First Due Medic

Identifiable names, numbers, and locations and been changed to protect the identity of the ones who my not want to be identified

I decided to wait a while before I recounted a call I ran on 18 Dec, primarily so that I could possibly share a good outcome. Unfortunately, this is not going to be the case. It’s rather troubling to me that this call had the outcome that it did, this in part because the one reason I do this work is to ensure the best possible quality of life for the people that I come in contact with.

It is my assumption that every person that is subjected to my care should benefit in a positive way from our encounter. Now we all know that this is not going to be the case every time. Life happens in a weird way sometimes and death does most certainly happen. Maybe it’s my glorified view of our chivalrous actions that makes me want for all that is good; for whatever reason. However, I’d like to hope that it’s just something engrained in my genetics that make me strive for the best for my fellow man, be it neighbor or stranger.

I had only been home from work for an hour or so the morning of 18 Dec. As is my custom, I left my pager on so that I could be available to lend a hand in the county volunteer system. The career side of my job doesn’t afford a lot of opportunity for a lot of EMS work outside of inter-facility transports, so I sort of have to stay involved at whatever level I can to stay sharp.

I was reading some blogs that I follow when my pager went off.

“CCom to Station 25…possible heart attack…caller is stopped at The Quick Store on 585 South…caller advised her husband started shaking and then slumped over, not sure if he is breathing…. CCom first page at 0959.”

The first thing that registered in my mind was that the person dialing 911 had stopped at a convenience store that was right below my house. If it were not for the trees, I may be able to see the store from my front porch. It was close and I was already on my way out the door before the dispatch was over.

Unfortunately there was only one person at the station at that time and they were in the process of requesting an EMT or a driver for the call as I started my vehicle. This was wasting precious time as I waited for the request for additional personnel to finish paging out so I could mark up>

“CCom this is 172” I radioed backing out of the driveway.

“172”, dispatch replied.

“I’ll be responding POV, have Station 25 roll a truck and meet me on scene”, I advised.

“Station 25 did you copy 172?”

“10-4 CCom, we’ll have a truck in route momentarily” came the standard reply for acknowledging a call.

I couldn't’t help but think of all the possible heart attack calls that we get on a weekly basis in our county. A call that we take so seriously, dropping everything to rush to the scene to start definitive care, only to find somebody who would be better served by a cab company. To top it all off, how many unresponsive calls do we get that end up being a patient refusal of service when we get on scene? There had been a few recently and I couldn't’t help but think that this be just another one of those type of calls as I pulled into the parking lot of the store.

“CCom to 172”, dispatch called over the radio.

“172”

“Caller advised she’ll be standing by in a red cavalier”, I was told.

“10-4, I’m on scene…I’ll be making contact in a second”, I said as I got out of my vehicle.

I zipped my hi-vis jacket and holstered my portable radio while I made my way across the parking lot to the red vehicle parked cock-eyed in front of the store. It was about this time that I heard the truck signing enroute from the station, thankfully they were no more than five minutes away if it turned out to be something. There was an older lady standing inside the passenger side of the red car talking loudly to a man inside the car and shaking him trying to get a response. She was visibly upset and started recounting the events in an excited fashion leading to her calling 911 as I approached.

“Hi, my name is Gate, I’m a Medic here in Horry County….calm down and tell me again what happened…slowly”, I told her as I reached in to shake the gentleman who was slumped forward in the passenger seat of the car. He was held back only by the seat belt that ran across his chest.

“We was coming to Millville to see my grand-daughter…about the time we crossed the county line he started having trouble breathing and he told me he didn’t feel right”, she told me in as calm a voice as possible. I shook the man by his shoulder and got no response, so I did a light sternum rub; nothing. Placed my hand flat on his chest to chest for rise and fall; nothing.

“Then when we was coming through the curves back there, he just started shaking and just fell over against the window”, she continued.

I grabbed his right wrist to check for a radial pulse while checking for a carotid with my other hand; again, nothing. All the while during my assessment the lady who turned out to be his wife, continued on with her recounting of the events leading up to this point. For all the important information that she may have been giving at this point, I was not listening; I was zeroed in on the fact that this man was or had been clinically dead for less than five minutes by now.

“172 to 2510”, I said into my lapel mic.

“2510, go ahead”, the driver replied.

“Step it up, I need you here five minutes ago”, I said with some urgency in my voice.

“10-4, we’re about two minutes out”.

“CCom this is 172…this will be a working code blue”, I advised them.

Reaching inside the car and unhooking the seat belt, I worked my left arm in behind his back and then placed my right hand under his right armpit. With one swift motion I lifted and pulled at the same time pulling my now patient free from the car. It was then that I noticed a small crowd had gathered, some realizing that something was wrong. I placed the man on the cold asphalt parking lot and again quickly checked for any signs of breathing and a pulse; again, nothing.

I located my landmarks on the patient’s chest and placed the heel of my left hand on his sternum covered by my other hand. The guy had some drool coming out of the corner his mouth I noticed. It was then that the germaphobe in me welled up and called for passive air flow. I was really thankful for the knowledge that the body has about 15-20 minutes of oxygen in reserves at the cellular level and that inter-thoracic pressure would move enough air passively to sustain efforts for a few minutes. I started to compress the chest of the man who obviously was in cardio-pulmonary arrest. 1 & 2 & 3 & 4 &…….I counted out loud.

“OOOOOOOooooo NOOOOOOOOoooooo”, came a painful wail from behind me. I didn’t stop to look around, but I could only assume it came from his wife.
“Is something wrong with him?” an innocent and obviously uninformed bystander asked from beside me.

“Yeah… he’s kinda dead right now”, I said before I could catch myself. I’ve always had a problem with stupid questions, and this was certainly one that qualified as stupid, but the answer was purely instinctual.

I was really getting some good compressions in when I noticed the potential for some head trauma. Every time I would compress, his head would come up off the ground and then hit the ground when I released. Realizing this was not a good thing in general, I also realized that there were people watching. Amazingly enough though, not the first person stepped up and identified themselves as a CNA who works at the nursing home, nobody said “I know CPR, need some help”. They were all just watching the big guy lunging into the little guys’ chest….maybe they were transfixed by my high-vis jacket, I don’t know. Anyway, I went to one handed CPR so I could use my other hand to cradle his head and keep him from getting a subdural hematoma.

Enter our local volunteer heroes. The ambulance can be heard coming down the road for miles thanks to the piercing wail of a Wheelen siren through 200w speakers. As the truck entered the parking lot at mach II, siren still wailing and bumper smacking the ground, dragging on the way in; I wasn’t too sure how this was going to go from here on out.

The driver of the truck, an EMT that we’ll just call Fred, comes huffing over to where I am empty handed and asks, “What do you need?” Now I know we’re a long ways out from national standards of training yet, but BLS skills are pretty much the same world over. We’ve got a working code, common sense says that the next thing we are going to need is a BVM and ….. a monitor/defibrillator. Instead of wasting my time having to recite protocols and bring everyone up to speed, I just tell him to get me a stretcher, which he dutifully retrieves. Over the radio I now hear our radio hog who also serves as the band-aid purchasing agent for the rescue squad signing on scene. The next thing that puzzles me to this day is why the next thing out of his mouth is him advising dispatch that we have a working code and we’re going to need ALS. However, there are some things I try not to think about only because it hurts so much.

With the patient now on the stretcher and moving toward the truck, I run ahead and get the LifePak 12 and I.V. set up. With the stretcher now entering the truck, I apply the quick patches and switch the monitor on and set the leads. Now let me state this before continuing on any further; I absolutely despise the quick patches. I think every truck should have paddles on their monitors…I digress. With the monitor now I on and CPR stopped, I immediately recognise V-Fib. "Charging…all clear"…ZAP!...and CPR continues. I did finally take an opportunity to insert an OPA at this point, place a pillow under his shoulders and give a couple good breaths with the BVM w/ O2.

Now let’s talk about CPR for a minute here. Well, rather who is doing CPR. Fred is a 5’6” 350lb man who wears nothing but sweat pants and t-shirts at any given time of the year. He is also known as the guy who has more belly to cover up than T-shirt to accomplish the job. Now Fred is giving it all he can with CPR, more than once exclaiming how hard it is to do this. Needless to say, I’m not really concerned how tiring it is, just do it and do it right. Band-aid purchasing agent is standing at the side door in spectating mode just enjoying the show. I would have much rather had him in the back; not too bright a kid, but he was a former Army guy and he was fit. There would be no chance of him coding too from doing CPR; but Fred said he had this covered.

Checking the patients’ arms, I quickly realize he is going to be a tough stick, but I notice he’s got some nice jugs.

“Trendelenburg, Fred!”, I say

“Huh”, came his reply accompanied with a bewildered look befitting his appearance.

“Put his feet up…raise the foot of the stretcher”, I clarify

“Oh...O.K., that’s what I thought you meant”, he said refusing to concede he didn’t have a clue.

I inserted an 18 gauge needle in the right external jug getting immediate flash, following with a flush and starting a line of normal saline fluid. Turning to my left to grab the drug box I notice Band-Aid purchasing agent still standing there watching all the festivities.

“Code 3 please, no lights…no siren. Nice and smooth”, I tell him. He quickly slams the side door shut and runs to the front of the truck and jumps into the driver’s seat. In no time flat we lurch into motion as me and Fred continue our battle with death.

With 5cc’s of Epinephrine drawn up in a multi-dose syringe, I go ahead and push 1mg and flush the line. In between all this I’m trying my best to oxygenate the patient. Thankfully his neck being hyper extended was doing the trick. As I’m getting a pre-fill of Lidocaine I notice we are closing in on our second set of two minutes of CPR.

“Hold CPR” I say to the only person doing CPR. A quick glance at the monitor tells me it’s time to defibrillate again to knock out this V-Fib.

“Charging…ALL CLER"...ZAP!!..."continue CPR”, I say, and then give a few good breaths with the BVM. By this time we’re starting to get some gastric backflow and I decide to chance an intubation. I glance up at Fred and felt sorry for the poor guy. He looked like he could just lay down on the stretcher with the patient and die right there. He was now getting to the point where chest compressions were just intermittent and circulation and perfusion was just wishful thinking. The intubation was unsuccessful partially due to the crap I had spread around the head of the stretcher keeping me from getting all the way down to head level.

I needed to get a round of Ladocaine in and quick so I urged him, “Hard and fast there Fred, you’re his heart now!” Just as I had assembled the Ladocaine pre-fill in true Johnny Gage fashion, Fred was taking another break from doing CPR and I looked at the monitor and saw an organized rhythm. Shocked at this but pleased, I checked for pulses; none. PEA I can work with, so I psyched Fred up some more by telling him, “Keep at it Fred, you’re doing it ‘ol man…we’ve almost got him back…stay to it!”

Back to work Fred went pumping for all he was worth and sweating like a logging mule in July. I hit our pt with another 1mg of Epinephrine, continued to ventilate and suction the airway as best as I could manage all the while getting the Atropine ready. One milligram Atropine in and by this time we were about one minute from the ER pad. Just for good measure I gave another round of Epi as we were getting everything together to go into the ER.

Once inside I give my report to the attending physician and they continue resuscitative efforts. After about ten minutes of multiple drugs and one more shock, he is now intubated and on a ventilator; they bring out the doppler to listen for a pulse. First there is the loud screeching rubbing sound, the room fell silent, then the faint sound of blood perfusing and the artery expanding and contracting….music to our ears!!

“Get me a pressure”, the doc says.

After a minute, “167/95”, came the reply.

By golly we had done it!! I went out to the squad room to get started on my paperwork, which would take the next 45 minutes. That would be followed by exchanging the drug boxes at the pharmacy to get us back in service.

By the time we left, the patient was in the cath lab. I was so excited I could barely stand it. Everybody wants a save, but now came my real worries. What quality of life would he have past this point? Only time would tell. I decided then that I would follow his route to possible recovery. My hopes for his full recovery were bolstered even further later that day when I received a call from the hospital. My patient had been taken to ICU and was on a vent.

I went by to see him only once after that. The nurse in ICU told me that his diagnosis was alcohol induced myocardial myopathy, so I guess that explains the flask in his jacket pocket. They said he had very minimal neurological response and again only time would tell. Another factor not in his favor was the 5-10 percent cardiac ejection fraction.

Fast forward eleven days. I find out today that that he has been moved to a long term care facility where he will most likely live out his days in a vegetative state due to hypoxic brain damage. I now question myself over everything done during the call. Was everything done perfectly? No. Could we have done some things differently? Absolutely. This will be another learning experience where I will never again wait until I get to the truck to start care; care starts at contact and transport comes after stabilization.

I’ve been assured by the attending physician and trusted co-workers in the field that whatever damage he suffered started before I got there and my job was to keep it from becoming worse. I worked with what I had available. In a perfect world or even in the ER his chances may have only been marginally better.

With this being my first “save”, I am more frustrated than ever because of the outcome. I can’t help but feel that this guy and his family would be better off if he would have died; but I’m not the one that makes that call. I do my job because that’s who I am, and I work with what I’ve got.

Gonna take it to the world

I just received a phone call a while ago from a trusted friend about a hair-brained idea he and another friend had. Looks like I'm going to be involved in a stream cast. With all the possibilities now days to broadcast yourself to the world, I guess it wasn't too long coming for me to jump on the bandwagon. It looks like there is a project in the works called Ask the Medic. Pretty clever title I guess, but nobody ever listens to the medic, and we certainly don't listen to each other. Now let me be clear about this, I am on board with this idea 100%, but I have some reservations.

Anybody who has been around the EMS/Public Safety scene for any length of time knows the EMS community is a hard nosed crowd to be around. We are, or can be the most cinical and critical of other providers skills, tactics and interpretations. I'm not really sure what the whole platform will be about with this production and I surely hope I don't develop the idea that this is going to change the world. It may. But so far other like "shows" and/or podcast haven't changed the world, but they are starting to roll the tide.

From what I understand there is going to be some humor to all this with my segment called "Ronnie's Raging Rants".....trust me folks, I'm good at it. If there's something that deserves a little rightous indignation; I'm on it! There will be some teaching and critiquing I'm sure, but most importantly of all, an opportunity to put a light on our own EMS system as it continues to develop. Maybe an opportunity to do some real in-depth interviews with local influences and a little research will avail itself.

Whatever may happen with this, I hope... no I'm sure, it will be for the good and betterment of EMS. A little tongue-in-cheek humor will no doubt will emerge and maybe even some issues that deserve a few minutes in the spotlight will get the attention they deserve...or warrant(pun intended).

If you've done this kind of thing yourself, let me know how it went for you. Give us some suggestions, ask questions and have a good laugh at our expense, we won't mind a bit.

As soon as I have more details I will post them here and on Facebook.

Until next time....Medic Up!!

Just not christmas

I feel bad for this, I really do! But for some reason, it just doesn't seem to be the same christmas that I knew when I was younger. It seems that christmas has been hijacked by commercialism and "It's OUR day christians". Everybody has an opinion about what to leave "in" christmas and what to take "out". It seems to me that christmas is now about what everyone else wants it to be about.

I really could not even get into the giving spirit this year just because of the lives of a certain segment of our community. There are so many who have lost jobs this year and are having a really rough time finding work. Naturally, they will have to prioritize and I'm sure there are plenty of kids who will do without to a certain degree. I've been into people's homes and seen the meagerness of their holidays, and it doesn't strike me as being a festive season. Although we have been blessed this year with steady employment and a fairly stable budget, there are those who haven't and I am no better than they are. I haven't chosen to join them per say, but only to deny myself the self-imposed obligation to get people a gift on one particular day of the year when I otherwise would not on any other day.

I simply chose not to go crazy this year. I personally spent less than $100 on gifts; my wife, well that's another story. But, the kids were surprised with some things and genuinely happy with others.

Tonight I will go to work, and will probably go into a home and see that someone else had a meager christmas as well. I will still wish that their circumstances were better, but I will not feel the guilt that would be associated with my extravagance.

Who's Training Who?

The one thing I take pride in is the amount of training that I have subjected myself to in order to get to where I am in my career. Granted, I'm not there yet and hope to never really get "there". I hope to be a lifelong learner and change with the times and advancements in the industry. More than the training is the amount of time my family has had to sacrifice, well, not being a family.

As of right now I'm on the last leg of becoming a National Registered Paramedic...four more months!! Luckily, I live in a state that has a level of certification that pretty much mirrors the Paramedic protocols as far as skill sets are concerned. It's nice to be taught at a Paramedic level and tested at that level and then given a year to work in the field learning and getting your street smarts in. I've been blessed to have been trained by a man who takes his job seriously and has a lot of pride in his program. He is a stickler for doing things right and having integrity and good moral character, and he tries his darndest to instill those values in his students. We are drilled hard on ACLS protocols, proper procedures and honesty is demanded when doing field and hospital clinicals. Over the past year and a half, these same values have been passed on to me and a few other in my class....some will remain true to their belief that a certification is all they need to make life good for them. I beg to differ.

What bothers me is that there are some agencies that will trump their professionalism just because they provide a career staff. They trump even louder because they require their employees to submit to mandatory bi-weekly "training"...well, some of the employees anyway. My eyes were opened the other day at a training session where we were supposed to do our quarterly skills check offs that are required to maintain an active certification. At this particular station was an EMT-Enhanced provider who was going to show us how to do an intraosious needle insertion. Now, let me explain this, an Enhanced in Virginia is much like an Intermediate in the rest of the country. They can do I.V's, D50, Albuterol, Epi during a code and not much else. In Virginia, an Intermediate can do just about anything a medic can do...some things we have to call for orders on, i.e. Dopamine ect. This guy in all his infinite wisdom proceeded to tell us that all we had to do was just locate the knee cap, come down a finger width under the knee cap...and drill. No Indications, contraindications and lets not overlook the fact that what was described was NOT the location to insert an I.O. needle. In this group was myself, another EMT-I and a Paramedic who CAN do this procedure being told wrong how to do something that he can NOT do in the field!! This insult to our combined years of training was further exacerbated when he began to instruct an EMT-B how to start an I.V.....inappropriatly again. Why was this individual assigned this task you might be asking. I can only assume it's because he has been in the "business" for about seven years and has garnered some favoritism as a reward for his loyalty; I really just don't know!

There has got to be a dividing line somewhere, and I'm just not sure where it is. If only all the talk of our company being the best were true. Sure, it all sounds good on paper and when giving a sales pitch, but when the rubber meets the road, it's all white-wash and fluff. The saddest part of it all is that there is no oversight of training and enforcement of state rules and regs are spotty at best. Most if not all or this validation is left up to the individual agency and leads to nothing more than the fox guarding the hen house. I do wonder though if this kind of stuff "happens everywhere"? Is it like this in a municipal service where there is supposed to be an established hierarchy that is qualified to teach, train and/or instruct?

If we are going to have anything, let's at least have some integrity. For all the profitability and good public relations that we would strive for, there is nothing more important than maintaining a level of professionalism that can not be questioned by anyone, whether it be internal or external. This leaves me in a state of frustration as I try to figure out how this situation can be fixed. I do realize that it didn't get this way overnight and it certainly will not be fixed by next week. What is even more frustrating, is that I am just a lowly field provider somewhere near the bottom of the totum pole. I have the ear of some, but their hands are politically tied and they are limited in their reactions.

But this I promise to those who will come after me and who are now working beside me...I will continue to stay abreast of the latest developments in pre-hospital and advanced medical care. I will honor those who have come before me by staying true to the skills they have developed and perfected through the years. I will with all that is in me protect the interest of the patient first, foremost and above all else. I will promote patient advocacy in any public forum in which I represent professional pre-hospital care. In all that I do I will...DO NO HARM.

The Birth of a System

Over the past month I have followed the happenings between two Paramedics who live and work 8,000 miles apart. I don't exactly recall how I stumbled onto their story, nor does it really matter...I'm just truly thankful that I did. Here's their story in a nutshell, Justin is a Firefighter/Paramedic in San Francisco, Ca and then there is Mark who is a Paramedic in the UK. Both have an affection for their respective jobs that rivals anything that I have ever seen here in my little section of southcentral Virginia. What I first noticed was that they were both thinkers; not a bunch of grippers. They went a lot deeper into their jobs than just protocols and shift schedules, but about important things like the health care system as a whole and how we as pre-hospital providers fit into this health care system.

Enter The Chronicles of EMS. This project was developed to be the beginning of an exchange of ideas and to provide an up-close and personal view of EMS. To make a long story short; Mark comes to the U.S. to work for a week or so and Justin goes to the U.K. to do the same. Both are now able to write about their experiences and share different viewpoints from each others respective jobs. This has allowed not only me, but thousands of others to have the opportunity to share a second hand experience that can challenge our ways of thinking about how we do our jobs.

After stumbling around related blogs and looking up protocols from other countries, I happen upon Garth Van Zyl who hails from Franschhoek, Western Cape in beautiful South Africa. Now this guy is the real deal as he is in the true beginning stages of building an EMS system and shares his thoughts in his blog . I'll leave it up to you to visit his website and read his story and inspiration, but turns out he is THE system for his community.

It is events and happenings like this that give me hope for a bright future in EMS. I live in a part of the country that is strong with the volunteer spirit. There's nothing more noble than to set aside your personal time, or your own life for that matter, and give for the benefit of your neighbour or a stranger in need.

For one to think that this way of giving to the community can remain the chivalrous act that it has been forever is naive. I have unfortunately seen some changes in the past three years in my county that should be raising red flags. These changes in attitudes, personalities, and methods of operation have caused me to to become an outspoken advocate for a change that will hopefully take us in the direction of becoming a true profession. I am not saying that volunteerism should go by the wayside! But there has got to be accountability for the actions or lack thereof when the system gets a "flat tire".

I do believe that the downfall of pre-hospital care began a downward trend when it started being seen as a money making opportunity. ANY agency that has their eye on the bottom line will not make decisions that are beneficial to the patient or the community, unless proper safeguards are in place to advocate for the provision of service.

Well, I did get of on a little tangent there didn't I? As I have stated before, I am optimistic that change and good things are on the way worldwide for EMS and/or pre-hospital care. This change will not come as a result of copious blogs and gripping around the station or even gripping at business meetings. Change will have to first start in ME and YOU! And when WE decide to band together and do what is right for the community and the citizens , and demand the same professionalism from those we work with, then and only then will change happen.

I titled this section The Birth of a System for one reason. I see a new way of thinking starting to emerge around the world. This way of thinking is going to cause some labour pains, but a birth is immanent and will be worth the pain in the long run.

Stay strong and focused my friends! We're almost there!!