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).

“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. 

On criticism

Recently, a co-worker of mine responded to an accident with possible injuries, which blossomed into an MCI with 4 patients, with 2 possibly critical.  While I wasn't there, and won't comment on the assessment or treatment of any of the patients, it's what happened after the call which is interesting.

One of the supposed (and I use the word "supposed" because there seems to be some debate about the actual status of the patient) critical patients, was a young female adult, with left-sided abdominal pain, and a mechanism which lead to a high index of suspicion for a bleeding spleen. 

The first medic on scene reportedly (by all parties involved) had two patients immobilized onto long backboards when the second crew arrived.  The point of contention seems to be what happened next. 

Instead of the second unit leaving rapidly, the crew members elected to remain on scene for (at least) an additional 8 minutes prior to departing to the hospital.  They performed a thorough assessment, and attempted IV access twice, without success.  The medic member of the crew did not suspect a lacerated or bleeding spleen.  While I do not know that particular medic very well, there is nothing I have seen for me to even remotely question his assessments. 

The first medic then subsequently immobilized two more patients, and departed for the hospital, arriving prior to the second unit.  When questioned about what "took so long" to get to the hospital, the EMT member of the second crew stated "we were doing a thorough assessment and trying for IVs."

Instead of objectively stating the findings of his detailed assessment, the EMT with 18 months of experience told the medic with 18 years to "mind your own business." 

One caveat here.  I fully believe in the assessment powers of my coworkers.  I have worked with many of them, and would freely put my life, or the life of my loved ones in their hands.  I always try to avoid criticizing the treatments or interventions performed by others. 

About 12 hours later, the EMT decided to insinuate on a social networking site that the first medic on scene was behaving in a "the sky is falling" manner.  This led to a long thread of comments, from no fewer than 6 people, on the merits of the call.  None of the interventions were called into question.  What was called into question was the professionalism of gossip. 

I could go on, but won't.  Mostly because this is not the place for such a discussion, and partly out of respect to all parties involved, in an effort to minimize the gossip and negative comments. 

What I have learned from events surrounding this call:

1.  When approached by a colleague, regardless of certification level, or experience, it's always best to listen with objective ears, in an effort to learn something. 
2.  Discussing a coworker behind their back, whether good, or bad, will always result in that employee finding out what you have said.  This is a small community, as referenced in my state, which has been licensing paramedics for 35+ years, with only 12,000 or so reaching certification, with a population approaching 10 million.
3.  If you are going to talk about a coworker behind their back, there must be a willingness to accept the ramifications of your actions.
4.  Everyone respects the patch, and everyone needs to respect the person wearing the patch. 
5.  Social networking sites may not be the best place for work-related discussions.
6.  Just because it says "Paramedic" on my patch doesn't mean that I can't learn from an EMT.

I have not lost any respect for either one of my coworkers, but have learned an invaluable lesson regarding my professional relationships. 

Don't stop, don't call

"Medic Sixtynine, respond to reports of an accident with possible injuries, Goofball Highway at Old Booger Hill Road.  Passerby advises there are 4 cars involved, unsure of any injuries."

Great.  This call sounds F-U-N.  And it's raining.  And Old Booger Hill Road crosses Goofball Highway at least 4 separate times within 6 miles.  In two distinct fire districts, covered by three different engine companies.

Lets run down why this call sucks:

1. Day after a holiday, at 8:30am.
2. In the rain
3. An unknown location
4. Some cellphone warrior was worried enough to call, but not enough to stop, and actually roll down the damned window and shout "Hey, y'all'rite?"
5. I haven't had my breakfast yet
6. I haven't had my nap yet
7 I haven't even put on my socks yet

We literally drive in circles looking for this wreck.  This cellphone warrior was kind enough to call 911, but couldn't give a description of the cars.  Fan-freaking-tastic.

We find a wreck.  A red SUV and a white Ram Truck. 

Not the wreck.  Fire says it "uppathattaway" about half a mile. 

Dark SUV, grey BMW, white sedan. 

Wrong wreck.  Turn around again, check another intersection of Goofball Highway and Old Booger Hill.

Find a wreck.  PD is on scene.  Eating a biscuit in his car.  (I am NOT kidding.)

"Hey, where y'all been?  We been waitin' on y'all for a while now."

"Shut up, Munch*.  Who's hurt?"

"Oh, ain't nobody hurt.  I done cancelled y'all 'bout five minutes ago."

I hate cellphone warriors.  And missing breakfast.

I put my socks on, and go in service.

Non-emergency?

Earlier, I discussed the disproportionate use of lights and sirens in our responses.  Sure enough, someone just has to prove me wrong.

We are responding to a doc-in-the-box that calls our service at least once a day.  This clinic doesn't have a stellar reputation, nor does it have a terrible reputation.  Just another urgent care facility. 

Apparently, they called my dispatch center directly and requested an ambulance.  Somewhere during that conversation, an employee at said urgent care facility mentioned that the patient was complaining of chest pain.  And difficulty breathing.  And has a history of PE.  And an abnormal EKG. 

...And wants us to come non emergency.

This patient was genuinely sick.  She was in sinus tach at 130, and in obvious distress.  Her room air O2 saturations were very easy to take, as the clinic staff hadn't bothered to administer any, much less check her SpO2.  It was 88.  The staff did, however, start a 24 gauge INT for me.  Sweet.

Her 12-lead, physical exam and history all scream PE.  And this doctor either:

A. Didn't know it.  (Which makes me wonder why not)
B. Wasn't that concerned about it.  (Which makes me want to ask him why) ...or...
C. Knew that I personally would be the one to respond and take care of the patient.  (Which makes me want to shake his hand.)

Maybe I'm just complaining too much.

Pleasant Vomiting

Respond emergency for a female who feels sick, and with a racing heart.

Sounds cool enough. (I like giving adenosine.)

We are met by the fire crew. "Leave your stretcher in the ambulance. She will be sitting on a john boat in the driveway."

Interesting.  (What's that bout a john boat?...)

"I vomited violently about an hour ago, and I want to go to the hospital. I laid down, and my heart started racing."

Sinus tach at 113.

"Violent vomiting" was mentioned no fewer than 15 times on the way to the hospital.

Straight to triage.

Red lights for this?

We go "emergency" way to much.  Period.  My unit is dispatched emergency to well over 95% of our calls.  I transport emergency to the hospital maybe once a month. 


At my service, the dispatchers will raise a unit for a call by saying "Unit soandso, copy an emergency."  It seems that every imaginable complaint under the sun is an "emergency."  And when we respond emergency, it means that we are going to a scene with some sort of fire apparatus.  It's not the dispatcher's fault.


Perhaps we should better educate the public on the definition of "emergency."


Why do we need 6 EMTs and 2 Paramedics in, collectively, a fire engine, rescue truck, and an ambulance for a 35 year old man with kidney stones?  Or for that matter, a child with a fever?  Or for the nursing home patient with abnormal labs? 


Those people need a taxi, not an ambulance, much less 3 humongous vehicles driving emergency, forcing cars to the side of the road for their bullshit complaint.


I think the call-takers in my county should be able to provide directions to the hospital. 

You can downgrade now.

A call for an infection in the leg.  Bullshit.


Not only does this guy have maggots in the open wounds on both legs, but he appears to have been incontinent for several days.  DAYS.  Literally, covered in shit.  The rest of the assessment is unremarkable, with normal vitals. 


I know it stinks, and you can smell it up front, but there's not really reason for you to drive emergency to the hospital.