If, in moving through your life, you find yourself lost...go back to the last place where you knew who you were, and what you were doing, and start from there. Bernice Johnson Reagon.

30 December 2015

I have not posted in a while...

...mostly because, well...I haven't.

Time, priorities, and writer's block.

But, there is this post over at the Ambulance Chaser Blog, so I am posting a link here.

Go read.

14 June 2014

Blauer 8" BLITZ duty boot wear test

I earned my EMT certification in 1976, the same year that the EMS classic movie. Mother, Jugs, and Speed was in theaters. The week I got my card in the mail, the number one song was Chicago’s If You Leave Me Now, the Montreal Canadiens were the reigning Stanley Cup champs, and Gerald Ford was president.

A lot has changed since then. Over the years, I have been a gearhead- still am to a degree. I am always testing out neat stuff, most of the time just because, well, I could.

So after all these years, it was pretty cool when I got an email from Blauer to test out a pair of their boots.

Over the years, I have worn a lot of different boots, partly due to my weird feet. I’ve had a hard time finding boots that wear good, fit good, and look good. You name it, I’ve worn it. Some lasted a long time but were not comfortable, while others felt good and lasted about eight months. So I was more than willing to test out a pair of Blauers. I’ve seen them advertised but they were about the only ones I had not tried.
For the past five or six years, I have worn Haix Air Power boots. They wore...OK...but never did get really comfortable. I was hoping that sometime they would break in, but they never really did. So yeah, I was looking for some replacements, and when Baluer came calling, I said "OK".

For my wear test I selected the Blitz 8” waterproof boot.

Look what FedEx left
They arrived on a Friday just before lunch, so I started the test that afternoon (yes, I get to come home for lunch...hey it's a perk of being the Training Officer with a whopping 1.1 mile commute!).

The first thing I noticed when I took them out of the box was the BOA lacing system with stainless steel cables. I was wondering how that would work but I have been pleasantly surprised. One of the problems I have always had with zipper boots has been getting a good fit and having 
the boot not slip up and down without getting them too tight. The BOA works wonders- the boot fits but it is not too tight.

Score one for Blauer.

Like every boot or show I have ever worn, my weird feet have always required a break-in period. Some boots never ‘broke-in’. Some felt good from the get-go but not too long later they felt ‘worn out’. My Blitz boots took a couple of days to get broken in, but by Monday afternoon (yes, I wore them over the weekend at my other gig- CCT paramedic) they were feeling pretty good. And if my feet are not hurting after work, that is a good thing. And they still feel pretty good now.
Score another one for Blauer.

I don’t normally stomp through deep water anymore (I guess that comes from riding a classroom), but the other day that sort of changed. We were doing driver training where I work and I was overseeing a backing station, when one of the "afternoon and evening" thunderstorms our area is known for in the summer time dropped in. So, I wound up standing around in 4” of water…and while my head and upper body was wet…and I mean soaking wet, my feet were, well dry.

And score another one for Blauer.
The Blauer 8" waterproof Blitz boots
Now I did not put them through some of the same "scientific" tests that fellow blogger Kelly Grayson did over at the Ambulance Driver blog. But, I have given them a general wear test, and there is one thing that counts above all- my feet don’t hurt at the end of the day. And that has not happened since I was issued my all leather army boots at basic training at Fort Jackson many years ago.
Also, there is something in the descriptive literature about 'antimicrobial' materials and such, which I take to mean 'odor suppressing', or something similar. And since my feet are know for their distinct aroma at times, this is a good thing. And since the dog does not get dizzy and stagger after I take them off or he walks past them, I guess it works.
The Blitz boot is billed as the "ultimate is public safety footwear". And from my feet's point of view, they are pretty damn close.
The only thing I would suggest to Blauer is to develop a pair with a safety toe, specifically a composite safety tow. I don’t know about law enforcement, but a lot of EMS agencies specify that footwear has a composite safety toe.

Other than that, two thumbs up.
I have worn Blauer stuff for years. One of my employers issued us Blauer jackets, shirts, and pants and they were always very comfortable. These boots continue that tradition.

19 May 2014

School Days UPDATE

My Dad told me once to get an education. I guess it meant a lot to him because he did not have one.

So in 1984 I set out to 'get a degree'. I got my Associate Degree in Fire Protection Technology in 1987. I always wanted a Bachelor's Degree, but back in that day, just getting an AAS was hard. It was the only degree I could get at the time with my work schedule, and most fire chiefs back then did not place too high a premium on getting degrees and stuff.

So fast forward to 2006. It was possible to get a Bachelor's Degree online. Plus, there was a program near by, I knew the guy running it, and I knew several who had graduated from it. In the fall of 2006 I started in the EMC program at Western Carolina University.

I had planned to be finished by 2010.

I have often heard that "if you want to hear God laugh, tell Him your plans". Yeah, He sure must have gotten a chuckle.

Life happens, and I had to skip a couple of semesters in 2010. Then I started back, but had to stop again in 2012. And it was starting to not look very positive. You see, when it gets down to it, college costs a lot of money. And you can get reimbursements and stuff, but you have to have the money up front, or you at least need to know that you can get the money so you can pay it back if you borrow it.

So, I got an email the other day from the NC Association of Rescue and EMS telling me I had been awarded a scholarship beginning in the fall of 2014.

I have four classes left. So maybe, just maybe, nine years after I started, I will finish up.

Here's to the Class of 2015.

21:30, 21 May 2014- This just in. Good news travels in waves. Humbled and honored to receive a scholarship form the Johnston County Rescue Association tonight. Looks like my summer, fall, and spring are full!

The other JOCO...and their approach to those plastic boards...

We put too many people on backboards...

I have said it before, as have others. There is even an EMS system out in Kansas quite a few EMS systems around the world that have taken a whole new approach to that whole plastic board torture routine spinal immobilization spinal motion restriction transporting people on hard plastic boards practice.

Maybe now people are finally re-evaluating the dogma long held belief that we have to put patients with curved spines on hard, flat surfaces.


26 February 2014

Another blog...and a friend's blog at that

Danny is one of the people I count amongst my friends. I worked for him at one of the EMS agencies I used to work for and many a day he would stop by and we would "talk puck". After I discovered that I was indeed a hockey fan, it was Danny who explained a lot about the game to me- the penalties, the calls, the plays......the game. It's one thing to enjoy something, it is still another to enjoy something AND understand it.

So after The Forks went away, Danny worked for one agency and I worked for another. I would catch him on Facebook from time to time, but then he decided to step away from The Book of Faces.

So now he has a blog- The Knives Den. Being that Danny is a Buffalo Sabers fan, I am sure he will be blogging about the Sabers, among other things. So if you are inclined, go check him out.

21 November 2013

Scenario of the day...part II

The "Scenario of the Day" was presented here. If you did not check it out, go on over.
OK…in looking at what you were presented, it is apparent that the driver struck the deer and veered off of the roadway then overturned. The signs and symptoms presented, along with the vital signs, suggest that the patient is hypothermic, highly probably given the patient’s age and the ambient surroundings. The inside of the vehicle being ‘covered with newspapers’ was an indication that maybe this guy is a newspaper delivery person and this occurred a little while ago and was only recently discovered. Nobody specifically asked, but that was the deal.
Couple of points about the vital signs-

As the body’s core temperature cools the blood pressure drops, the heart rate slows, peripheral pulses fade out, and the respiratory rate slows. If you cannot get a good blood sample, you may get to get the ‘error’ message on the glucometer and you are probably not going to be able to get a good sample. The temperature is a deal clincher, but then the ECG provided the next big clue- Osborn waves, which are prominent as the core temperature goes below 90°F. Blankets are in order- surely more than one. And be wary of exposing the patient- we have to, but remember that the body loses heat by way of convection and radiation. If it is cold outside, put a blanket on the backboard to act as a little bit of a barrier between the patient and the cold backboard. And don’t forget to warm up the ambulance. If you’re comfortable, it ain’t warm enough- turn up the heat.

Even though the SPO2 is only 62%, remember, that peripheral circulation is slowed due to vasoconstriction during hypothermia, which reduces the ability to get a good reading with a pulse oximeter. The lack of cyanosis could be a good clue that the patient is still oxygenating. Given that we lose body heat through respiration, judicious use of oxygen, especially arbitrarily via NRB, should be considered.
Given the patient’s depressed mental status, it is reasonable to go with spinal motion restriction precautions (be alert to potential airway compromise if the patient vomits). There are no apparent extremity injuries, and even though many would consider the blood pressure as ‘low’, it is still above 90 mmHg systolic, so be judicious with the fluids. Also, ‘warmed’ fluids would be appropriate, but be careful not to rewarm the patient too fast. Don't have an IV fluid warmer? There are some ways to accomplish that, but...you're not trying to rewarm them, just stave off the continued drop.

With the fast extrication he obviously was not pinned. There were no obvious injuries, however, just due to the GCS and his age in the setting of a potential traumatic event, he meets Trauma Notification Criteria per CDC guidelines. However, that does not necessarily indicate flying him out. With the short drive time, it will be doubtful if there is any true time savings going by air. If you're not going to save any clinically significant time, why bother. I know, helicopters are sexy.
Cancel the bird.
But what if the helicopter lands? Well, if the patient needs it, and the helicopter is going to save a significant amount of time, the put them on it. But, when you figure in the turnover time, the loading time, the take-off and flight time, along with the off-loading time and going into the hospital, you are not saving anything over a 20 minute ground transport time. This guy is fine to go by ground.


20 November 2013

How well do YOU take care of people?

Not long ago a friend of mine relayed his experience with EMS in another county during a family emergency. That chat reminded me of an experience my parents had with EMS several years ago.
A while back over on The Happy Medic, San Francisco Fire Department Paramedic Justin Schorr wrote about his family’s experience with a child’s medical emergency. And of course, Justin zeroes in on some EMS related issues. Be sure and go over to read his blog. Good stuff, it is.

But anyways, once again, it kind of got me to thinking. How well do we really take care of people?

It depends upon what you think it involves. Of course, we have protocols to follow, skills to do, and on and on and on. But there are other things that we need to do that are just as important. And they have nothing to do with starting an IV, reading a 12-lead, or any of that other stuff you learned (hopefully) in paramedic (or EMT) school. It’s all about how you take care of people.

Justin mentioned something in his blog about warming a stethoscope. So just how many times do you take the time to warm up a stethoscope before you place it on a patient? Especially in the winter time when it has been hanging in the back of an ambulance, probably on that catch-all-netting at the head of the bench. Even when it is wrapped around your neck it gets cold. Little kids and elderly patients are kind of sensitive to that cold stethoscope. And guess who makes up a large number of our patients? Yep, you got it. So take a few seconds, tuck the bell under your arm. Probably would be a good thing to do when you are introducing yourself to your patient. You do introduce yourself to your patient, don’t you?

Another thing I have noticed is that the entrance to Walmart is smoother than the entrance to most of this area’s Emergency Departments. So, do you take it easy over those entrances, or just bump on across? Based upon what I have seen, most of us just bump on across. Probably feels really good with that broken hip, bone cancer, or any one of many maladies that hurt when you move. 

And when entering the ambulance entrance to several of the area EDs, it seems that the worse part of the trip is when you are turning into the ED. And we know doubt know it since we do it enough. So how many of you just turn on in, bumping and swaying? And how many of you think about your patient (and partner) in the back of the specialty vehicle you are driving that is NOT known for its smooth ride? If you are the one that just drives on in without consideration for your passengers, I bet you are the one that does not slow down and ease across railroad tracks as well.

But what about other things along the lines of ‘taking care of people’?

Do you explain what you are going to do and why you are going to do it? As I get older I am exposed to the healthcare system just a little bit more. At my colonoscopy I saw a wide variety of ‘explaining’ and the lack thereof. The nurse that started my IV had a good technique (well, her tourniquet technique sucked) but she barked out orders like a drill sergeant- “Put your arm down”, “Make a fist”, “Hold still”. And when she was done she just walked away. Oh yeah, and there was that introduction- “I’m gonna start your IV”.

Well, she did tell me what she was going to do. And what do to. In no uncertain terms. But ‘why’ would have been nice. So would a personality.

I always tell my patient (even if they are unconscious) what I am going to do, why I am doing it, if it’s going to hurt, etc. And you should too. It is part of the reassuring process. For a lot of people (I like to think most of them) the whole process of getting hurt or sick and calling 9-1-1 is a pretty stressful and frightening event. A big part of our job is reassuring them and alleviating their fears. And to do that you must tell them what you are doing, why you are doing it, and quite frankly, if something is going to hurt. Before we do it.

And how well do you ‘relate’ to your patient? You know, that rapport that you have to establish early on to gain their confidence. I have seen some people that are really good at it, while others…well, some people are really good at it. It’s all of the stuff above, and a little more. In my old system we used Panasonic TOUGHBOOK laptops to complete our call reports. And there was a natural tendency to type as you rode. And that is OK if you can pull it off. By 'pull it off' I mean that you have to maintain that rapport, that relationship, with the patient. And that means you have to talk to them. Pay attention to them. And, egads, reassess them.

Reassess means more than let the Zoll's blood pressure monitor recycle every few minutes and take a look at the pulse oximeter reading every few minutes or so. It means talking to them. It means asking them if they feel better, if the oxygen is helping them or if the pain medication is working. Or if they’re feeling worse. And you CAN’T sit in the ‘captain seat’ and do that. And sitting in that captain seat, typing away, and asking your patient, from behind them, without making eye contact, if they are OK, to me, is worse. I know someone who did that and arrived at the ED with a deceased patient...who was not deceased when they put them in the back of the ambulance.

Taking care of people is a total package. Sure, starting that IV and reading that 12-lead is important. But being nice (because nice matters) is just as important. Maybe more so. In the end, it is the total package that matters. It is the total ‘A’ game.

And you have to bring that total ‘A’ game to every call, every time.

Anything less is not doing your patients (or their families) any favors.

19 November 2013

Scenario of the day...(UPDATED)

You are dispatched for an MVC at 06:33. The location is on a rural road approximately six miles from your station. A fire officer arrives, establishes command, and tells you that you have an elderly male, unresponsive, and entrapped in the vehicle. Command notifies the dispatch center to “put a bird in the air”.
You arrive to find an approximate 65 year old male in the driver seat.  Damage is as noted in the picture. There is no passenger compartment intrusion and the patient appears to have his seat belt on. The inside of the vehicle is covered with newspapers (dozens and dozens of them) and many more are on the ground around the vehicle.
First look at the patient- GCS 1-1-1, RR 12 shallow and snoring, pale looking skin.

There is a large, dead deer lying along the roadway near the crash.

It is early morning, the sun is rising, it is cloudy, 34° F, 54% humidity, and the wind is at 15 mph out of the SW. Traffic is light. You have an EMT for a partner. You have a QRV-based supervisor within 15 minutes; your next nearest ambulance is 20+ minutes away.
What are you going to do?


The first vital signs after you get in the vehicle-

BP 94/58
HR 40 weak and irregular
RR 10 shallow and snoring
Pupils equal and reactive
Finger stick gets an ‘error’ reading
Tympanic temperature 84°F
SPO2 is 62%
Skin is pale and dry without cyanosis

The first ECG-
courtesy of Dr. Smith's ECG Blog
 Ground travel time to Level I trauma center is 15-18 minutes. Travel time to community hospital is 15-20 minutes.
The fire department has the patient free within 10 minutes. The helicopter is “five minutes out”.
Patient is exposed- no obvious deformities to any extremities. Chest expansion is equal bilaterally and lung sounds, while faint, seem to be clear. Carotids are faint- radials and pedals are absent. Upon extrication patient GCS is rated at 3-4-5.
You find three pill bottles in the vehicle (you DO take a quick look for such things, don't you?)- levothyroxine sodium, morphine sulfate, and paroxetine hydrochloride.
I have one response so far (Thanks, Cathy!). C'mon folks...
What do you think? What special things (if any) are you going to do? Is there anything different that you might do? Let's hear it.
Note: If you need a bigger copy of the ECG, email me at the address to the right.

08 September 2013

How long does it really take?

Dispatched for a motor vehicle crash (MVC), Upon arrival there is a patient who was riding an ATV and was struck. The patient was ejected and then part of the ATV landed on him. There are obvious patient care issues and such, but which mode of transport do you use? Air or ground?
Some things to consider-
1. You have a Level I trauma center 30 minutes driving time away (it could take longer- that depends upon traffic conditions).
2. It is clear weather.
3. Your patient meets CDC Trauma Notification criteria.

Should you fly the patient? After all, flying is quicker. Isn’t it?

Well…maybe not. There are a few things to consider.
First, how long before the helicopter gets to you, assuming that it was not requested until you arrived. If it was ‘placed on standby’ while you were en route, how long before it gets to you? Figure five minutes to get into the air (based on what I have seen while watching helicopters take off) and then whatever the flight time to your location is. Then there is the landing and the crew exiting the aircraft. And no, it is not like any DUSTOFF mission you have ever seen where the flight medics and/or crew chief jump from the aircraft and run to the medics.

Second, how long does it take to provide a patient report to the flight crew? My experience? Five to six minutes. What I have seen documented? Anything from five to twenty-four minutes (yes, you read that right).
Third, they have to load the patient onto the helicopter. Again, this is not like Vietnam or Afghanistan where they open the doors and the patient is rapidly placed into the aircraft. No, this is a process. I have never seen it done in less than five minutes. Maybe it can be done quicker, but sometimes it takes longer.

Then there is take-off and flight time and landing. Then the patient is unloaded and taken into the facility. At two of my local facilities, this is five minutes or so. And no, they are not running.
So how long did that flight actually take? Figuring in best case scenarios of five minutes for each phase listed above, and allowing for a twelve minute flight time, then we have taken about 27 minutes from the time of patient report to unloading the patient at the facility.

For a 30 minute trip, we have taken just under 30 minutes. In ideal conditions, we have shaved three minutes (maybe) from the transport time.
But, what if you have to take the patient to the landing zone? Depending on where that is located, we are talking maybe five minutes. Or more.

Based upon some research on call records I discovered the following intervals. Documented.
1. Travel to landing zone- 5-9 minutes.
2. Patient turnover to flight crew- 5-24 minutes (out of several flights, only one was 24 minutes; one was 18 minutes, the rest in the 5-9 minute range)
3. Loading the patient onto the aircraft- 5-9 minutes
4. Figure a flight time of 10-15 minutes.

Then, when you figure in timed observations at a couple of the local facilities for unloading the aircraft and taking the patient into the facility of 5-8 minutes, that short flight to the trauma center actually can take takes 30-50 minutes. Yes, you read that right.
At best, that 30 minute drive turns into a 30 minute flight.

So we have saved…what?
Now, don’t take this to mean I am totally against medical helicopters. I am not. I think they are a fantastic resource in certain circumstances. I also think it is pretty neat flying on a helicopter. And I think they just look cool.

But, I also think I have to do what is best for my patient. All the time. And if I can get the patient to the trauma (or STEMI or stroke) center in a reasonable time by ground, then I need to hit the highway.
Helicopters can save time in certain circumstances. If the landing zone is close by, and the helicopter is waiting for you when the patient is extricated, and the driving time to the facility is extended (40-45 minutes or greater, then maybe there is an advantage to cutting 5-10 minutes off of the time it takes to get the patient to the hospital.
A lot of the research says otherwise, but I know how some people feel about the research.
The 'romance', if you will, with medical helicopters grew out of the 60s. Many people have a memory of news video from the Vietnam war of Army UH-1's with red crosses emblazoned front and sides, landing ever so briefly in a rice paddy for the wounded, then hustling them off to army MASH units.
We became enamored with flashy terms like "The Golden Hour" and ""The Platinum Ten Minutes". But where was the research into those time frames? Sure, it is intuitive that a trauma patient gets to a trauma center quickly, but how quickly?
You can search the internet now and find videos of DUSTOFF missions from Afghanistan where UH60s swoop in, and after just a minute or two on the ground, hustle their wounded cargo off to field hospitals, bypassing the less-than-developed road system, laden with IEDs, that is Afghanistan.
But that is a different world than what we live and work in.

07 August 2013

Homes and Stability

For the record, I have never been homeless. On the other hand, a couple of times I have been close. Such are the times we live in. You can make the right decisions, or at least not the wrong ones, or even big wrong ones, and things, well, implode.

A lot of attention is thrown towards homeless veterans. There are a lot of reasons why it turns out that way, and deep down, there is a part of me that truly believes that no one really wants things to turn out that they are homeless. With nowhere to go.

In reading the comments, there are a few people that think this is a bad idea. I guess it is part of that ‘give a man a fish and he eats for a day, teach him to fish and he eats from now on’, or something like that.

Of course, in my travels on an ambulance, I have seen my share of homeless people. And for the most part, they are basically good people that either life through a curve ball, or maybe they did not make the right decision(s). Sometimes, it can be about not being taught what the right decisions are.

My hometown has a large homeless shelter on the south side, and there are a couple of other places for folks to go. But of course, those are not intended to be long term solutions. And somehow, I don’t think this is a long term solution, but it is a start.

Things are a lot easier if you know you have a place to go, a place to eat, a place to sleep, bath, and keep your stuff. Maybe it is the difference in getting back onto your feet and making a difference.

And some people will say this is another form of socialism, of hand outs, or pandering.

To you I have one thing to say…maybe.

But, these folks have demonstrated that they can work, that with a little, well, supervision and stability, they can contribute.
And in my mind, anyone that rose their right hand to swear an oath to defend the constitution of the United States, against all enemies, both foreign and domestic, then well, they have earned that extra helping hand, whether it is healthcare or help getting a place to stay, or priority points in getting a job.