28 November 2009

It's not what it was dispatched as!!

This is a response to a local managed care facility, dispatched as a person experiencing difficulty breathing.....below is the reason why. The patient was having an AMI covered up by the SVT; not good.

She was an 83yo lady having "difficulty breathing", and she was, w/ upper resp. "grunting", bases=rales...NRB to replace 2L/NC she was on. Pulses= absent perf. and thready carotid...to say the least she was symptomatic.

Due to proximity to ER (-5min) I didn't waste a lot of time w/ I.V. and/or meds because her veins were so depleted. Just to be doing something enroute to the ER I do a quick EKG because she has a history of bradycardia. Turn it on and...THIS!! By this time, we're less than 2mins out and I had no time for Adenosine or time to cardiovert. It was probably for the best that I didn't have time to do either one for this patient, because with this presentation all the squiggly lines might have straightened right out. Pt has a DNR and expires 10min after arrival at ER.

My lesson was this. Regardless of time, I have at my disposal the same initial tools that the ER is going to utilize when I do get there. So as it should be, the ER is brought to the patient for one on one care. The ER may have one MD and four nurses for twenty patients.....I am their best bet.

Take the time to diagnose and begin interventions as soon as you realize something is not as it should be. After all, that is the reason we do this job.

25 November 2009

Thankless Giving

There are moments when we must ask ourselves why we do this job. I am grateful that these times of true evaluation are few and far between. I'm not sure if it's my type "A" personality that allows me to to enter a chaotic situation and try to instill some order. Or, is it my underlying belief that each and every one of us have a duty to their fellow man and neighbour to be of assistance in their time of need. Whatever the reason, this I know to be true, death and I must come to an understanding and develop a better working relationship. Death is more powerful than I alone or in the company of the greatest physicians in the world will ever be. Death has more tools and ammunition available than the meager supply of medications, algorithms, and quick wit that I have. While I will never agree with the job that death must do, I do question the method in which it must be carried out sometimes.

Tonight I heard the cries of anguish from a mother who watched life cease for her 12 yer old son. For all the begging and pleading with her god, it was to no avail. I don't know what could have happened in the hours leading up to the time when he decided that putting a cord around his neck and hanging himself seemed to be better than his circumstance. Was it sadness? Was it anger? Loneliness? Frustration? What could have been so bad that this young boy on the brink of manhood would side with the opposing side and concede defeat? I wonder if he heard his mothers wailing and sobs as the final neurons in his brain ran out of fuel. Did he feel the pain of chest compressions and defibrillation? Was this the finality as he imagined it would be? Were his questions about life and death revealed in his final moments?

I have no doubt that through out the coming days and weeks that his mother will be asking the same questions. These are some of the questions that will remain unanswered for a lifetime. Tonight I grieved with this mother, as did all those around and within the sound of her cries. Some choked back emotion and continued about their work while I, and others removed ourselves from the environment to quietly reflect on our own lives and to shed tears with and for the mother.

In a twist of true irony, I was less than a half mile from this young boys house having dinner with my fellow crew members when he made his final decision. About that time a family was getting up from their table to leave when the husband stopped just past our table, took a few steps back and said, "I just want to say thank you for what y'all do, not just because tomorrow's Thanksgiving, but we really appreciate it". With the utmost in humility we returned the thanks for his generosity and kind words. All the while just up the road, a group of seasoned medics and firefighters waged war with a ruthless thief.

Death, my adversary, and I will continue doing our jobs to the best of our ability. With all that is in me I will fight against it's efforts and effects. I only hope that in time I will come to understand the meaning of its existence. Until then, we coexist, with purpose and passions that only the giver of life will ever understand. I, and others, will continue to give. We will give our all with or without thanks or public recognition. Only because that is what we were made to be; givers.

23 November 2009

Not soon enough

Today they are holding a funeral for a lady that didn't get to fulfill her final dinner plans. It almost seems inappropriate that it's cold, raining and just plain miserable outside today. This lady and I had never met before 20 Nov '09 that I'm aware of. It's quite possible that we'd passed in Wal-Mart or at Kroger grocery shopping. As far as I know, her family had never known or met me before that day. But on that Friday I became a part of that families memory of a mother, a wife, a sister, an aunt, neighbour....and I'm sure the list goes on.

I wasn't even supposed to be on shift that day. I work night shift; graveyard if you will. I was just doing a favor to fill in for personnel shortage. My partner was a new guy that I had just shook hands with earlier that morning, I didn't even know the guys last name at this point. He was a career firefighter in a neighbouring city and an EMT in his own right, but he was a hose monkey through and through. And he liked to talk....A LOT. He had a line of questions that would rattle off like a Gatling gun not even waiting for a complete answer before firing the next. Needless to say, he had gotten on my nerves already in our short acquaintance since I'm not a big talker myself.

We had just gotten cancelled from a call for a volunteer agency in the county so I stopped at one of the out-lying stations to hit the john. This was more of an opportunity to waste a little time before heading back to our main station, since it's somewhere I don't particularly like to be during the day. So there we were headed back across town. We were sitting at a traffic light at a pretty big intersection; I was on the phone with the Paramedic course director at the local college when it started.

"Base to 12"

"Hang on a sec Jay.....12"

"Respond to 350 Woodlawn...subject unconscious"

"Responding...any further information?"


"Just great", I think to my self as I turned on the lights, gave a few "whoops" with the sirene and started to ease across four lanes of traffic to make a left hand turn. The good news is that we were in a great spot for this to occur, less that three miles from location and a straight shot with only two turns....five or six minutes out, tops. I had a pretty good idea where the road was so I hit it kinda hard getting there.

We arrive on location and backed into the driveway. Approaching the house I notice it is a modest brick home in a well kept neighbourhood, nice cars in the drive. "Might be something to this one" I think out loud approaching the side door. Usually when you get a call to a house like this one, it's a legitimate call.

"EMS", I announce as I knock on the door.

Through the door I see an older man coming across what must have been the den talking on a cordless phone kind of anxiously. Nothing too weird with that except he was only wearing a pair of red and white stripped boxers and his glasses. Yep...defiantly not good.

"I think she's left us...she's in here", he leads the way to a very normal looking kitchen, not so much clutterer, but used. My first impression when seeing the patient was not a good one. Her head was laying against the corner of a stainless steel stove, she lay in between that and a kitchen table. I didn't see any blood pooling under her head and was very thankful for that. The husband told me that he was downstairs getting dressed, they were going out for dinner, when he heard a loud thud from upstairs. He called out to her and got no response so he came upstairs and found her like this.

No pulses, no voluntary respiratory efforts. Not good. I tell my partner to get me the ZOLL, IV and drug box. I radio in to the county dispatch center that CPR is in progress. It is then, and only then that they decide to dispatch an engine company for first response and manpower, better late than never I guess. I give a couple of breaths with the BVM and start compressions, painfully aware that the husband is directly behind me watching this saga unfold. All the while he is on the phone giving a play by play to whoever it is he's talking to about my efforts.

My partner re-emerges with the requested equipment with-in two minutes. Drug box in one hand, monitor in the other and IV box tucked neatly under his arm. I was pretty impressed by this actually, until he spoke.

"Want me to start a line?" he asks.

"Can you do that?" I replied with a quizzical tone in my voice. I thought he was at least an EMT, if he was higher trained it would have been nice to know by now.

"Well, I mean...do you want me to set it up"

"Absolutely...after we get the pads on...post haste". I'm sure he didn't know it at the time, but this is my way of saying hurry it up and get it in order.

I'm doing some pretty good CPR while he tears into a shinny pack of defib pads all the while fumbling with wires and cords. He's got the defib pads in his hands and tracing a cord to find the end. I quickly realize thet the cord he is tracing is the power cord that didn't get unplugged from the back of the monitor. I direct him to the rear pocket and tell him to put the two red ends together. Done. I cut the lady's sweater and bra while he applies the pads. Monitor on...pads....analyze...hot damn, course Vfib! We've got a fighting chance here I think to myself as I tune up 200 joules and push the charge button.


I continue CPR while man-child is going to 'start me a line'. The next time I look up he has a lock and a pre-fill in his hands looking at them like he had just gotten bit or something.

"Which end goes on the tube?" he asks so innocently. Maybe they're not used to the needless system in Pitt county, but he ain't got a clue as to how this is supposed to work. I ask him to take over CPR while I get the stuff set up. Instead of coming over to the side where I am and taking over, he starts pumping where I need to be. Now I've got to crawl over him to get to the IV and drug boxes. Equipment assembled and in hand, I crawl back over the mountain of EMT that is my partner to start the IV.

"Hard and fast" I remind him. He had obviously taken a CPR course from TV due to his weak symbolic efforts.

I'm quite impressed that I can see a pipeline of a vein screaming for an 18ga, and get it without having to chase and fish. She's patent, 1mg epinephrine in. Analyze, and its still Vfib...charge..."ALL CLEAR!"...zap.

By this time the first responders have arrived and boy am I glad to see them. They bring in a back board and the stretcher from our truck without even asking what we needed. One guy was on his game that day and I was so glad that he took over extrication at that point.

"Don't worry about the spider straps...get her on and get her out...one man on each corner", he instructs this newly assembled mass of eager helpers. This frees me up to get the drug box and monitor out to the truck and set up while they extricate.

I lost track of the husband during all the rush and didn't really notice it was him standing at the back doors, now fully dressed, as they brought his wife out and loaded the stretcher in the truck. He stood there, watching strangers doing things to his wife that must have seemed so brutal and barbaric to the average person. I only hoped that he realized we were doing everything by the book for her. I felt sorry for him as I put aside the thought of my own wife and how I would feel if our roles were reversed.

Out of all the people that show up to help, I end up with ONE in the back of the truck. She's a pretty seasoned Enhanced provider so at least the patient will get adequate CPR. Hose Monkey jumps in the drivers seat and we're at warp six in no time flat. After all the cables are hooked back up, a quick glance at the monitor and we've got an organized rhythm! If only we should be so lucky I think to myself. No pulses, carotid or radial. DAMN...PEA!!

I delve into the drug box and grab the atropine, flipping the pre-fill and injector caps in true Johnny Gage fashion and push it followed by a flush. I then try to pull up a multidose of epinephrine but that requires two hands. At this point I'm thinking maybe I could ride the mechanical bull at Arizona Petes or do some west coast surfing the way this guy is driving. Forget trying to intubate with all this action, so I sink a combitube just to secure an airway. I wish I had time to do this before, but the OPA we had was working. Then the truck comes to a near screeching halt and I hear from the front "Do I got right or left". For the love of god, can this get any more dysfunctional!

"To the right, Hero" I say as I peek out the front realizing the hospital is now in sight. It is only then that I realize he had missed the turn that would have taken us directly to the hospital. But if he would have made that turn, we would have missed all the stop lights and turns.

"Did you call in a code?" I ask.

"Do what?" he asks like I had just asked to borrow a hundred dollars.

It was only as we were wheeling into the trauma room that I realized he finally did call it in...as we were pulling onto the pad. Nurses were scrambling and no doctor in sight, but we continue to do our job.

We worked this lady for 45mins, and it was a long, grueling 45 mins that ran a full gamut of emotions. I'm not entirely sure what made this lady collapse and I may never know. But what I do know is that we got there as quick as we could and worked through a cluster of problems, but in the end our efforts were futile. Her husband had said his last I love you, the last goodbye and had their last dinner by himself. The sobs of a greiving husband is a sound I will never get used to, because I painfully realize that I too one day may be one.

Later that night my wife and I went out for dinner with the kids. Dinner had a special meaning for me as I greived silently for this man and his wife that I had never met.

09 November 2009

The Few....The Proud

Why The Gate Keeper? Because I...we need to be, and you probably agree! Unfortunatly we are in a day and age where someone has to be the one willing to stand up for what is right. There seem to be too many who are wiling to circumvent the rules, regulations and the standards that are set forth to dictate what is right and or decent.

In my profession there is a great divide between the true professionals and the wish-we-were professional paramedics. Granted, we're not doctors, but we know just enough to work independantly of medical oversight and provide a favorable outcome for the patient. This is what sets us apart from the rest of the health care professions. With this responsibility woven into the mantel that we wear, one would think that we would have at least half the respect of a real doctor. But due to the abuse of the priviledges and courtisies afforded us, disregard and lack of adherance to a code of ethics, we continue to relegate ourselves to that of a bastard child of the allied health care system.

In this blog I hope to teach myself to be more forgiving of others as they grow and become well rounded in their art and skills. It is too easy to be hyper-critical due to the inconsistancies of the respective systems throughout the United States and even the world. From my daily routines in EMS, whether it be on the career side or volunteer, I hope provide a more clear picture of the evolution that is taking us from good samaritians to that of a respected professional health care provider.