Pre-Hospital Box of Chocolates

I struggled with the title of this post since it may cover more than just this or be a little off topic. At any rate, sorry for the confusion.

I've been in the EMS profession since 1988, a relative newcomer but old by other standards. I've practiced pre-hospital medicine all over the world on 5 continents. I've gotten to see a lot and do a lot but by no means everything. I've experienced a wide array of calls, had some really odd ones, had some confusing ones, had some that were textbook and some that were so far-fetched that the book seemingly needed to be rewritten.

But no matter where I've gone I always come across one group of providers that has always given me fits. Generalizing? Yes, I have to. I cannot and won't be specific but this particular group seems to give me more trouble and make me scratch my head more than any other.

I really want to go in to specifics but I'm letting my better judgement take hold here and reserving comments.

For some reason some people seem to make things, how should I say it, "difficult?" I realize that some people do not necessarily have pre-hospital experience or education, and that's understandable. But they should still have some of the basic things down pat, especially if they've been in the medical field for any length of time.

Just some of the "top of my head" things I've seen or been told (feel free to add your own);
1.) A nasal cannula @ 15 lpm
2.) A non-rebreather @ 2 lpm
3.) A patient who's talking, a & o x 4 with a pulse ox of 39%
4.) CPR being done on a patient bed that bounces up and down with every compression
5.) CBG (blood sugar) of <10 with no patient deficits
6.) Blood pressure of >300 with a normally functioning, no pain, no complaint patient
7.) Patient on the toilet, called for a cardiac arrest; arrived to simply lift the patient's head (to open the airway) and they began breathing again
8.) Numerous calls to 911 for transportation (as an emergency) to the local hospital for headaches, ear aches, a "tickle in their throat," and for one "runny nose"
9.) Patients stating they have one complaint and the staff stating the patient has a completely different set of complaints
10.) Patients who are normally in a vegetative state with no ability to communicate period somehow tell the staff they have a complaint of pain or problem

These are all calls I've had that I can easily remember for one reason or another at one place or another. There are more but this is a good start. It's not uncommon to get called for a cardiac arrest only to arrive and find the patient awake, alert, and talking. What happened? It's also not uncommon to get called for a simple transport only to find out the patient is in dire need of medical care immediately. It's one of those, "you never know what you're going to come across when you get there." Be prepared.

Assessing a patient, you'd think, can be a simple task. Go from head to toe, assess the simple ABCs and go on from there. Do a complete secondary survey and find the finer points. Be detailed. Find out all the smallish items that may indicate an underlying problem that may not be readily seen yet don't overreact if it's not anything of importance. Take note of it and go on.

But it still floors me how assessment skills can be so different from prehospital to anywhere else. Take this call for example that I did with a BLS crew. Patient with a CVA history among other things. Has had a cough recently, is febrile, I & O normal, everything else appears fine. Patient's GCS is a 15, Very alert, oriented, knows surroundings and is very pleasant to converse with. The Cincinnati Stroke scale was normal x 3, 3 hours prior per staff.

We were told the patient's pupils were unequal and non-reactive, was complaining of chest pain, was febrile, had unequal grips and could not use the right side (where old stroke was), very confused and disoriented. Their diagnosis was another stroke.

The patient's grips WERE normal bilaterally. NO chest pain, used right side (all of it) without a problem, knew exactly what was going on and recited family history and family members as well as local happenings along with time, date, day of the week. Pupils were BOTH reactive and responsive to light. All of this was done in front of the staff as we assessed this patient prior to transferring to our cot.

Huh??? Where did these observations come from? We were told all of this came on within the last 30 minutes prior to our arrival. The patient even told me that they (roommate also) were watching TV together and talking about the shows (roommate confirmed this).

One correct finding? She was febrile.

It is true that we never know what to expect on any call, no matter the background of the call or where it may be located. We are called to a sick person and it turns out to be an overdose. We get called for an MVA and it turns out to be a shooting. We get called for an injured in a fall and it turns out to be a cardiac arrest. Anything is possible. Our station used to have a plaque on the wall stating, "Expect the worst, hope for the best." True words by someone who knows and has experienced a lot. We always have to prepare and expect the worst possible scenario and hope that it's not, for the patient's sake.

Assess everyone no matter how routine a call it may be. Even the simple transfer from ECF to a doctor's office for a checkup needs a quick once over. Do a good head to toe. If nothing else, those are the patients who are good to practice basic assessment skills on. Listen to the lung sounds and different fields. Look at the diagnoses and see if you can see any of the stereotypical signs that come with what they have. Look and feel the extremity edema of a CHF patient. What does it look like? What does it feel like? Do you see any JVD? Can you find a good pedal pulse on someone who has gross pedal edema? Do you feel any masses or pulsating areas in their belly on palpation? Do you palpate bellies? Do you rock their pelvis or feel their neck? Do you look at their ears or nares to see if there's any exudate? What about their mouth? Any open areas or bleeding?

All of these things can be very helpful in determining what may or may not be wrong with a patient. True, not all of them will be pertinent to every patient, but some of them may very well help diagnose what's wrong with them and better lead us down the right path of treatment prior to our arrival at the hospital. As always, document what you see, felt, and heard (or were told) as well as the responses to the treatments given.

Details, Details,... Good Documentation

"It was a dark and stormy night,..." Don't all run sheets usually start that way?

My first big trauma run came during my senior year in high school, about 2 weeks before graduation. I'd been an EMT for about 5 months and loved being a part of EMS. Big nasty single car accident with both driver and passenger ejected. Here I was still fresh out of EMT class and learning all that I could get my brain wrapped around. I loved the EMS world and all it had to offer; the skills, the challenges, the patients, everything. I embraced everything with open arms.

About 10 years later I happened to be running around the station and was talking with some people about old runs. That particular run came up and became the main topic. I still remember it vividly and I still have some of the newspaper clippings and pictures in one of my old scrapbooks. As we were talking about it I asked about seeing my old run sheet. "Here's the keys," I was told. So I set out on a mission of rummaging through years and years of old run sheets to find this one needle in a haystack report.

About 30 minutes later I found it. I was shocked. I was dumbfounded. I couldn't believe how I'd done my report. It was all handwritten other than the headings for the certain sections. My narrative? Less than 3 complete sentences. This was a BLS narrative for an ejected passenger, unconscious, decorticate posturing, with shallow breathing and crappy V/S. I know because I remember what I saw because of the run, not from my run sheet.

Since that time I've been to court and given depositions on a handful of cases. I've been talked down to by lawyers, I've been cross-examined by lawyers, I've been made to feel that I don't know what I'm doing in the EMS world by lawyers. It happens. They do it for their clients, not because they don't like or trust me. But one constant comes from every time I've been to court or given a statement; documentation is king.

I was floored at the amount I could recall about this incident and the utter lack of details actually put on paper. Laziness? No time? Education? Were there specific reasons why this was like this? Back then we had to leave our run sheets at the hospital before we left there. On rare occasion we'd finish them later, like if we caught another run before we got done writing it. This one? No clue. I will say that in my EMT class documentation was never harped on or drilled in to our heads.

Fast forward about 1 1/2 years from then. In Paramedic class and again, documentation wasn't stressed. If anything, I learned documentation from my boss who was one of my preceptors. He schooled me in the fine art of documenting a run. All the details, the pertinent negatives, the treatments and responses, the finer points of the scene that were visualized that may have played a part in the patient's history of the present (or past) problem; things that should be documented. I got my run sheets torn apart thoroughly by him on a routine basis, even the BLS transfers I did for him he'd go through with a fine-toothed comb.

While a lot of services and departments are going for ease, efficiency, and time saving measures when it comes to reporting, I'm still and always will be a fan of good documentation and a thorough narrative. I worked for a service a while back that began toying with electronic "notepads" for their run sheets in an effort to reduce paper use and speeding up sending reports to the main office for billing purposes. There was no place for a narrative. None. My questions were these: Does a narrative need to be generated on a BLS nursing home or doctor's office visit? Sure it does. What did you see? Why was there a need for this transfer? Is it not possible that this patient could change in front of your eyes or you see, and document, something that an extended care facility staff member did not? How many times have you heard about people getting calls about missing personal effects a patient had? Ever gotten a call from a facility asking about a hematoma or mark on the patient's body that wasn't documented on the transfer sheets? Guess where the blame will lie on that one.

Has it happened? Yes. The best defense we have is our documentation. Even though we typically only see patients for a short period of time, our run sheets need to paint a vivid picture of what we saw, what we did, and how they reacted to our treatments. Sometimes these run sheets come back to haunt us years after the fact. Can you remember every run you did in 2008? How about 2009? I'm sure there are the memorable runs but what about the mundane ones? Is it not possible that the mundane BLS car wreck on January 4th, 2009 ends up being a court case where someone is getting their pants sued off and you're called to be deposed? Even more, you or your department could be named in the suit for malpractice. Possible? Very. Does it happen? Damn right it does.

Spelling, grammar, punctuation, capitalization all matter on run sheets. I'm not the world's best but I do a fair job of being detailed in my reports. If spelling is wrong you may get called "lazy" by a lawyer for not taking the time to spell check. "Since you didn't use spell check and were lazy in your reporting, were you lazy in treating my patient? Did they get the care they deserved because of your inattentiveness?" Or incorrect grammar and / or punctuation could lead to, "Since you don't care enough to use proper grammar or not use the correct punctuation then you obviously don't care enough about patient care and treating my patient to the best of your ability."

These run sheets may need to be recalled years down the road. Other than pictures our documentation is the best thing we have to help us remember, jog our memory about a particular run. Take your time putting them together. Put pertinent details and the pertinent negatives. Make it easy to read; not necessarily a book, but one huge long paragraph is difficult to digest sometimes. Try to keep things in chronological order; what you saw, what you were told, what you did, how you did "it," what the responses were, end result when arriving at your destination. It's all about CYA. Protect yourself and your department the best you can.

Pride

I'm part of a smaller department in the Midwest. Our EMS is separate from the fire service but located in the same building. Most of the people on the fire side belong to the EMS service. We're one of the lucky departments on both sides because staffing seldom has been a problem. Other departments know that usually if they call us they'll get a fully staffed truck or crew out the door in a matter of minutes. We have about 40 people on the fire side and roughly 90 on the EMS side. Both sides are volunteer save 2 paid EMTs during the weekdays and our paramedics are paid a minimal hourly wage.

One thing I've seen year in and year out is a lack of pride. I've been a part of this service since 1988 and certified in something since January 1989. I was giving narcotics to patients before I was 21, which was old in itself.

There are a lot of us around that have been a part of our service since high school. Some grew up around the department. Me? I just knew I wanted to be a part of it. Nobody in my immediate family is, was, or has been anything medical anywhere. I enjoy the thrill and challenges that the fire and EMS services both throw out each and every day.

Probably the hardest thing to deal with is pride and the lack of it I see quite often. I speak about it often to people, I practice it every shift, I wear my department attire with pride; I like to show it off. I don't use it as power to stand over people. I don't flaunt who we are and what I am. I am one of millions nationwide trying to make a small difference in my area and maybe elsewhere through education, communication, or experience.

We boast a lot of people as members of our service. Yet time and time again we see just who the people are who take pride in our department and what they are. These are the people who show up for meetings and public events, cover shifts, train and educate others, and truly want to make a difference. These are the same people who want their voices heard about opinions or issues, take care of the equipment we have, and want to help others out. Pride, pure and simple.

The same core group is there day after day, shift after shift, helping others out without fail. Donating time or energy is second nature. Helping others is human nature. What's "volunteering" called? Maybe "dedication?" I'm one of those that realize that had it not been fore our departments I wouldn't have gotten to do or see half of what I have since high school. I've traveled the world and gotten to do things most can only dream about. I credit it all to where I began my EMS career, at a small volunteer BLS service.

How do other departments get others to take more pride in who they are, what they are, and what they represent? Is it that generations have changed that much? Have thoughts and cultures evolved to the point where respect has gone out the door? The generation coming up now is being raised by my generation. I'm not that old yet I see kids today that don't have the same desire, work ethics, or passion for things like I used to, like my generation did when we were their age.

Like most EMTs, AEMTs, EMT-Is, and EMT-Ps, I busted my ass to get my certification and license and I was damn proud to show it off. I still am. I've made a living by helping others and one that I'm very proud of. I feel like I've made a small difference in peoples' lives through education, caring for others who were sick or injured, or just by being "there."

I love what I do. I still do after all these years. Next year begins my 20th year as an EMT-P and 23rd as an EMT. I'm proud of what I've accomplished. I'm proud of what I've become. I'm proud to say that I've made a difference in some peoples' lives. I'm proud of my roots and where I began my career and I'll always come back here.

Teach pride as best you can. Make others proud of what they have and who they are. Hopefully the generations to follow will keep the same level of pride in the EMS and fire services that we have. Remember that pride in who you are, what you do, what you're a part of, can be defined differently by all. Be proud of everything you do. Take pride in your work and efforts.

We, the Caregivers

I was reminded this weekend just how much we do to help patients as well as their families.

Got called to the house of a soon-to-be frequent patient we'll transport. This call was in the wee hours of the morning so I'm already worn out as I hadn't gone to sleep yet. The call was for "altered level of consciousness." Those are those kinds of calls that you never know what to expect since that can be caused by a myriad of things.

When I got there the BLS crew was already in the house attending to the patient and finding out a brief history of what was going on. As I walked in to the very clean and neatly kept house I was met by the patient's son who was about my age, maybe a couple years older. He kindly directed me to the back of the house, to the master bedroom where his ill father lay on the bed.

So I made my way through the halls and found the bedroom, brightly lit with nothing out of place, the carpet neatly vacuumed and the furniture glowing from a recent polishing. Smells of a faint vanilla from an unseen air freshener emanated throughout the room. Pictures of kids and grand kids and old wedding pictures dominated the top of a large chest of drawers detailing to all who entered that this couple loved seeing their family in print every time they walked in and out of their room. The bed was neatly made and creased ever so slightly at the top edges, save for an elderly gentleman laying horizontal across it with his head square on one of the huge down pillows.

This man had been recently diagnosed with leukemia and was a clergyman, according to his wife. He hadn't been feeling too well recently and had been to the doctor's office a lot as a result. Tonight wasn't any different for him but he just had a "far away look" in his eyes, according to his mate, that "just didn't look right."

As I began peppering her with questions to find out a little more extensive history to put together I stopped myself and realized just how upset she truly was. Tears were welling up in her eyes, her upper lip quivered as she spoke, her eyes constantly on her spouse of 57 years as he was being attended to by the BLS crew, and her left knee was bouncing ever so slightly with worry and apprehension.

I looked behind me to make sure the crew was doing all right and to see if they needed my help. They all were doing fine. I returned my attention to the wife and politely apologized to her for not introducing myself. I offered my name and hand and she returned both to me with a slight smile and look up in to my eyes. I slowed down my questioning and lowered my voice just a little bit for her. I wasn't yelling but quieting things down a little usually helps tone the entire scene to a bearable level. The crew loaded our gentleman on the cot with assistance and out they went.

I stayed behind.

This wonderful, yet truly worried woman would be following behind shortly to the hospital with her son. The crew was fine without me so I offered an ear and a shoulder to this man's wife. They had been together for 57 wonderful years, built a wonderful family with lots of visible grandchildren in the pictures. I got to know a couple of their names and a smile came out as each of them was told to me. I knelt down on one knee so she could look down on me and not up. I wasn't "above" her and I don't like being perceived like that. I'm here to help and have been for 23 years, less than half the time these two people had been married.

As I asked her simple questions and talked to her about her family I got several pats on the shoulder, small smiles, and lots of tears. This woman was terrified of losing her husband. She questioned why he was now sick with this disease at his age. Why now? Why him? What was she going to do without him? She was truly frightened by that prospect and rightfully so. I stayed and talked with her for a while and offered what positive, comforting words I could.

I left her in the care of her grown son to take her to the hospital. We left each other after having only met about 20 minutes prior with a wonderfully warm hug. It was one of those hugs that made me think I'd known the woman all my life because it was a genuine "thank you" hug, one that made me feel pretty good. It made me smile.

Not that we made everything all better but we were all there to help her and her husband. He wasn't feeling well and she needed a shoulder to cry on. More and more I realize that we, as caregivers, need to be more attentive to the family, bystanders, and friends of those we take care of who are sick or injured. They need care and attention just like the patient does, just not in the same sense.

We need to make sure we slow down and take the time to talk to them, speak to them on a level they can understand, show empathy and compassion, and let them know we'll do everything within our powers to help them both out. In this case is was something very simple; someone to talk to, someone to hold her hand, someone to lend a shoulder to cry on, and someone to receive an absolutely wonderful love-filled hug that merely said, "thank you."

9/11, Never Forget

The day after 9/11/01 I wrote this letter and emailed it to our local paper. I was offshore in Trinidad working at the time and was glued to the TV watching CNN and CNN world. I flew home through Miami exactly one week after to find that my letter had been published in the paper as a "Viewpoint" article. Here it is, complete as it was published in the Herald Bulletin.

Over the course of the last week I have sat and thought about what I could say to the rest of the world. I am an ordinary US citizen and have virtually no power to talk to the rest of the world. Yes, I do have email and a telephone but I cannot reach as many people as I would like to. I, the everyday citizen who has no special talents, am not an actor, am not a political figure with a booming voice that can be heard through political circles around the world. This is my media to express my opinions and thoughts. This is the way I can communicate with people; with other normal everyday people to show the thoughts and feelings of one individual.


I am currently at work and in a place that I am confined to for several weeks at a time. When I get here I cannot leave unless relieved. I cannot go home to spend time with my wife and unborn child. I cannot go out to the movies. Normally I accept all of this as part of my job. But this last week this has been damnable. It has been very difficult to stand by and not be able to do anything. I have been here all along watching these tragedies unfold in front of my very eyes on the television and read about them in the local newspapers. I have internet access and have seen the pictures and read the stories posted on various web sites. I am saddened by all that I have seen. I am even more saddened by the fact that I cannot leave here to offer my knowledge and skills to those who need it. My heart aches. My sense of security thrashed. My nation violated. My assumed safety horrified. My anger increasing. My sympathy mounting. My tears always flowing.

September 11th was America’s second “Day of Infamy.” That day will always be remembered by the generations alive today. History has been written and will be re-written. It will be seen, heard, and remembered by the future generations in their history books, on old video archives, and on old press clippings on microfilm at the local libraries. That was a day that I will always remember where I was at, what I was doing, and wondering what the future will hold for not only me but the rest of the world.

I have read articles and editorials from the various newspapers around the country and world with messages of hate, anger, revenge, sorrow and sadness, and most deplorable of all, jubilation and victory. It is our granted right in America to have freedom of speech and opinion. Maybe this is one reason why someone has chosen to smack us down simply because they live in a place that does not offer these basic freedoms. The reason why these acts happened may never be known. So for now all we can do is wonder and formulate a hypothesis as to why.

The images I have seen of people cheering and celebrating are heart wrenching. It hurts. It makes the anger in my soul boil like nothing ever has. I am a patriotic person who gets choked up at the National Anthem during sporting events. I am not a vengeful person but I, like most Americans, want justice done. I do not wish to see innocent people around the world suffer the way our people suffered through this. That would not be right and morally just. But I want justice to be swift and merciless. I want those responsible to pay for what they did to the American public as a whole as we saw or heard about those acts in our homes, offices, cars, airports, or wherever else we were on the morning of September 11th. I want the justice to teach others a lesson that these types of acts will never again be tolerated anywhere in the world.

Fortunately and thankfully the world as a whole has come together to see that this is a problem we all face. This is not simply America versus the terrorists. This is most certainly the world against terrorism. NATO and the European Union have pledged support and I honestly believe they will be there to help in any way necessary. Always before the Americans have been the “helpers” to other countries. Now, unlike before, people are turning to extend the favor back to us. The corporate help from around the world is immense. The governmental responses from various world leaders has been quick and unrelenting to support this cause. They realize that these acts could have easily taken place in their offices and on their homeland. Solidarity around the world is alive and well.

I have cried numerous times viewing the pictures and reading the stories depicting the scenes of these crimes, the damage done, the innocent people lost, the families traumatized forever, and for the people of our great nation who will be forever scarred by these horrendous acts of violence. I have also cried for seeing people come to the rescue, the swiftness of change to help ensure our safety and security, the fast-moving responses by various assistance organizations, and for seeing the ordinary citizen help out with food, a bed, or simply standing on the street holding a candle, saying a prayer, waving a flag, or cheering for those who have come to help in our nation’s greatest time of need.

President Bush commented that we will react on our terms when we are ready and at our choosing. I have faith that he will and the rest of the nation will stand solidly as one behind his decision. Yet when those actions, whatever they may be, are carried out we will not cheer, jeer, or jump up and down in the middle of the town square celebrating others’ demise. We will refrain from that simply because we will know that justice has been served. We will take solace in the fact that our families, friends, and co-workers have been avenged. We will not “be even.” We will not have “settled the score.” We will, however, feel that justice has prevailed for now and for the future in hopes that the world will remain a safer place without those despicable people a part of it.

I thank the government of our blessed nation for the votes of confidence to see these actions are retaliated against. This reaffirms that our government is full of people working for the people and doing the peoples’ wishes. They know and understand just how badly we have been hurt. They also know, as do we all, that our nation will rise above this terrible day and remain as strong as ever and even stronger than we were before. We are bruised and bloodied but not down; not by a long shot. We have come together and will continue to do so in unimaginable numbers and strength that the world has never seen before. Good will over power evil. We are a great and powerful nation. We will prevail. We will be strong and support each other. Raise your chins and be proud to be a part of the greatest nation on Earth.

Finally, for every citizen around the world who said a prayer, who stood in the street for a moment of silence, raised a flag in solidarity with their American brothers and sisters, felt sympathy or empathy towards our nation, has come forward and offered assistance, has donated their time, money, or skills, or has comforted someone else who grieves, I thank you from the bottom of my heart.

God bless America, the land of the free and home of the brave.