On the Way to Paramedic in Northern VA
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Saturday, December 22 2007
(Serving Suggestion)

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.


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Posted Tuesday, January 15 2008 14:11  Site Meter