BLS Skills

We went through BLS skills the other day in medic class. These include bandaging, splinting, spinal immobilization, simple airway management, etc. We were going over splinting and an instructor chose one of us to demonstrate splinting of a tib/fib closed fracture. This person works in a service where this type of fracture should be a relatively common encounter, yet when it came to putting on the splint… he forgot the splint. Maybe he doesn’t work well under pressure? Either way, he’s no longer in the class.

I actually wrote this post a while ago, but since then we have had 45% of the class re-test on splinting. Of those people, 30% failed a second time. Suffice it to say, the lead instructor was not happy. We practice intubation next week.. I have a feeling some people will be embarassed.

Patient Quote of the Day

Everyone in EMS has patients that say or ask “the darndest things”. Maybe I’ll make this a series, we’ll see.

PT: “me dan dos dólares para el autobús” (give me $2 for the bus)
Me: “No.”
PT: “No?”
Me: “No. No tengo dinero.” (I have no money)
PT: “Me dan pesos!” (give me pesos)
Me: *blank stare* “estamos en el hospital ahora” (we’re at the hospital now)
PT: “Muy malo…” (very bad)
Me: “Get out of my ambulance” (get out before I request ALS to sedate you)
PT: “Que?” (what?)

Ok, maybe I made up the last part…

Shift Change

I worked the overnight shift recently and had a call that got me thinking about an interesting pattern I’ve observed.

Around 0030 we were assigned a call to one of our local nursing homes known for “legit” calls at night. Why they are known for this will become evident. It came over as “labored breathing”. We take it on an easy lights/sirens run, unfortunately dealing with significant traffic due to it being the weekend. Riding the elevator upstairs I propose to my partner to guess what the answer will be to the obligate “how long have they been like this” question. She guesses 6 hours, my guess was 3 hours; I guess she is more cynical than me. But something made me tell her as the doors opened that my guess was actually “since the shift change”.

We find a nurse who points us in the direction of the room (I can hear the breathing already, not a good sign), and actually accompanies us to the room rather than conveniently disappear. The patient has two pulse oximeters on her fingers, and by my confused look the nurse then explains the first pulse ox showed 40%, so he got the second one to make sure it wasn’t broken. Nice. She’s satting in the 80’s now. He had put her on a non-rebreather mask at high flow, which is impressive considering many times I’ve arrived to find patients like this on a nasal cannula. She is barely alert, breathing is very distressed with sternal retractions and other accessory muscle use, has wheezing in all fields and is febrile. Ok, so, “how long has she been like this?” His answer: “since I came onto my shift around 11:30pm.” Nice. It’s now 0045, I didn’t bother asking why he waited to call us.

Our next call was a little comical. Another nursing home, it came over as “bradycardia”. Turns out the patient was in 3rd-degree heart block, had an altered mental status, along with cool extremeties. Not sure why, but I find heart blocks pretty interesting. The patient didn’t have a pacemaker. The funny part? The patient’s daughter wanted us to take her 30 miles away, when the closest hospital was about 1 mile away, and there are literally over 15 hospitals closer than the one she wanted. Yeah, she ended up at the nearest ER.

Old Timers in EMS

Picked up a shift for someone that couldn’t make it to work today, so I had a new partner. He could be my grandpa. I’ve never worked with him before, but I’ve heard about him; he’s apparently the oldest employee in our service.

On our first call I began to prepare the stretcher before we transferred the patient. I’m pretty meticulous about this. Unless seconds count for the patient, I prepare the stretcher pretty much the same way everytime, you won’t see me walking into triage with a patient half falling off, no sheet over them, and the straps over their bare legs.

Anyway, I started prepping it, and as I finish, my partner grabs the sheet and pulls it all off as I stand there, mouth agape. I ask him, “what are you doing?” He says, “making the stretcher up right, gotta keep the patient warm.” Okay, I’m already annoyed since I always make sure my patients are well-covered. But my annoyance turns into awe as he finishes preparing the stretcher … and it’s exactly how I had it before!

Throughout the day it took him until our 6th call before he remembered our bus number. In addition, he would fall asleep on the way to calls, which would normally be funny except for the fact we are operating in his service area and not my normal one so I don’t know the best routes.

That said, he seems friendly enough, but I feel like he’s been an EMT so long that he has gotten lax. I had to twice remind him to bring up equipment, and I don’t think he did a single true patient assessment.

I’m looking forward to getting back onto a regular shift where I don’t mind whether I tech or drive because I trust my partner to handle anything if he’s in the back and not me. Wish me luck.

SIDS

An interesting and depressing subject came up in medic school recently. We were going through various scenarios where we have a patient that is either found in cardiac arrest (he has no pulse) or goes into arrest while in your care. The main point was to review legal/ethical issues for patients with a DNR order (do-not-resuscitate) or for those that don’t have one, yet express a desire to not be resuscitated. In short, if in any doubt, do CPR. Oh, and for the guy that says “just let me die!”, well, he might die, but then we’re doing CPR — sorry buddy.

Anyway, we eventually exhausted most scenarios, until we arrived at the situation where we find a SIDS baby (sudden infant death syndrome). We are asked what we would do if we arrived on scene and find a baby that is cold to the touch, pale, and has obviously been dead for a while. The parents are hysterical and pleading with you to do CPR. You and your partner know there is absolutely no chance the baby can be brought back. So, what do you do?

We are told that generally the safe thing to do is to start CPR and transport the baby to the hospital in order to make the parents feel that everything was done. The instructor says no harm will be done by doing CPR even if you know it won’t be successful. I disagree.

One, CPR is a brutal thing we do to patients, but we do it because it may save their life. In the case presented to us, it is not medically necessary. Two, the receiving hospital has to have a team ready to accept the baby and do it’s own (futile) interventions. Granted, they probably won’t make a whole-hearted attempt once they hear the full story, but will likely go through the motions anyway. As a result, they won’t be able to care for other potentially critical patients that may have a real chance at life. Finally, by starting CPR we give the family false hope, and they will have to essentially see their baby die a second time when the doctors inevitably stop resuscitation.

I’m not sure what I would do in that situation, and I’m sure the right thing is not cut and dry. A baby that been dead for an hour has no chance, just like an adult, but because it’s a baby we treat the situation differently. I think possibly either response, CPR or no CPR, may be equally right, but it’s a tough call for sure, and one I hope I do not have to make.

New Medics

I started paramedic school last week. It’s a class of about 25-30 people, all EMT’s in New York City or nearby. The course is pretty expensive relative to average EMT income, but still less than you’d spend at a California university for a year. Either way, it’s a big commitment, consuming something on the order of 1300 hours of training in 11 months. About 30% don’t make it to the end, and 15% of those that do make it will fail the NYC “MAC” test, supposedly the hardest paramedic test in the country.

That said, I’m already concerned for a few of my classmates. We finally finished all the orientation/legal/ethical shenanigans, along with a healthy dose of “this is a very tough course, it’s a big commitment, your girlfriend will leave you, your friends will think you’re dead, etc., etc.,” and then began some EMT skills. We broke off into small groups of 5 with instructors, whom presented a theoretical patient encounter.

We started with the general impression (after BSI/scene safety, of course!), which was a 52 y/o male found sitting on the couch in his apartment complaining of chest and epigastric pain for the past few hours. Great. We move through the ABC’s: airway is patent (he’s awake and yelling at his wife), breathing appears normal, so let’s check out circulation.

The instructor asks a student across from me to evaluate circulation for our chest pain patient. He says, “well, the first thing I would do is check his voids for any major bleeding.”

*smacks head*

For those not in the medical field, the assessment he mentioned (checking the voids) is recommended for trauma patients in order to check for bleeding we may not catch otherwise. Due to the fact that our patient was MEDICAL, I don’t think he would appreciate us checking under his arm pits, and between his legs just in case he fell out of his window, walked back upstairs, cleaned up all his wounds, and then forgot to mention the incident to us. Right. We’ll see if this guy is part of the 30 percent.

Different Perspectives

Yes mamn, I understand you’ve been in the ER all day and night with your mother, and that you probably can’t wait to get back home at 3 in the morning. And yes, maybe the nurse is moving a little slowly filling out your discharge forms. But, that’s no reason to get in her face and call her names and incompetent in front of everyone in the emergency room and then turn to me and ask me what took us so long to get here. No, your mom, who can walk (albeit slowly) does not need an ambulance to get home at 3 in the morning. A cab would have sufficed. But, the nurse was nice enough (unfortunately for me and my partner) to call an ambulance for you. Oh, and to answer your question about why we were late, we were busy caring for a patient with sepsis in respiratory distress. My FULL apologies. Finally, telling us you are “not rude” does not make it true, and instead makes me want to tell you “I do not think that word means what you think it means.”