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.