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.

26 December 2011

Frequent flyers...

You know, when the ED nurses call you by your first name as you are escorted, ambulatory, into the ED, and can recite your birthday without hesitation, I think it is safe to assume you have spent way too much time in the ED...just sayin'...

22 December 2011

Implications...

Around these parts a case that happened in an adjoining county has once again made the news. You can go to the WRAL TV5 website and see this report, with links to several more.

Basically, EMS was called to the residence, something occurred between the responding paramedic and the patient, he was not transported, and he died a short time later. That is basically what I know of the call. Other than the legal maneuvering that has gone on in the aftermath. That report can be found here.

So...yesterday I put up a status update on Facebook hoping to generate a little discussion. And it worked. Of course, it was sort of one sided. Kind of a "yeah, he screwed up, but they are throwing him under the bus" sort of thing.

Again, I am not privy to the facts, except as reported, and of course what I have heard from folks who worked in that county at the time. Yes, some mistakes were made, and we will never really know exactly what happened that afternoon. There are two stories, and I think what actually happened is somewhere in the middle.

But, I am sort of reminded of my experience years ago with a patient who refused treatment and transport and was dead within 90 minutes of his signing of the refusal form.

The dispatch was for an 'unconscious person'. After traveling the 14 or so miles out into the rural countryside, as we arrived, I saw an older man walking across the road to a small house, waving us down. When my partner and I entered the living room, I immediately headed to the older female who was lying on the sofa, since she looked like she was pretty sick. She then pointed me to the older man, who was seated in a chair.

He looked worse.

Pale, ashen, diaphoretic. A little cyanosis around the mouth and the hands. And what seemed like labored breathing.

Yep, seen that before. It wasn't good those other times, either.

Long story short, over the next 45 minutes I begged and pleaded with this gentleman to allow me to treat him and take him to the ED. I did get a pulse check (cool and clammy skin with a weak and irregular pulse) and a capillary refill check (a little over two seconds). He adamantly refused a blood pressure check and an ECG (although I could not have run a 12-lead with my now-classic Marquette 1200 'boat achor').

Finally, his wife said "Why don't you just do to the damn hospital?" To which he replied "Naw, God dammit, I ain't. And ya'll can get the hell out of my house!"

He did agree to sign my refusal (and I bet his signature is still embedded in that aluminum clipboard). We went back to the station and I sat down to write (yes, write...we used to have to do things that way) my call report.

And a short time later, we were dispatched to the residence again.

There was no one outside to wave us down this time. I heard the crying from the front yard. His wife was still on the sofa. "He's in the kitchen." There he was, prone on the floor. He had gotten up to get a glass of water and collapsed as he was drinking it.

We started the code, according to the latest guidelines at the time. We had to wait for a neighboring agency ambulance to arrive to help us out (30 minutes later). We emptied the drug boxes (because that is what we did in those days) and transported to the nearest ED about 20 miles away.

Twenty-four milligrams of epinephrine 1:10,000. 300 milligrams of lidocaine. Three milligrams of atropine. 100 mEq of sodium bicarbonate. The maximum dose of bretylium (I don't remember how much that was). 3,000 ml noraml saline. Two IVs. A well placed 7.5 ET tube. And he's still dead.

Word got around fast. At that time, there were only about 15 practicing paramedics in the county. We were a small, tight knit group. And there were a couple of folks at the local hospital who did not count me as one of their favorite people (it may have been my outspokenness, or maybe my winning personality). They were looking to blame this man's death on my cold heartedness.

Remeber that call report? Well, I had documented that I had offered to provide an assessment that he repeatedly refused. I had documented my dozen or so offers to take him to the hospital that he refused. I documented that I had told him that I thought he was having serious medical issues (I actually told him 'heart attack') and that if he did not go to the hospital he could die. And I documented that he repeated it back to me.

And I documented, word for word, what he told me when we finally left.

The medical director reviewed the call, and contrary to what some other folks wanted, he found that I did nothing wrong, that I had handled the call well, and that was that.

All because of a thorough call report narrative.

Now, I don't know the details of what happened in Orange County, but I have to ask this- was there a good call report written? Did he document attempting to contact paraents, neighbors, or school officials? Did he document that the patient, although a minor, had demonstrated capacity to udnerstand the consequences of not going to the hospital? Did he document a thorough assessment, to include more than one set of vital signs, lung sounds, and an ECG?

I don't know. But I do know that a good call report can save your ass, while a bad one will leave it hanging.

10 December 2011

There is more than one way to skin a cat, so they say...

Recently I had the opportunity to meet a very nice older lady who was complaining of chest pain. In my EMS system, that gets you 324mg of aspirin pretty darn quick. Usually, the firefighters have given before I get there, but on this occasion they had not.

Allergy.

I asked the nice lady about her allergies and she told me that she was allergic to Benadryl and aspirin. She said Benadryl made her sleepy and that aspirin upset her stomach sometimes.

Just about that time my partner handed me the 12-lead ECG that displayed ST elevation in V1, V2, and V3, with reciprocal changes in II, III, and aVF. Add to that her being pale, diaphoretic, and more than a little restless….

So, I told her that it was really important that she take the aspirin for her heart, and she quickly told me she could not take it because she was allergic to aspirin.

OK… plan ‘B’.

Me: “OK, tell you what. Let’s try this newer drug that works just like aspirin.”

She: “OK. Because I am allergic to aspirin. What’s this new drug called?”

Me: “It’s called acetylsalicylic acid. It’s abbreviated ASA.”

She: “OK.” (chews them up)

She: “These sure do taste like aspirin.”

Me: “They do taste like aspirin. But they are acetylsalicylic acid.”

She: “That’s fine. You know what’s best, young man.”

07 November 2011

What we got heah….

…is failya…to commun’cate. 


Anyone who has seen the absolutely superb movie “Cool Hand Luke” no doubt remembers that scene. It is one of my two favorite movies of all time, and by far that is my favorite scene of any movie.

Failure to communicate.

You would think that in this day and time communication would not be a problem. As a society we are very ‘connected’. The phone that I carry can connect me with anyone in the world in an instant. I can access weather reports, the internet, and the blogosphere, as well as drug information, and a whole host of other information in a matter of seconds.

My television has access to hundreds of channel via cable. Via my home phone I can call anyone in the world. My laptop that I am typing this on connects me to the internet, various instant messaging programs, Skype, and all manner of TV and radio.

At work, we have a digital radio system that enables me to talk not only to my co-workers anywhere in the almost 860 square miles in my county, but, being part of a statewide network, I can talk to other agencies and responders beyond my county’s borders. Add to that multiple ‘talk groups’ with multiple channels each, and there is a lot of capability.

Contrast that to ’the old days’. I carried a couple of quarters to make phone calls. We did not have ‘call waiting’ or ‘call forwarding’. On many long distance calls you had to get an operator involved. We had three TV stations. To get our news we had to, egad, read the newspaper.

And back in ‘the day’ our radios were limited, too. Pretty much ‘line of sight’ was the most we could expect. In one county I worked in we had one fire channel and one EMS/rescue channel. In that county a large metro area about 200 miles away constantly overrode our transmissions. And the EMS channel was a statewide channel.

I guess you could say that communication has come a long way. When we use it.

Yep, when we use it. And when we don’t, well, that causes surprises on the emergency scene. And if a little communication will prevent some of those surprises, well, why don’t we?

I tried to find a Timeless Tactical Truth about keeping secrets and preventing surprises, so I guess I will write it now-

“There should be no secrets on an emergency scene. Secrets cause surprises. Surprises are seldom good.”

Basically, that means share the information. We have the ability today, more so than at any time in the past, to share information. For EMS, that means taking a little something from the fire department’s playbook. If you haven’t noticed lately, the guys and gals here in the Capital City are providing a lot of information on their size-ups. It’s change, and it is something to get used to, but they seem to be getting better and better at it.

Unfortunately, here in the EMS world, we have gotten pretty reliant on ‘the button’. The button on the MDT that says “arrived”. The problem with that button is that it does not relay a lot of information, other than you have arrived.

Lately, I have been assigned to a single person unit. I get dispatched to calls with other units and a lot of times I am not the first on the scene. So recently I was dispatched on a “not a cardiac arrest” call. Somewhere along the line that call was upgraded to a “cardiac arrest”. Several more units were trying to add themselves to the call.

Anyway, the first unit arrived. Then the second. Then the third. There was nothing more than a change in status on the MDT map.

So I arrived and noticed one of the responders standing at the back of the residence. Not knowing what the actual situation was, I asked if the need anything. The reply was for a particular piece of equipment to move the patient.

Well, since we work full arrests in place, and no one had announced “working code”, I retrieved the specified article and walked around to the back of the residence.

To discover chest compressions and ventilation in progress.

Over the course of the call a couple of pieces of equipment were needed that would have been on hand if the announcement “working code” had been made.

Over the years I have had a lot of those not-so-pleasant surprises from on-scene units that had not provided a verbal update. A few cardiac arrests, gunshot wounds, babies in the process of being born, and more.

And it is so easy to avoid those surprises. Let some one know what is going on. Everyone is quick to say “you can cancel” (well, most of the time). So why not let someone know if you are working a code, have multiple patients, or the like.

In this day and time, we should avoid the “failya to commun’cate” every chance we get.