From time to time Transport EMS will generate an interesting or entertaining call, but nothing beats the 911 experience for bulk delivery of great stories (suitably modified to protect patient confidentiality, of course.) For this reason if no other DTs has been lazily swatting at 911 gigs as they came by.

The first two tries, actually, were with the same system, but each got no further than the "Meet with the Panel" stage. Details are in here somewhere, I won't bother with them again.

So I thought, "What the hell. Let's give a different system a try." Something I'd been avoiding because DTs has no repeat no interest whatsoever in becoming a firefighter.

Most of the systems in Northern VA/DC/MD still use the archaic Combined Fire/EMS approach. I'm given to understand that much of the country is the same way.

Basically, one is trained as a Firefighter, and an EMT-B. Some systems require an employee to then get at least an EMT-I within two years; others let one stay a FF1/EMTB and only require the "I" or "P" certification if one wants to be a medic.

If, on the other hand, one wishes to be a medic, this is the routine in those systems:

One is trained as a Firefighter, and an EMT-B, then goes on to earn the "I" or "P" certification.

Yah. Really.

"Why," I can hear your plaintive cry, "Do they make a medic be a firefighter? It makes no sense! For," you continue, "If there is a fire, there are many a fresh-faced boy slavering to dive in with mighty hose and subdue same; yet, if there is an injury, surely someone not fighting the fire is required to treat and deliver to hospital."

I agree, I agree. And it is not a double-standard, methinks, to require firefighters to have basic EMT skills:

"Hey, sir, nasty car accident! You okay buddy?"

"Nnnnngngggg"

"Here, lemme help you outta there... door stuck... gotta pull you out through the window... I'll just pick you up by the head and slide you through. Maybe a little twist here..."

Still, as She Who Must Be Obeyed said, "It's just another class; go through it and be done with it."

For lo! Whilst doing lead-seat time with A County, DTs was pulled aside by the Rescue Chief who said unto him, "Come work for us!". On another occasion, a Captain: "Join us!". Yet again, another High Level Gentleman: "Why not work here?"

Fine fellows all! Actually, some of the best I ever met. And yet, the fireguy angle. As one of them put it, "Just get through fire training, and get your FF1, and I promise you can be on the medic the first day out of recruit school. You'll never have to ride the engine in your life if you don't want to - but you will have the option, with FF1, if you ever need or want a break."

Hmmm. And yet....

I would not, could not, with a hose,

I don't like wearing Turnout clothes,

I would not, could not, with an axe,

Or wearing heavy High-Rise packs

The victims don't say "Feeling good!"

Surrounded by that burning wood

Fire guys: Bring them to me!

I'll give O2! I'll start IV!

I'll take them to the doctor, true,

Then come right back and cover you

Tonight, when there's a "Pain in chest"

I'll run the call, and let you rest.

But then I thought, "What the hell."

Again, it's a process - first the written (passed) after which, a physical test known as the CPAT. More extensive and more demanding than the EPAT taken on the previous tries, DTs really had to buckle down.

From Jan 7 to current I've lost 20 lbs and 8% body fat while gaining muscle, working out at least six days a week (in some way/shape/form) and trying to avoid over training.

The CPAT practice sessions offered by A County have been wonderful learning experiences. Some who attended seem to use the sessions as actual exercise opportunities. "I've only done the stair climb twice so far, I need to go again..." DTs used them in another context. Try each of the eight stations, see where the trouble was (eg "Quads still burning during the step climb"), get out and give others a chance at the stations. Make notes in the car, then use that info during the week to modify home gym exercises. Return for next CPAT practice to repeat and modify. It seems to work.

Whether DTs has over trained is debatable; there is no question, though, that he definitively avoided over-thinking.

Jut alors! "Methinks I had best be getting this documentation in order," said DTs last night. "These background check things sometimes take a week or so and... son. of. a. bitch!"

He read:

"Background packets must be turned in to this office by 3/14/2008, no exceptions..."

CPAT practice ends 4/12, and SOMEHOW DTs got the idea that the packet was therefore due on 5/14. Would that he had paid attention!

So now, pessimistically, it shapes up thus:

DTs:

Older, wiser head: Very desirable candidate.

Already a Paramedic: VERY desirable. Can go to work almost immediately.

Multilingual: No Barry Farber, but working on em. Plus mark!

Wants to be on the band aid box: Most fireguys do NOT, and must be prodded. DTs = Good

Self motivated: You betcha. Looking good on the CPATs and everything.

Mastery of Calendar skills: Not so much.

Embarrassing, stupid, inattentive PUTZ!

I guess I'll continue the workout regimen and think on this... Would that I had thought before!

"Often, statistics are used as a drunken man uses lamp posts... for support rather than illumination." - Andrew Lang

"There are two kinds of statistics - the kind you look up, and the kind you make up." - Rex Stout

And without further ado, the 2007 edition of the Annual DTs Too Much Stew From One Oyster Presentation.

A note on the 2007 schedule: The usual schedule for DTs: 24-on, 24-off, 24-on, 24-off, 24-on, 48-off, 24-on, then six days off. Stated differently: Every other day (about) for four days, then six off, then repeat. Simplified further: I work two days a week and get a week-long vacation between checks. There were very few off-schedule (eg overtime) runs involved, and the same days are represented in each two-week period. While the dates and times of each run is available to me, I don't believe in the Full Moon Madness hypothesis, and seriously doubt that the nature of the runs would change if more Friday nights were included.

Stats weren't kept until sometime in Feb 2007, so there's a month of data missing. During the 11 months represented, though, my crew was called out 741 times, but placed in service 62 times (more often than not to attend a more-urgent call) for a total of 679 completed runs.

Information on patient demographics is entered into a PDA before patient contact, based on dispatch information, and updated with non-dispatched info after the call is complete and the patient is turned over to the receiving facility. Patient care, in other words, is never left off for this project.

And, as I stated a few posts back, this info cannot in any fashion be used predictively - "Uh oh, here comes March - March is always tough." Rather, the information can be used to proactively guide a few study areas, namely Cardiac and Geriatrics.

NICU and PICU are Neonatal and Pediatric Intensive Care Unit, generally with a pickup-crew of three from one of several hospitals in the area. CCT calls are for the most part patients on ventilators, where an extra hand is needed in the back of the CCT truck in the event of equipment failure. ALS is anyone needing a cardiac monitor, or non-KVO or non-saline drip, or a patient who meets certain criteria our dispatch has been told is ALS. BLS is everybody else.

Until I actually generated this I suspected there were "dead zones" on the clock, but evidently, I'm wrong

Patient sex still seems to be fairly well-balanced.

When a patient can only speak one non-English language, or only a few words of English, they enter these categories. If a family member can help interpret, that's wonderful, but I have caught husbands telling bruised wives, "Say to them, this is what happened..." when they thought I didn't speak whatever language it was. Tell him what he's won, Johnny: Why, it's a visit from Adult Protective Services! Yay! Anyway, according to these numbers I'd best serve my community by spending my time polishing up my Spanish, rather than trying to tack on Romanian.

If these age groups seem rather arbitrary, it is because they are. Stupid EXCEL, to which the data was dumped for clumping, wouldn't let me nest all the IF statements I needed to do a more reasonable age breakdown and I had to fudge it up. Still, one gets the drift. Aging population, to a point, is still the norm.

In the latter half of 2007 I changed the way Chief Complaints were entered into the mix; up to that point the wording was rather arbitrary, based on the dispatch information. Rather than go back and attempt to normalize previous entries based on my spotty memory, I'll just see how 2008 pans out. In the meantime, most of the CCs with 5 or more entries are listed here, to make of them what you will.

I don't know why I even do this, except it's a neat, big figure. This average, though, includes all the Under Age 8 patients, as well as the Over 90 Years patients (who tend to be rather slight in stature, as one may imagine) and is therefore completely useless for any reason whatsoever, so here it is:

On a personal note, DTs would like to mention to one of his partners that the term is "Geek". "Dork" is another animal entirely, and while DTs may in fact BE a dork, you really meant Geek there, that time. Just saying.

One of the nicest things about running a primarily-transport ambulance is that we have some idea of what we're getting when a call comes in. A typical 911 call is dispatched as "difficulty breathing". Our same call is dispatched, "Pulmonary embolism".

A 911 crew will show up at your house and take care of you. We show up and talk to House at the hospital. We get all the labwork, CT, X-rays, MRI, previous medical history, etc. Some of that sometimes finds its way into our dispatch pages.

The advantages to us in having this information are obvious. On the way to the call we can whip out the handy-dandy pocket guides and read all about Condition X, refresh memories about signs and symptoms, associated problems, "gotchas", stuff like that.

Knowing our patient's weight, which is usually part of the dispatch information, we can guess at an age. This helps immensely when the sending nurse states, "His last pulse was 140". Instead of saying, "Holy cow!" we can instead nod sagely, because our patient weighs 7 kg (making him about 6 months old) and that's an entirely appropriate pulse for that age.

In other words, we can and usually do plan ahead.

A recent call was no exception. We were dispatched to Faraway Memorial Hospital, the chief complaint was "premature labor". The doc ordering the pickup wanted a lights-and-sirens get-here-now kind of response. Not much to go on, but okay, we planned. Since my partner du jour was one with whom I've worked but a few times, we went over each of the ground rules on our way over.

"If I tell you to," said DTs, "Pull over at the closest safe area and gimme a hand in the back. Watch yourself getting out of the truck. If the baby's crowning, I'll be near the double doors controlling the delivery, so you enter from the side door..." blah blah blah.

Having done that, it was time to check the Protocols (cue angelic choir and spotlight).

Now, as extensions of our Online Medical Direction, the doctor under whose license EMS folk operate, we are beholden to same to follow The Doctor's Rules when handling our calls. The Protocols are the written instructions which act as basic guidelines for each type of situation we may encounter. Chest pain? We have a protocol. Hyperthermia? Here's how the doc wants it handled. Amputation injury? This is what you do. And so on.

Each protocol, depending on the complexity of the condition, is around 1 page of information. "If the BP goes above THIS number, do THIS. If it goes below THIS number, do THAT. Use THIS drug when the patient turns bright blue, THIS drug if they turn orange..." and so on. As I said, usually a page for each condition.

OB protocols: 10 pages. Tack on another 4 pages if your pessimism requires "Neonatal resuscitation" protocols.

This in itself indicates a couple of things. One, our OMD is very, very careful with OB calls - makes sense, as there are really two patients - and Two, many, many things can happen. Therefore, my Instructions Were Explicit.

We arrive to find a woman in active labor - contractions every three minutes, lasting about a minute each.

Strike 1: My protocols (my doc) states that under no circumstance am I to transport a woman who is about to give birth. Remember, we're already in the hospital - "back of the ambulance" is wonderful for 911 but for most of our patients it is a step down, environment-wise.

Dilation? "Oh, a little over four centimeters last we checked," says the nurse.

Strike 2: "If cervical dilation has exceeded 4 cm, delivery and stabilization of both the mother and infant should precede transport to prevent delivery in transit." (this, in my protocols, is ALL-CAPS)

Any spotting or bleeding? "Yeah, for the last two days, she says."

Strike 3: Antepartum hemorrhage is criteria for a Critical Care medic (a step above your humble narrator's Paramedic certification).

"I'm sorry, but my orders say she ain't-a goin nowhere until she delivers," says DTs.

"But she must!" exclaims the nurse. "She's just over 20 weeks. We can't take care of the baby if it's delivered here at Faraway Memorial." The sending doc strides in and, very nicely, seconds this assessment.

Damn. A call earlier in the day was for a 26-week old, slightly smaller than my hand. On THAT call, however, we went with an entire Neonatal Intensive Care Unit (NICU) team - two RNs and a Respiratory Therapist and an incubator.

One hand, protocols say "No." Other hand, baby is still "in the bag" - no NICU team needed. Gripping hand, she could deliver in transit and I'll have this teeny-weeny thing to ET-tube. The RN and the doc both made it clear that This Patient Is Not Delivering At This Hospital.

If I refuse the call, which I was leaning towards, Faraway would just call 911 to do the transport. They're no less skilled than me, but have less equipment (ventilators, IV pumps, etc.) - and the likelihood of delivery in transit increased for every minute I spent dithering about it.

Decision: Bump it up to a Higher Pay Grade for instruction.

"Sure, go ahead," says HPG. "Why are you even asking about this?"

"Um, you know, the thing. The protocol thing."

"Oh, yeah. Well, you know, there's some flexibility in there..."

Really? REALLY? Very well.

We package mom-to-be (for whom this is Child 2, by the way - and labor goes quicker for Already a Moms).

"New instructions," says DTs to his partner. "No lights and sirens. Easy ride. Potholes do not exist, therefore we will not encounter any. Loud noises from me in the back always mean Go Faster. If you smell poo it's me, but it'll be because Mom delivered, and that smell's your signal to call God or somebody to come help us."

Now, having invested all this time in reading this I'm certain you want to hear that there was a sudden "Pop!" and DTs was possessed of a 1 kilogram truffle-of-joy, but this was Not To Be. "No Stork Pin For You" says the Stork-Pin Nazi.

But it was a little interesting for me, because of the Pucker Factor, so I thought I'd share. Thanks.

It's time once again to drag out the Inner Geek and see how the statistics are shaping up. These data cover from 16-Feb-07 to 27-Aug-07, so call it six months of data. Note that these numbers express only the calls of DTs and his Merry Crew.

To reiterate what I believe I said before, Statistics Can Help You. One notes, for instance, that the average adult patient age in the last six months is 58 years; given a limited resource (time to study) would one's time best be spent learning the signs and symptoms of Severe Acne Poisoning, or the subtleties of chest pain? Hmmmm....

Again, the reason for keeping this information is not to reduce the patients to statistics, but rather to use statistics to help future patients. Granted that the chart shows we ran 58 "Chest Pain" calls and perhaps one "Partial evisceration and uncontrolled jugular bleed". Of the two types, obviously the latter is the high-adrenaline oh-shit-oh-dear call which needs superb BLS and ALS skills to give the patient any kind of chance. But statistically, you spend your time honing your Chest Pain skills, because chances are you'll be using those most.

Take a peek at your average male. That huge bulge which acts as a belt-buckle warmer is an apron of fat called the Greater Omentum. Damned difficult thing to get rid of if you ask me. It's easier to lift our patients, though, if we don't have to lift such a load of our own as well. Doesn't hurt to hit the free weights once in a while, either.

The following information is for patients 16 years or older:

Yes, that's right - DTs and his partner (99% of the time it's a two-person crew) lifted over 30 tons of patient in the last six months. Not once, but four times: from the ER/Floor bed to the cot; into the ambulance;out of the ambulance; and finally, into the bed at hospital, rehab facility, or home. True, some few of the patients were ambulatory, but still.