I have been catching up with old friends lately. Mostly through Facebook, but also through emails and other correspondence.
I am impressed with the level of success that my friends have obtained.
JB, a friend from Sunday School and Church, is now the Dean of Admissions for a large, Division 1 university.
TG, an old bicycling friend, is now a recognized figure in the "fit" movement, and a big part of Tony Horton's P90X program, and has been featured in videos and blogs and such. (His work has inspired me to become "unfat" as I like to say.)
RL is an old partner of mine from the renal roundup days. He is now a physician in the New York City area.
GK, another friend from Sunday School, now runs his own healthcare supply corporation, and travels all across the country, making money and playing golf.
HG, an old classmate, is a very successful lawyer, and political activist. He always has my support if he decides to run.
KA, my pizza-making buddy from high school, is making quite the career for himself in EMS.
Bubba, my college golf buddy, is now making a killing on the PGA Tour, and I look forward to seeing his continued success. He really does hit the ball a long way. Even if he does use pink shafts...
I'm very impressed by the success of my friends. I am glad to know them, and glad to see them mature into the leaders in their respective fields.
That's all for now.
Wednesday, September 21, 2011
Good advice
On the advice of my good friend, and trusted colleague, Flash Larry, I decided to remove the previous post.
While I stand by what was said in my post, his assertion that such comments might not be in my best interest is a good one.
Perhaps I will revisit the previous post in the future, but it will be done in a more tactful way.
I still know that I was right, and the complaint was baseless and ill conceived.
Flash Larry is a smart guy.
While I stand by what was said in my post, his assertion that such comments might not be in my best interest is a good one.
Perhaps I will revisit the previous post in the future, but it will be done in a more tactful way.
I still know that I was right, and the complaint was baseless and ill conceived.
Flash Larry is a smart guy.
Saturday, September 17, 2011
I see dead people
This post arose from a discussion I had with a colleague. I was being singled out, and essentially berated, for terminating resuscitation efforts on an 87 year old man who died while his wife was in church. His wife agreed, as did the physician on the phone. I was at the hospital after obtaining the physician's order signature to terminate resuscitation.
My colleague stated "people aren't dead until they are in a hospital, and a doctor says they are dead."
My colleague is an idiot, and thankfully, does not wear the same patch as I do, and does not serve in a primary caregiver role.
He is of the thinking that there is "something that they can do" that we can't. Like open cardiac massage on a 60-something year old patient? Hardly. This job is nothing like television makes it out to be. (Did anyone ever get pooped on during an episode of E.R.?)
Death is the most unavoidable part of life. From the moment we are born, or from the moment we are conceived, depending on your political leanings, we are destined to die.
The CDC reported 2,436,652 deaths in 2008. Only 170,314 of those were attributed to "Accidents (unintentional injuries) Intentional self-harm (suicide) and Assault (Homicide). We are ten times more likely to die from heart disease or cancer. Interestingly enough, Blacks have a much higher infant mortality rate, more than twice that of whites.
EMS responds every day to people not breathing, and without a pulse. Out-of-hospital cardiac arrest has, for lack of a better term, a terrible prognosis. On the high end of the prognosis, 8% of patients in prehospital cardiac arrest survive to discharge, while the low end cites a percentage of 2. The prognosis for in-hospital cardiac arrests are much higher, but still gravely low. One could argue for the importance of early defibrillation, and the access to healthcare providers in the hospital. (Even the janitors at my local hospital have CPR certification.)
Patients presenting in the prehospital system with either ventricular fibrillation or pulseless ventricular tachycardia have a 10-15 times greater chance of survival.
These are statistics from one source, the CDC. I doubt you would find a prehospital provider that would argue with these statistics, however. Personally, in my years of experience, I have seen a total of 2 patients who presented initially in ventricular fibrillation survive to hospital discharge, 2 patients who presented in pulseless ventricular tachycardia, and 0 who presented in a pulseless electrical activity (PEA, EMD, Ventricular escape, whatever...) survive past the emergency room. I could not tell you how many cardiac arrest calls I have run, but I would venture to say it is well over 200, which would be in line with the (admittedly doubtful) Wikipedia article.
Transporting patients without perfusing rhythms is fruitless. It does nothing but provide false hope for family members, increase the risks of accident enroute to the hospital, and increase the opportunity for injury to a provider in the back of the ambulance.
As mentioned by a person much smarter than I, "asystole is not a workable rhythm, it is a confirmation of death."
Granted, there are times to perform CPR and transport these patients to a hospital. The elderly person who collapses at the Sunday buffet is a good example. It simply wouldn't be prudent to leave a dead body covered by a sheet in front of the salad line.
There are also times in which transport is not warranted. The person in cardiac arrest, with a patent airway and intravenous access, with no signs of life, and no response to pharmacological intervention should, with family concurrence, have efforts terminated on scene.
Medical directors who insist their medics continue to transport dead people emergency to the closest hospital do nothing to advance this field. Medics who are not ready to challenge those medical directors are doing nothing for the field either.
We, as a whole, should stop transporting dead people to the hospital, only for a physician to confirm what we already know.
My colleague is still an idiot.
My colleague stated "people aren't dead until they are in a hospital, and a doctor says they are dead."
My colleague is an idiot, and thankfully, does not wear the same patch as I do, and does not serve in a primary caregiver role.
He is of the thinking that there is "something that they can do" that we can't. Like open cardiac massage on a 60-something year old patient? Hardly. This job is nothing like television makes it out to be. (Did anyone ever get pooped on during an episode of E.R.?)
Death is the most unavoidable part of life. From the moment we are born, or from the moment we are conceived, depending on your political leanings, we are destined to die.
The CDC reported 2,436,652 deaths in 2008. Only 170,314 of those were attributed to "Accidents (unintentional injuries) Intentional self-harm (suicide) and Assault (Homicide). We are ten times more likely to die from heart disease or cancer. Interestingly enough, Blacks have a much higher infant mortality rate, more than twice that of whites.
EMS responds every day to people not breathing, and without a pulse. Out-of-hospital cardiac arrest has, for lack of a better term, a terrible prognosis. On the high end of the prognosis, 8% of patients in prehospital cardiac arrest survive to discharge, while the low end cites a percentage of 2. The prognosis for in-hospital cardiac arrests are much higher, but still gravely low. One could argue for the importance of early defibrillation, and the access to healthcare providers in the hospital. (Even the janitors at my local hospital have CPR certification.)
Patients presenting in the prehospital system with either ventricular fibrillation or pulseless ventricular tachycardia have a 10-15 times greater chance of survival.
These are statistics from one source, the CDC. I doubt you would find a prehospital provider that would argue with these statistics, however. Personally, in my years of experience, I have seen a total of 2 patients who presented initially in ventricular fibrillation survive to hospital discharge, 2 patients who presented in pulseless ventricular tachycardia, and 0 who presented in a pulseless electrical activity (PEA, EMD, Ventricular escape, whatever...) survive past the emergency room. I could not tell you how many cardiac arrest calls I have run, but I would venture to say it is well over 200, which would be in line with the (admittedly doubtful) Wikipedia article.
Transporting patients without perfusing rhythms is fruitless. It does nothing but provide false hope for family members, increase the risks of accident enroute to the hospital, and increase the opportunity for injury to a provider in the back of the ambulance.
As mentioned by a person much smarter than I, "asystole is not a workable rhythm, it is a confirmation of death."
Granted, there are times to perform CPR and transport these patients to a hospital. The elderly person who collapses at the Sunday buffet is a good example. It simply wouldn't be prudent to leave a dead body covered by a sheet in front of the salad line.
There are also times in which transport is not warranted. The person in cardiac arrest, with a patent airway and intravenous access, with no signs of life, and no response to pharmacological intervention should, with family concurrence, have efforts terminated on scene.
Medical directors who insist their medics continue to transport dead people emergency to the closest hospital do nothing to advance this field. Medics who are not ready to challenge those medical directors are doing nothing for the field either.
We, as a whole, should stop transporting dead people to the hospital, only for a physician to confirm what we already know.
My colleague is still an idiot.
Friday, September 16, 2011
A what plan?
20 something female, pregnant, having contractions. These are usually lame calls.
I mean, you've known for how many weeks you would need a ride to the hospital? One would think you could save enough money for cab fare in 40 weeks. But ambulances are free.
This is a nice neighborhood, where kids go to private schools. This call is getting lamer.
Met by a nice, well dressed gentleman who directs us upstairs, to his wife, who is allegedly having contractions. I say allegedly, because I'm not sure if she is having contractions, or simply auditioning for a dying walrus.
She hands my partner a 2 inch, pink binder.
"This is my birthing plan. I want to make sure it gets to the hospital with me."
"Excuse me, what? A what plan?"
"My birthing plan. I want to make sure everything goes the way I want it."
"Was going to the hospital by ambulance part of your birthing plan?" (Hey, I'm just curious.)
"Well, no. That part wasn't in the plan."
The binder doesn't make it with us. We forgot it. Honestly.
I mean, you've known for how many weeks you would need a ride to the hospital? One would think you could save enough money for cab fare in 40 weeks. But ambulances are free.
This is a nice neighborhood, where kids go to private schools. This call is getting lamer.
Met by a nice, well dressed gentleman who directs us upstairs, to his wife, who is allegedly having contractions. I say allegedly, because I'm not sure if she is having contractions, or simply auditioning for a dying walrus.
She hands my partner a 2 inch, pink binder.
"This is my birthing plan. I want to make sure it gets to the hospital with me."
"Excuse me, what? A what plan?"
"My birthing plan. I want to make sure everything goes the way I want it."
"Was going to the hospital by ambulance part of your birthing plan?" (Hey, I'm just curious.)
"Well, no. That part wasn't in the plan."
The binder doesn't make it with us. We forgot it. Honestly.
Easy? Sure.
"This job is easy." Said the man with his paramedic patch that had been sewn on less than 12 months ago. "I mean, why do people think this job is so complicated?"
"Because it is complicated, that's why" came the reply with the more seasoned, yet not a veteran, paramedic.
"No, it's not. This is easy. I can't believe they pay me to do this job, it's so simple."
"How much time a week do you spend studying?"
"Why would I need to study? I already finished paramedic school and passed National Registry."
"Exactly."
It's scary to think we can trust lives with some of these people.
"Because it is complicated, that's why" came the reply with the more seasoned, yet not a veteran, paramedic.
"No, it's not. This is easy. I can't believe they pay me to do this job, it's so simple."
"How much time a week do you spend studying?"
"Why would I need to study? I already finished paramedic school and passed National Registry."
"Exactly."
It's scary to think we can trust lives with some of these people.
Damned Germans
Took an old guy home the other day. Well, not "home" as in his private residence, but "home" as in his very expensive, clean-smelling senior living facility. This is the kind of place in an affluent neighborhood, that costs $10,000 a month just for a room. Well, a suite, really.
These are fun calls for me. They take me out of the 911 system, and I can relax for a few minutes.
He is somewhat hard of hearing, but really nothing is wrong with him. He certainly doesn't meet Medicare guidelines for non-emergent ambulance transportation. That's not my problem though.
He and I talk. He was married for 63 years, until his wife died recently. He still considers himself married, and still wears his wedding band. He has 4 children, 11 grandchildren, 27 great-grandchildren and 2 great-great-grandchildren. He knows each and every one of their names, where they live, and what they do for a living. He also knows which ones come and visit him, and which ones don't. He says I remind him of one of his grandchildren, and that he likes me.
I tell my partner to drive slower and take the long way.
We talk some more. He tells me his secret to staying married for so long was to smile at his wife and say "I'm sorry" alot. He says he married his best friend, and that they never spent a single night apart. He doesn't tear up, but he is visibly saddened that his bride isn't with him any more. He smiles when he talks about her.
We get to his senior-living facility, and wheel him inside. He is obviously very popular with the staff and residents. Every single person says hello to him. His suite is very nice. He has lots of pictures of his family, and they all are attractive people, with big smiles on their faces.
Slimm and I lower the stretcher, and I help him to his chair. He asks me for a favor; to go to his bar and make him a scotch and water. I like this guy even more now.
I bring him his drink and notice a shadow box on the wall. In this shadow box I notice some military insignia, medals, ribbons and such. I notice a Silver Star, Bronze Star, 2 Purple Hearts, and various other medals and ribbons. I count 18 ribbons in the shadow box. I don't recognize the first one. It's blue, with thin red stripes on the ends, with a smaller white strip between the red and blue. I put that image in the back of my head for Wikipedia later.
I notice his Colonel insignia, and I feel mildly ashamed that I called him "Mister" instead of "Colonel." I prefer to call veterans by their rank. I may not have been born in this country, but I certainly feel admiration and respect for veterans.
"What did you get all this ribbons and medals for?"
"Killing all of those damned Germans."
Damned Germans, indeed, Colonel.
Slimm and I both shake his hand, and he gives a manly, respectful handshake, and makes eye contact, and says "thank you" while he does. We bid him goodbye, and make it back to the ambulance to go in service for the next call.
I pull out my iPhone and look up the ribbon online. It's the Distinguished Service Cross. It is the second-highest decoration, only behind the Medal of Honor. I feel honored to have spent time with a true American hero.
Damned Germans, indeed.
These are fun calls for me. They take me out of the 911 system, and I can relax for a few minutes.
He is somewhat hard of hearing, but really nothing is wrong with him. He certainly doesn't meet Medicare guidelines for non-emergent ambulance transportation. That's not my problem though.
He and I talk. He was married for 63 years, until his wife died recently. He still considers himself married, and still wears his wedding band. He has 4 children, 11 grandchildren, 27 great-grandchildren and 2 great-great-grandchildren. He knows each and every one of their names, where they live, and what they do for a living. He also knows which ones come and visit him, and which ones don't. He says I remind him of one of his grandchildren, and that he likes me.
I tell my partner to drive slower and take the long way.
We talk some more. He tells me his secret to staying married for so long was to smile at his wife and say "I'm sorry" alot. He says he married his best friend, and that they never spent a single night apart. He doesn't tear up, but he is visibly saddened that his bride isn't with him any more. He smiles when he talks about her.
We get to his senior-living facility, and wheel him inside. He is obviously very popular with the staff and residents. Every single person says hello to him. His suite is very nice. He has lots of pictures of his family, and they all are attractive people, with big smiles on their faces.
Slimm and I lower the stretcher, and I help him to his chair. He asks me for a favor; to go to his bar and make him a scotch and water. I like this guy even more now.
I bring him his drink and notice a shadow box on the wall. In this shadow box I notice some military insignia, medals, ribbons and such. I notice a Silver Star, Bronze Star, 2 Purple Hearts, and various other medals and ribbons. I count 18 ribbons in the shadow box. I don't recognize the first one. It's blue, with thin red stripes on the ends, with a smaller white strip between the red and blue. I put that image in the back of my head for Wikipedia later.
I notice his Colonel insignia, and I feel mildly ashamed that I called him "Mister" instead of "Colonel." I prefer to call veterans by their rank. I may not have been born in this country, but I certainly feel admiration and respect for veterans.
"What did you get all this ribbons and medals for?"
"Killing all of those damned Germans."
Damned Germans, indeed, Colonel.
Slimm and I both shake his hand, and he gives a manly, respectful handshake, and makes eye contact, and says "thank you" while he does. We bid him goodbye, and make it back to the ambulance to go in service for the next call.
I pull out my iPhone and look up the ribbon online. It's the Distinguished Service Cross. It is the second-highest decoration, only behind the Medal of Honor. I feel honored to have spent time with a true American hero.
Damned Germans, indeed.
Wednesday, September 14, 2011
ProQA Fail
Partner of the day and I had just finished working an incredibly impossible arrest. 17 defibrillations, and almost a complete drug box used. 17 minutes were spent in the house prior to moving the patient, mainly because the personnel on scene were all waiting for a rhythm change, be it positive or negative. We never got one though. That's a different story.
Seriously, who stays in v-fib for 40 minutes?
So, anyway, we get a non-emergent run dropped on us. These are pretty rare, since I have responded emergency to runny noses, and eye pain. This was for a man who was dizzy, which was also interesting. Usually, if a caller even mentions that someone in the house, or the near vicinity, might even be close to remotely being dizzy, or if they know of someone who has ever been dizzy, then a full response is warranted. A full response being a BLS Engine, an ALS Rescue, and an ALS ambulance. Again, I digress.
Suffice it to say that the call taker must have really thought this call was stupid to call it non-emergency.
So, POD and I drive in to this very nice neighborhood, which isn't rare in this part of the county. The houses probably start in the high 400s, and the house we find is probably nearer to the top of the market in this neighborhood.
We've got a waver!
I love wavers. If we didn't have people jumping up and down screaming at us (as if we can hear them from 800 yards through the rolled-up windows, over the diesel engine, the radio traffic, and our general conversation) I have no idea how we would ever find 123 Main Street.
Except for the numbers on the mailbox.
This is a nice looking gentleman, probably not our patient, since our dispatch information is suggesting a 60ish year old. This guy is probably early 30s.
POD and I decide to take in the monitor and the stretcher. Hey, it's the least we could do, right. This call sounds like utter horseshit, but we might as well grab some equipment. And the computer for a refusal. These people usually just want their blood pressure checked.
The waver walks up to us and begins to talk.
“My father and I got home from the gym about 30 minutes ago, and he's been really dizzy since then.”
Okay, maybe not an utter horseshit call, but it still sounds kinda stupid. Waver has an accent that, coupled with his thick, dark hair and complexion, lead me to believe he is middle eastern. That's about as specific as I can get. I can hear a Yankee from across a parking lot, however.
It's 68 degrees in the well-appointed home. I know this because I immediately felt cold when we walked in the door, and happened to walk past the thermostat, where I saw the 68. Just into the living room was a man, lying on the floor. He didn't look good.
Okay, maybe it's a genuine call. This guy looks sick. You know how white people turn kinda blue? This guy looked kinda like a blue middle-eastern guy. And he was wet.
Like, just got out of the pool wet. Obviously, I have a real patient.
He seems to be awake, but to compound his sickness, his son tells me that he only speaks Farsi. I most vertainly do not speak Farsi. I ask all the normal questions for a guy who looks like this.
30 minutes onset after coming home from the gym. No chest pain. No difficulty breathing. No nausea. No vomiting. No syncope. Had a stent placed in Iran 7 years ago. No meds. No allergies. Yada, yada, yada.
All this is going on while I do my best to dry off this incredibly diaphoretic, hirsute man, and get the electrodes to stick to him. Times like this I wish I carried tincture of benzoin in the monitor bag. B/P cycles 72/43.
Well, no wonder I couldn't feel a radial pulse.
The monitor is on, and prints it's initial rhythm strip:
Oh, snap! I would be dizzy too if my heart rate was in the 40s. And if it was junctional.
“Can you tell your father I need to shave some of the hair on his skin, and put more stickers on his chest? Mmmkay, thanks.”
The monitor keeps saying something about “Noisy data.” Forget that, print a damned 12-lead.
Okay, time to go. I reach for the combo pads, just in case this goes south, and also because of a lesson taught to me a long time ago by a coworker.
My Farsi-speaking patient now has eyes the size of dinner plates. His eyes look like he knows I am about to "light him up" or something. He looks at his son and says something incomprehensible to me, and his son in turn looks at me.
“Can you tell me what is going on with my father?”
“He's having a heart attack.”
Surprisingly calm. “Okay. Can we go to Secular Hospital (with no PCI, and notorious for screwing stuff up).
Surprisingly calm. “Okay. Can we go to Secular Hospital (with no PCI, and notorious for screwing stuff up).
“No, but we can go to Saint Catholic, right down the street.” (World-renowned, PCI-capable, and will actually listen to a paramedic and activate the cath lab on our word.) Thankfully, son agrees. As if he had a choice. I am NOT going back in to CQI to explain myself.
POD gives me a nice, smooth ride, which takes about 15 minutes. I get a 16 in an AC somehow, and give him a good, hefty fluid bolus. 324 of aspirin is in. Blood pressure comes up a few points, to 90 systolic. Hey, it's better, but nothing to be too excited about. Thankfully, my service transmits 12-leads, and Saint Catholic felt like answering the phone.
Not only that, they actually hand the phone to not just a physician, but the interventional cardiologist who is awaiting my arrival. I literally transmitted this 12-lead 5 minutes ago, and there is a PCI doc waiting on me?
Cool.
The rest of the story is pretty boring. He went to the cath lab, he got stented, spent the night, then went back home to his son's house. I'd like to check on him, but I probably won't. There's lots of patient's I would like to check on, but I never do.
Sometimes, I start an IV and not much else.
Good call, even with the interesting mistake between 911 call and the actual dispatch. I'm not a dispatcher, but I wonder how something like that happens.
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