed, saved a person’s life. It’s a team effort. I don’t have the tools or the skills to do it alone. I MAY have held off death long enough for some additional help to arrive, but as of yet I am not superman. I’ll let you know when that happens.

Stuff, Things, and Background

 So if you’re a blog reader and stumbled on this one, you will immediately recognize that this is the ‘necessary background post’. One of those posts you, the reader will need to understand the writer’s point of view. If anything of value is written, you are bound to ask yourself “what is this guy’s angle?” (or “what is this guy’s Problem?”) You need a post like this to fill in the blanks.
 I do a short introduction of myself every class I teach for the benefit of the students that may not know me. I should do no less for you, the reader. Well, I have to do a little less. I can’t tell you my state, but I can tell you we have 90+ Degree (F) in the summer time and -5 or more Degree days in the winter. Yeah, it snows, and we get thunderstorms, hurricanes every few years, tornados from time to time, but I don’t think we’ve had more the a few small earthquakes in my lifetime. We are only about 20 miles from the nearest (very) small city that has a career department, and about 90-100 miles from the closest major city.  This is an anonymous blog so I need to be somewhat sketchy or elusive on most points, but I’ll try to give you enough to give you an honest, if general, picture.
 I’m a Firefighter. I’m an EMT. I’m a pro-board Fire Service Instructor. I am a volunteer. I am a line Officer. I’m getting near the end of my game (aging out), but I love this job. I also have a career that provides me with a livelihood and that involves working as a professional in the Engineering field. My job also permits (or demands, it’s a fine line) that I travel from time to time. I have a few kids, all growed up and sort of on their own.
 Everybody knows there is a lot of disparity between the Volunteer and Career Fire Service. The same holds in the EMS world. Most volunteers think they are the greatest thing since sliced bread. I do not. Most career folks think they are the only professionals. I do not. I have seen a lot of poor work, bad training, ugly decisions, sloppy tactics, lazy approaches, and downright unprofessional behavior from both sides to convince me that we ALL have enough problems to keep us busy. I have also seen glaring examples of extreme skill on both sides, be they paid or not. In the coming posts I intend to explore some of these issues in depth.
 Some time ago I was at our State Fire Academy taking a week long class. It was a rare week when alcohol was allowed on the campus under a special permit (this was intended to keep the students in my class, an experienced group, from leaving in the evenings to stay on campus to study and do project work). At any rate, there were a few of us sitting in the lounge and shooting the breeze. The normal exchanges of who belonged to what Department and what they did took place. As it turned out, the two fellas I was speaking with were from one of the largest and busiest city departments in the country and these gents were part of one of their specialty Rescue Companies. They do building collapse, high angle, dive work, recovery work, and all the ugly stuff. They are (in my eyes) the elite of the elite. They asked about me, and I sheeepishly replied that I was just a volunteer in a little rural department. One of the guys (the Lt.) perked up and asked me where exactly, my Department was. I told him and he immediately recognized the area. He said “Wow man, I don’t envy you. You guys get those NASTY high speed car accidents on that State road that goes through the middle of town.” I just mumbled that it could not possibly compare to the type of work these guys are called on to do every day. He stopped me cold in mid sentence and looked me straight in the eye as he leaned forward for effect. He said “Listen Mister Let ME tell YOU something, it doesn’t matter if you take a paycheck from this or not, dead is dead. You put your ass on the line, just like I do mine. I have an income and some protection for my family if I don’t come home, you don’t. You guys do it for FREE and keep asking for more. That just blows me away! Last year I drove through your town and saw one of those holiday weekend accidents. I couldn’t even tell where one car ended and the other started. I was gonna jump out and offer a hand, but you guys had everything nailed and I would have been in your way. To tell you the truth, I did a quick size up and realized I wouldn’t know where to start that job. Don’t ever sell yourself or your Department short!” We talked on into the night about everything from the routine nonsense we all deal with, to solving some problems in our state, to well…. most of you know what firefighters talk about.
 So what I learned that night was that it’s all about respect for each other. Since that day I have made a point of carrying that idea forward in how I teach, train, and work with others. The jobs are tough enough, why make them harder?
 Some days I feel like I’m in a cosmic void, stuck between planes of different existence. Career doesn’t play with Volley, EMS doesn’t play with Fire, and Battalion doesn’t play with the Line Officers. I want to scream “Does ANYBODY here realize we are all here with the same goal?!
 Anyway, more of that stuff to come in the future.
 Got to run, the pager’s dropping tones….

Friday, November 27, 2009

Chronicles Of EMS

I had to make this one of my first posts. The Happy Medic and Medic999 have just completed the grunt work on The Project which was then rolled into something else called the Chronicles of EMS. What this is turning into no one can really say, but what we do know is that it will be something worth keeping. There will be some sort of movie/video coming out from Setla Productions in the near future.
 If you were too lazy (or riveted by my prose!) to click on the links above, The Project developed as Mark and Justin had their own blogs and began to read each others. That led into swapping notes, complaints, and thought about their various agencies and systems. Mark is a Paramedic Team Leader in England, and Justin is a Firefighter/Paramedic in San Francisco. Blogging back and forth, then some emails, then phone calls, all lead up to them getting together. Mark spent about a week working with Justin in S.F.F.D. with camera crew in tow, and then Justin followed Mark back to the UK for a week at Mark's agency.
 The reason I lay all this out for you is that I fear you might be living under a rock and need somebody else to bring this to your attention. You see, this is something you have already missed in the 'live' stage, up to this point, but while everything is still fresh, you should follow all the links and catch up on the videos. There is much more to come from the project and everything up to now id just the raw stuff.
 Justin and Mark and getting re-acquainted with their respective families after about a 20 day non-stop odessy. They be back in about a week and start giving us the real lessons learned from their trip.
 We in the EMS community owe them both a debt of gratitude. While we don't know yet exactly what changes will come about from The Project, we do know that they have clearly opened the door and shown that we all have something to learn from each other, none of us have the perfect solution, and all we need to do is ASK.
 I started this scrawny blog today much because I have been reading Mark and Justin's stuff for well over a year now and know they have something to teach me. I also realize that I just might have something to teach others (my Instructor's credentials not withstanding). So let's see how this goes and if I can keep it up. In the meantime, go catch up on what Justin and Mark have been writing. I don't know these guys on a personal level, but I feel like we've been friends for a long time. (by the way HM, Capt. Tom says "Hello")