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Tuesday, February 14, 2017

Truck 51, Responding.

The tones chime around 21:30. A medical aid. I've picked up an overtime shift and am driving at my own station. Always a plus. I listened to the address and go to the map. I knew the street but I want to check exactly which house it was. As I stepped into the rig my captain said in a tense voice, "Get us there!"

In the dispatch notes my captain had read that we were headed to a pediatric full arrest. In plain English we were headed out for a baby that no longer was breathing or had a beating heart. 

Normally when driving a fire truck with lights and sirens there's a lot of caution involved. A 70,000 pound vehicle rolling through red lights can be dangerous. On the way to this call the limits were pushed. Seconds counted. We listened above the growl of the siren to the dispatcher rattle off all the units that were responding. Truck 51, PD, AMR, AMR Supervisor and at our request, Engine 52. Dispatch informed all responding units that CPR instructions were being given and that this was for an 8 month old boy. 

One police officer made it to the scene before us, He had just enough time to go in and grab the lifeless kid and bring him out to us. I started chest compressions while my firefighter set up the BLS airway. After a minute of CPR the AMR unit pulled up. Without hesitation we moved. As a cohesive unit we transferred the entire operation from the front of the house to the back of the ambulance.

On our way to the hospital, in the back of the ambulance, there were three medics and an EMT. My firefighter continued with compressions gently forcing the child's heart to pump blood. I inserted an intubation tube into the airway of my patient. With that in I then connected the end tidal CO2 tubing and continued to breath for the baby. The AMR supervisor used a drill gun to sink in an IO needle for vascular access. He then was able to administer what we hoped would be life saving drugs. The AMR medic watched the heart monitor for a rhythm and kept track of time for us. It's remarkable easy to lose track of time on a full arrest.

By the time that we reached the hospital the RNs were waiting for us at the door. Our ACLS protocols had been followed perfectly. Even better than they would have been in the hospital. This is what we do.

Inside the ER the staff takes over continuing with ACLS. Another 20 minutes go by and there's been no change. The family has arrived. Mom and dad stand in the hallway looking for a miracle. As I come out of the room they look to me for answers. The hospital staff hasn't had time to talk to them yet and I'm the one the parents remember rushing their baby away giving them hope. The father asked what his vitals were in a way that told me they had heard that on a medical show on TV and were sure their boy was supposed to have some sort of vitals.

I take my time with the family explaining what was going on. I prepared them for the worst because I knew it's coming. Years of experience told me what the end result of this call would be. After a few questions another ER doc came by and took over for me. As he was talking I slipped away.

I headed back out to the ambulance bay and helped my firefighter put all of our gear back together. Just as we were leaving the AMR supervisor came out, caught my eye, and shook his head. Nothing more needed to be said.

The ride back to our station was quiet. Somber. None of the usual banter and at times dark humor that usually follows a serious call. None of us talk about it but we're all fathers. This one hit close to home. As we approached the station the radio beeped and the dispatcher came on.

"Truck 51, medical response...." I knew where were headed. I reached up and flipped on our lights. My foot stepped on the floor button that winds up the siren. Over its high pitched scream I hit the air horn.

Truck 51, responding.

Thursday, January 28, 2016

And I Thought I'd Heard It All

At 0530 the tones went off. Just early enough to make me grumble about missing a little bit of precious sleep but late enough that I knew I was up for the day.

We were being dispatched for a 14 year old male feeling ill. That's dispatcher speak for 'we have no idea what's wrong with this person.'

When we pulled up we were waved down by a friend of our patient. By the looks of him, something serious must be wrong.

We walked into the apartment and found our patient. He was sitting on the couch and looked to be in zero distress. I walked up to him, sat down on my drug box (which doubles as my chair on a lot of calls), and introduced myself.

During introductions I evaluated his pulse (steady and strong), his airway (completely patent), his respiratory effort (breathing nice and easy), and his skin signs (completely normal). Not being able to detect a reason for the 911 call I then asked the question...

"So, why are we here?"

His answer was one that I haven't heard before. He had called 911 because, and I quote, "I was feeling lazy."

My mind raced! Really?! LAZY??!? I really wanted to say that I had toilets at the station he could scrub as a cure. Heck, he had a toilet there at his own home he could scrub. But before I could figure out which smart a** response to go with AMR showed up. And with them, a paramedic intern.

As the intern walked in I gave him a quick report. 14 year old male, chief complaint...feeling lazy. The poor medic intern didn't know what to do with that one.

I talked for a moment with his preceptor and then we cleared the call. The last thing I heard from the AMR crew was them explaining to the patients father, who was already at work, that he had to come home to sign his son out AMA since his son called 911 and was a minor.

I think dad will correct that situation.

Sunday, January 25, 2015


The familiar click of the speakers turning on let me know we were getting a call about a second before the tones went off. If you're used to working at my station you can hear that quiet click over all kinds of ambient noise. We were being dispatched for a residential fire alarm.

We roll on a lot of false alarms. Residential fire alarms are almost always the result of someone over cooking their dinner or a bag of popcorn. So many false alarms can lead to complacency, just like the villagers in the story of the boy that cried wolf. We were just like those villagers, unprepared to act when the time came.

We pulled up to the 3 unit apartment complex and found the courtyard between that building and the one next to it full of people, including a lot of kids. It was a weekend, it wasn't too cold, and it wasn't too late. Besides, the fire department was coming. Everyone likes to see a spectacle.

My captain and I were both "turned out" but neither of us had our bottles (SCBA) on. There was no smoke, This was another false alarm.

We headed over to the apartment and someone approached us. They said that they lived above the unit in question. They heard the smoke detector going off below them and smelled something like burning food. They had knocked on the door but no one answered.

It wouldn't be the first time that we've been to a house where someone left a pot on the stove. We knocked on the door again just to be sure. We also checked the windows. They were all closed and locked with the curtains drawn. The windows and the door were cool to the touch so there was little concern.

We determined that the renters and the manager had been called but there was no answer. With the indications we had that something wasn't right, my captain gave me the word. It was forcible entry time.

Let me just take a moment to say how much I love being a firefighter. It's fun. Especially at times like this.

I was already lined up with the front door. I did a forward kick that would have made my kids MMA instructor proud. When the door flew back I was greeted by a wall of smoke that extended from the ceiling to the ground.


My captain and I ran back to the rig to grab our SCBAs. We should have had them on already. Crap. I hate that feeling.

I grabbed the pack from my seat and threw it on while I walked back to the apartment. Now the crowd had moved back. No one wanted to get in our way. By the time I reached the door I was masked up. I stepped up to the doorway then disappeared into the smoke.

While the entire place was filled with smoke is wasn't thick and black. There was also no accompanying heat. The fire had snuffed itself out, suffocated....starved for precious oxygen. I made my way to the kitchen and found that there was indeed a pot on the stove with the burner going. The family had placed several baby bottles in a pot of boiling water to sterilize them and forgotten about it.

Once the water had boiled off the plastic started to burn. The knobs on the stove were melted and the paint on the wall was charred and blistered.

We opened the windows and doors and used a fan to remove the smoke. We moved the burnt items out of the house and then disconnected the stove and moved it to the center of the kitchen. With all that done we again checked to make sure the fire hadn't moved into the walls or the cabinets.

It could have been much worse. At least they had working smoke detectors.

And I learned a valuable lesson about complacency.

Thursday, September 18, 2014

Postponing The Inevitable

In my area resources are dispatched to EMS calls in two waves. First, as soon as the location of the medical emergency is confirmed, the fire department is dispatched. We roll with lights and sirens to all of them because the person calling 911 doesn't always get things right (for instance calling because their husband fell and needs help getting up only for us to find out he fell because he's dead). The call taker in dispatch then triages the call (using an EMD program). Once the severity of the call is determined the ambulance is dispatched with the appropriate response (code 2/3, low, medium or high priority). This allows the most critical patients to have access to an ambulance theory. Once the ambulance is dispatched the dispatcher will inform us on the radio the nature of our call.

We were on our way to get dinner in the East end of our district. While sitting at a signal light waiting for the green arrow the radio chirped. Beep beep, "Truck 51, medical response. 1234 5th street. Map page 117 xray."

We were only a couple of blacks from the address and we were facing the right direction. My engineer flipped on the lights and hit the air horn. We were no longer waiting for that green arrow.

We pulled up to the house less than a minute later. The 911 call taker was still getting information from the caller when we walked up. The ambulance had yet to be dispatched.

I asked the lady what was going on. She replied that her husband had collapsed in the bathroom and was no longer breathing. The call had taken a turn for the more serious.

I turned to my captain and asked him to go grab the Autopulse. I grabbed the victim and drug him out into the bedroom where we would have enough room to work. I immediately checked for a pulse and then started on chest compressions. He couldn't have been down very long.

My engineer grabbed the BVM and started breathing for the patient. My captain soon returned and let me know he had called for the next due engine just in case we needed the manpower. Once the Autopulse was on things started to get a little less hectic. I placed the defib pads on the patients chest and checked a heart rhythm. PEA or pulseless electrical activity.

PEA is a heart rhythm where the heart, electrically speaking, is working ok. The problem is the muscles are not responding to the electrical impulses telling them to pump.

We resumed resuscitation efforts. AMR showed up and they had an intern with them (the son of a member my department). I allowed him to start the IO and then to intubate the patient. The intern performed both skills perfectly.

We then settled into a routine of medication administration, CPR and heart rhythm/pulse checks. My captain had already talked to the wife and explained what was going on. She was prepared for the worst.

After a third round of Epinephrine and some more chest compressions we preformed another rhythm/pulse check. On the heart monitor the wave form had changed. And at my patients neck there was a corresponding pulse of blood.

 He had a pulse.

We quickly but carefully moved our entire operation to the back of the ambulance. There the poor intern tried to remember all that he had to do while being peppered with questions from his preceptor and me. He did a good job.

Before arriving at the ER we had a repeat set of vitals, a 12 lead EKG and had started inducing hypothermia. My patient was even starting to fight the ET tube. A good sign. He might actually live.


A couple of weeks later we stopped by the house where my patient had lived to check on him. His wife informed us that he had lived for 10 days in the ICU under heavy sedation. He had suffered a stroke which had caused the cardiac arrest. There was no possibility for recovery. All we did was postpone the inevitable and give the family a chance to say good bye.

Thursday, September 4, 2014

Emergency Medical .....Prevention?

In the fire service there is a saying. The fire service is 200 years of tradition unimpeded by progress.

While not really true it can, at times, feel like it is. There seems to be some in the EMS world that are trying to follow that tradition.

Recently an article was written for the Contra Costa Times that covered a pilot program in Alameda County. Some of the paramedics from two departments within the county (Hayward and Alameda City) are receiving extra training. They, along with medics from a total of 12 projects throughout the state, are going to be able to not take patients to the hospital. Instead they will have the latitude to take the patient to an urgent care or other health clinic. This would potentially save the patient an expensive ambulance ride to the hospital and would (again potentially) free up the emergency department to treat someone that is actually seriously ill.

The program also includes post clinic visits by the paramedics for some limited patient follow up. The goal is to prevent the need for another 911 call. Prevention is better than a cure.

There has been some serious opposition to this pilot project. I'll start with the opposition in the paper...The nurses union. The nurses union is screaming that paramedics aren't capable of doing something like this. That we lack the training/knowledge.

Tricia Hunter, executive director of American Nurses Association/California said, "They're still not licensed registered nurses, not licensed physicians, not licensed mental health professionals." 

She's absolutely right. Paramedics are not RN's or MD's. We are however licensed paramedics. Paramedics can do most (if not all) of the commonly accepted nursing skills in CA (starting IV's, assessments, medications administration...) plus medics can do some things that RN's can't like pleural decompression. For a list of what paramedics can do in CA click here and scroll down to scope of practice. Oh, and did I mention that paramedics are trained to do these things generally under standing medical orders (meaning we diagnose which patients need what treatment and do the treatment without consulting anyone) and to do them in the field? Anyone can start an IV in a well lit Emergency Room. Try it on a freeway, in a wrecked car that's upside down, in the rain and at night.

So let us not go down the road of paramedics not having the training.

Really the nurses union is worried about losing jobs. Paramedics taking their patients to other care facilities and  medics going out and trying to prevent the need for emergency health care in the first place (by visiting patients in their homes) could lessen the need for nurses. I get it. That's the role of a union. Save jobs. But I don't agree with that, if it means we can't even look into the possibility of a better method of health care delivery .

Vicki Bermudez of the California Nurses Association said, "We think the money is better spent on existing services we know work." 

Really? You think our current model of health care works? Long wait times in Emergency Departments. Outrageous costs. Everyone seems to blame health insurance companies but they're not the ones charging $5 for two pills of Tylenol. Clearly you haven't been a patient in a while. Anyone with some common sense can reasonably deduce that our current health care delivery model isn't working. Let's try to fix the system. I'm not saying this is the solution but it may be part of one. Let's try it and find out. 

And obviously the guys with the medical license (the know...the guys and gals that medics and nurses work for) think this idea has merit. So get with the program.

Enough with me ragging on the nurses union.
Now I'll move on to other complaints I've come across from people that have read this article. I'm going to generalize these somewhat.

There is the complaint about a cousin/brother/father/grandmother that was treated incorrectly on a call one time ergo medics can't do this. All these stories are anecdotal. To the people that use these arguments I have two points. First, you weren't there and you probably don't have all the facts. It's quite possible what the medic did was correct. Second, hypothetically speaking, if you were there AND had all the facts, that doesn't preclude the possibility or even the likelihood that the medic that treated your family member/friend/significant other was probably an idiot. They are out there in every profession. You may have just been unlucky and got one.

Then there are people that claim medics can't do this because of liability issues. Now remember, I'm talking about CA and not anywhere else. I don't know the laws in the other states. Here (and I assume almost everywhere else) medics work under the medical license of a doctor. As long as paramedics follow proper protocols they are covered. 

The CA Health and Safety Code Section 1799.104 (b) states "No EMT-II or mobile intensive care paramedic rendering care within the scope of his duties who, in good faith and in a nonnegligent manner, follows the instructions of a physician or nurse shall be liable for any civil damages as a result of following such instructions."

Section 1799.106 (a) goes further and states, "In addition to the provisions of Section 1799.104 of this code, Section 2727.5 of the Business and Professions Code, and Section 1714.2 of the Civil Code, and in order to encourage the provision of emergency medical services by firefighters, police officers or other law enforcement officers, EMT-I, EMT-II, EMT-P, or registered nurses, a firefighter, police officer or other law enforcement officer, EMT-I, EMT-II, EMT-P, or registered nurse who renders emergency medical services at the scene of an emergency or during an emergency air or ground ambulance transport shall only be liable in civil damages for acts or omissions performed in a grossly negligent manner or acts or omissions not performed in good faith. A public agency employing such a firefighter, police officer or other law enforcement officer, EMT-I, EMT-II, EMT-P, or registered nurse shall not be liable for civil damages if the firefighter, police officer or other law enforcement officer, EMT-I, EMT-II, EMT-P, or registered nurse is not liable."

As long as medics aren't negligent I think we're ok.

Next there are those out there that think paramagics don't have the ability to figure out where a patient should go.

Are you kidding me? Paramedics make destination decisions all the time. where I work we have to decide between the closest hospital, trauma centers, stroke centers, burn centers, and cardiac centers all while keeping in mind patient condition, traffic, helicopter flight time and helipad at the hospital, and patient requests. In other counties in which I've worked we had to decided weather a kid needed to go to an emergency department approved for pediatrics, a pediatric medical center or a pediatric trauma center....and that was just for the kids. I don't think that adding one or two more possible places to drop off our patients is going to be very taxing.

Another thing detractors say is that the medics in their area are too busy to do follow up visits. News flash. Paramedics in almost every urban area are busy. But if we take the time to do a little preventative maintenance on our frequent flyers maybe, just maybe, they will call 911 a little less often. Which in turn will me the medics will be a little less busy. Also I'd much rather do a follow up visit at 2 in the afternoon versus responding to a 911 call to the same person at 2 in the morning. That's the same as saying that fire departments are too busy to work on fire prevention. Do you have any idea how many lives have been saved by smoke alarms/detectors, better fire codes when in building construction, sprinkler systems and the like? I bet it's not a small number. Again, prevention is better than a cure.

And the safety net (my phrase not theirs) that the nurses union says we are operating without (I know I said I was done picking on them. I'm not)....that's why we have cell phones. My medical director, a doctor, is just a call away. When in doubt, call for further direction. And if we're not sure weather a patient should be going to an ER or Urgent Care....take them to the ER.

Now I understand that this is a pilot program. When we try it things may not work out the way they are supposed to. But the current system is broken. We need to do something. Why not this?

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