On the Way to Paramedic in Northern VA
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Monday, September 19 2005
Ahm not a smaht man, but I know what a trauma ee-is

About two in the morning we're toned out for a possible unconscious, "Caller reports patient lying in roadway". We arrive to find an elderly man lying face-down in the thick mud between the curb and the sidewalk, where one day the construction company will place sod. His head, chest, and arms are covered with mud, but a ragged laceration in his forehead has bled much of the mud off his face. A baseball cap lies on the ground perhaps ten feet away.

Was this guy hit by a car and thrown onto the sidewalk? Was he mugged? Did he just trip? No way of telling. I take c-spine while the crew grabs backboard and cot.

"I'm okay, I'm okay," the man says in a very weak voice. "Can I go home now?"

"No, sir, we need to check you out. What happened?"

"I fell, I think. Can I go home now?"

Backboard is ready, we roll the patient onto it and begin strapping him on. The whole time he's whispering, "I just want to go home," over and over. We place a collar.

The patient stops talking. And moving.

"Oh shit oh dear," says DTs. "Sir!" No response. Sternal rub. No response. One of the crew takes the patient's wrist, says, "I can feel a pulse." Carotid pulse is present also. I look, the patient is indeed breathing - he's just not responding. In EMS lingo, he's DFO - done fell out.

DTs is precepting a young lady to become an EMT-B lead. She calls the county to ask if a medic is available for this call, and is told "negative" - all the medics are busy. Phooey.

Load and go. We grab a quick set of vitals, then the lead preceptee asks me to call the hospital while she and our third cut the patient's clothing to check for non-obvious injuries.

"Charles Cullen Memorial ER."

"Hi, ambulance 502, we're responding to you with a male, 65, found prone on a sidewalk, periods of unresponsiveness, head lac, unknown mechanism, boarded, collared, vital signs BP 174/91, pulse 109, pupils PERL, Sa02 99% room air, dexy 120, see you in three minutes."

"Okay," says the ER.

The patient's O2 sats do not warrant oxygen, but we give him a non-rebreather at 15lpm anyway - we've noted a tendency for his breathing to slow when he goes unresponsive, which he does twice en route. Each time, though, he pops back up within ten seconds and says, "I want to go home."

We arrive, wheeling the patient into the ER. Recent construction has modified the nurses station to include partitions so they don't have to see you when you walk in. Our driver wends through the mini-cubicles to the admitting nurse.

"Ambulance 502," he says.

"Yes, I know," she says. "Just wait."

"Hey, we got this guy," he says.

"I'll be with you in a minute," she says. The driver peers around the partition to give us a helpless shrug.

"Okay, put him in the hallway," says the nurse.

"Hallway," our driver says to us.

We move the patient on the board to the bed parked in the hallway. Another nurse comes up.

"What are his O2 sats?" he asks.

"99% on room air, but -"

"Take that thing off his face," the nurse orders. Goddamn, I'm starting to get a bit pissed, here.

The admitting nurse comes around to the bed. Her eagle eyes miss nothing.

"This patient is on a backboard!" she says.

"Of course," says DTs.

"And this patient has a collar!" she exclaims. "Why is this patient on a backboard with a collar?"

"He was found prone on a sidewalk," I begin, but she's cleverly deduced everything.

"This is a trauma patient! This patient should be in a trauma room!"

"Yes, yes!" says DTs. She's getting it! There is hope!

"Did you call this in as a trauma?"

"Yes."

"Where's the medic?"

"There was no medic," our young preceptee begins.

"Should have been a medic. Why didn't you call a medic? You're just a basic unit. This patient needs a medic..."

What this patient needs, I thinks to meself, is for you to STFU and call a doc; what this patient needed was our four minute transport to the hospital, versus waiting on scene 10 minutes until a medic was available. What this patient needed was to not wait five minutes until you graciously allowed us to place him in a goddamn hallway bed.

A doc arrives, gets things moving in the trauma room, then steps outside to get the story from the precepting lead. He nods his head a few times, says, "Okay," then turns back into the trauma room.

Later, the doc pulls the preceptee aside. "You did exactly the right thing," he says. The patient was suffering from ETOH mixed with a lot of heavy-duty prescriptions - not something a medic could have done anything about anyway, had they been available.

The next time we came in with a patient, the same nurse was there, and a sight more friendly and responsive. I wonder why?


Tuesday, September 13 2005
Psychic Powers

I wrote a while ago about EVOC and driving, then what happens? We get an ambulance stolen. I wrote next concerning EMS and scene safety, and now this. Psychic power, or coincidence?

I prefer coincidence, meself.

DTs' regular driver has business to attend, and so a fill-in generously steps up to the plate. She's able to both drive and perform patient care, so as a change of pace DTs assumes the role of driver. Rather poorly assumes it, as we shall see.

The tones drop, and we're called out to injuries from an assault at a convenience store. The address is close to the station. "Relax," says DTs, "Let's just stage here rather than picking some other spot equally distant." His Lead agrees, but suggests that we stage in the bambulance, ready to roll. Make it so, Number One.

"Ambulance 2," says the dispatcher, "Patient has been struck in the head by a baseball bat. Scene is secure."

Huzzah! Lessee, here, doors open, check; blinky button, check; woo-woos, check; brake off, gear on, away we go. We arrive less than a minute later at the scene, but DTs slows and does not immediately pull into the parking lot.

"There it is, that's the place," says his Lead.

"Yah, but where're the good guys?" asks DTs. "I kinda wanna park next to a lot of flashing blue lights."

"Dunno," says his Lead. "There's someone waving. Pull in."

"He crawled over there by the dumpsters," says the Waver. "These five guys walloped him with a bat, then went away."

Went away? Went AWAY? DTs' exceptional imagination fills in the Waver speaking to the police: "And then, while these brave, now lifeless EMTs were heroically saving this poor unfortunate's life, They came back and bunted them into the Afterlife. Whooda thunk it?"

I'd of thunk it. Meanwhile, the Fearless Lead is opening her door-

"What are we doing, here?" asks DTs.

"I have a feeling; we're okay," says his Lead. She exits.

Sigh. DTs exits, grabs bags. "Hey, let's wait for the good guys before we leave the relative safety of these bright lights," he bargains. "I don't want us to be bent over this guy if the animals come back."

A beat. "Okay," she agrees, but reluctantly. Every instinct says Go Help Patient.

Now, here is where DTs is not a Good Driver, but rather a Lead Buttinsky. "Call dispatch, get an ETA on the police; advise 'em scene isn't secure, get an ETA. Stay next to the unit, be ready to jump in."

Folks, if one is not in charge, e.g. Lead, one should not give orders. Bad DTs! Bad! However, rather than point out this Universal Truth, or argue, this exceptional person simply does it.

PD shows up, the patient is found and loaded. A medic climbs aboard and we roar off to the hospital, DTs at the helm.

DTs needs more practice in Closing His Yap, granted. After apologizing profusely to his Lead, he admits this.

But Mr. Dispatcher, I would certainly like to know how bad guys sauntering off with a baseball bat is equivalent to a secure scene!


Wednesday, September 07 2005
I wouldnt venture out there fellas. This snipers got talent - Pvt Jackson

Sitting in the day room last week, I couldn't help but wonder at the outrage and disbelief expressed by many of my co-workers when CNN announced that someone was sniping at EMS in New Orleans. If you missed it, it's all in their article, Sniper fire halts hospital evacuation.

Outrage? Absolutely. Asshat snipers. But disbelief? Not if you're over thirty.

Ah, this starry-eyed generation! Snipers were a big problem in the LA riots of April, '92, after the Rodney King verdict. A favorite tactic being to set up on a rooftop across from your arson, then pick off the responding firemen. So, yeah, there were a bunch of people being total asshats.

Skip back a couple of years and riots, 1968, in Trenton and Washington DC, where the weapon du jour was bricks thrown at fire fighters. "Oh, bricks," you say. Hey, a brick is damned heavy. They still stone people to death in some places. Again, a bunch of people being total asshats.

And forget about the August '65 Watts riots. Everything was going on there.

Hells bells, the story is basically the same for every big riot, and not just in America. Civil disorder and chaos begins, and otherwise normal folk take the opportunity to loot and pillage like damned Visigoths. Lo and behold, anyone representing Order would - gasp! - mean an end to this, so let's make 'em duck and cover.

Now, we get shot at (and shot) on plenty of occasions - it doesn't have to be a riot. This article, for instance specifically discusses EMS and body armor, just because some folk take exception to us covering up the pretty gunshot holes they made in a gang banger. They see us saving their victim, so they plug the victim a few more times to finish him off and give us a couple to think about, too. It happens, too often, but then again once is too often.

It all boils down to scene safety. We're not supposed to go in unless everything is safe. I wouldn't be at all surprised, however, if there were some elements in EMS who float the idea of arming the medics - just in case the police are occupied elsewhere. Personally, I think that would be the wrong image, but armed responders do seem to work well elsewhere.

A well-written, two-part piece describing EMS in Israel points out that terrorist bad-guys have been gunning for first responders for decades. Snipers are common, as is the use of secondary devices - a second bomb timed to blow up while police, fire and EMS are on the scene of the first explosion. While the article states that no EMS personnel has ever used his side arm while on duty, there are plenty of stories where one came in handy. Of course, almost everyone in their system is IDF, and well trained.

Should EMS go armed? Well, being armed does not prevent police officers from being sniped, so in that respect, probably not. Amateur snipers probably have a heightened sense of invulnerability anyway. They can take their time to pick their spot and set up, and can usually vacate before they're pinned down - they wouldn't care about a glock.

How about for the gang-banger? In my opinion, anyone who is still on-scene after a shooting, wandering around with a gun, is crazier than a... well, would probably not be impressed.

Guess I'm content to continue letting the cops do their job while I do mine.


Saturday, September 03 2005
Very Boring Entry.

So. In lieu of anything interesting, we ask DTs, "What's new?"

Several things. DTs is now precepting as a medic. A shocked silence greets this news. "DTs," you stammer, "You lying bastard. You told us lo these many months ago that you had passed your NREMT-I and were now a bona-fide Paramediate!"

Even so. Yet, considering the nature of the work, e.g. people's lives, you might be driven to agree that the more time spent in study, the better. Therefore, precepting.

The precepting process is not unique to EMS, but an explanation might be in order. Having passed the rigorous tests imposed by the National Registry, DTs was entitled to wear the coveted "Intermediate" rocker patch on his sleeve. The NR tests were comprised of both written exams and practical stations, wherein the candidate proved he could perform certain actions - read an EKG, intubate adult and pediatric patients, start IVs, administer medications... the list goes on.

Am I then given a big ol' box full of drugs and told, "Go forth, DTs, and do Good in the world." Hell no, and for several good reasons.

First, have you ever crammed for a test, and passed, only to be unable to recall much of the information a week later? That's one way to pass NREMT, but it's not a good way to provide patient care. We still gotta remember all that stuff, and memorization comes with repetition. Second, performing say an intubation on a manikin while standing comfortably at a table in short sleeves is quite different from doing it, oh, upside down in a ditch, reaching through a windshield in driving wind and rain while wearing turnout gear. While your fire guys are cutting the car up to free the patient. So there's the reality thing, there.

Precepting is a bit closer relationship than mentoring, I believe. While precepting you do everything under the watchful gaze of someone who's been a medic for ages, knows it all and shares what he knows.

Anyway, the hours are better - 24 "on", 24 "off", another 24, then six days off. Guaranteed 8 hours OT every week, and use your six to fill in extra shifts or putter about the house, as you will. Oh, and study, of course. Sweet.



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Posted Tuesday, October 04 2005 11:15  Site Meter