Dialysis

The other day we got a call to our local dialysis center. Let me tell you how much I hate these places. When I worked as an EMT we transferred a lot of patients to and from facilitates just like this one. The people aren't happy, the place has a distinct odor and the staff was always upset that you were too early or too late. Thankfully I only go to these centers now for critical patients.

This time an EMT crew was there to pick up their patient. She was a 30 year old female that didn't look as if she had taken care of herself during her short life. We were there because she was nauseated when the BLS crew showed up to take her home and when they took her BP they discovered that it was low. To their credit they recognized that ALS procedures may be needed and they called for us.

We showed up at the same time as AMR. While they grabbed the gurney I grabbed their drub box and airway bag. Once inside I just acted as a super EMT doing everything that the medic wanted before he would ask. The staff had already set up an IV so once the paramedic finished up his assessment we loaded up.

A fairly short but typical call to the dialysis center.

Worried Kid

We got a call right in the middle of dessert. A young woman was worried about her mother.

Arriving on scene we were met at the curb by a borderline hysterical 15 year old girl. By catching every third word or so we were able to determine that her mom was in the back bedroom of the the apartment and that she wasn't acting right.

Our patient was laying in bed and not very alert. It took repeating every question several times to get something of an answer. At least her vitals were stable.

By the time AMR showed up we were able to piece together that the patient had a history of chronic pain and depression. This night she had taken a little extra medication to dull both.

The daughter was visibly relieved to see her mom getting medical attention. We made sure there was a family friend there to stay with her before we left.

Her Seat Belt Trap

It was a lazy Saturday afternoon. The rain that had been coming down for several days now had mellowed out everyone and things were quiet. Some of us were on our safety nap, others were on the computer and others still were watching the glowy box. That's when the phone rang (if there was a way to may a ringing phone sound go off right now it would be great but since I can't, use your imagination).

I picked up the phone and discovered that it was the ranger down the road. He said that he had found something interesting. Someone had gotten themselves stuck in their seat belt and had stopped by the state park to get help. He had just sent them our way.

Out in front of our station pulled up a small SUV. There were three women in it, a grandmother, mother and daughter. The young woman in back had decided to lay down to sleep while on their drive. Thinking 'safety first' she decided to wrap the seat belt around her waist in a manner similar (but more knotted) to the girl in the above photo. She then stretched out on the back seat. 

When she awoke she sat back up. This is when she learned something about seat belts. When pulled all the way out, the seat belt pretensioner (#47 in the drawing below) will only allow the belt to retract (don't believe me, go try it out on your car). This is done so that the belt can be used to strap down car seats. When she sat up she unknowingly cinched the belt tight, trapping her.

Her mom and grandmother were good sports about the entire situation. They laughed and made fun of their daughter the entire time. We tried to slide, push, pull and contort this poor girl in every way imaginable to get her free. Once we exhausted our Tetris skills we decided something else would have to be done. 

Using the vast knowledge of automotive design that all firefighters have (ok, I really just followed the belt until I found a bolt, #40 in this drawing, that I could take off) I found the point at which the seat belt bolts into the frame of the vehicle and decided that was our best course of action. Do you have any idea how long it takes to unbolt something like that when you can only turn the bolt 1/8 of a turn at a time. 

A few minutes later we had our victim freed and and the vehicle put back together. 

While looking for the picture of someone twisted up in the seat belt I noticed that almost all the videos and photographs of people that have been stuck are of women. I'm sure there's a joke in there some where, I'm just not sure I want to make it....

We Don't Just Fight Fires

This is a video I found about the Redwood City, CA fire department but it could easily be about yours.

A Dangerous Job

In today's economy budget cuts are forcing the downsizing of fire departments across the country. I've seen politicians argue that our job as firefighters is mostly sitting around waiting for calls. While this is true, we are paid for what we know and are willing to risk.

Several firefighters in Southern California were injured last night in a ceiling collapse. Here's a video from NBC with the story:

View more videos at: http://www.nbclosangeles.com.

I read a little more on the fire and found this article on Firefighter Nation. The thing that amazes me is just how many firefighters (80) were on scene at this blaze. Now I understand that LAFD and LAcoFD have more resources than most other departments but still. At my department we would have been fighting that same fire with a lot fewer resources. 

There's no real way to tell what would have happened if that were in my jurisdiction. Maybe we would have gone defensive and wouldn't have been inside when the collapse happened although I doubt it. If the owner had still been inside we definitely would have been in there. 

What is certain is that we, as firefighters, are being asked to do more and more with less and less. The danger is real. Train hard and be safe.

Cold Feet

At 0500 we were toned out for a medical aid at the gas station closest to the freeway. We knew that, because of the rain and the location, this was probably a call from a homeless person. We also knew that we would already be on a first name basis with our 911 caller.

When we arrived on scene we found one of our local homeless celebrities. We had run countless calls on him for years. He loves our city and our department because we always are nice to him, regardless of the nature or time of the call.

This time our patient called 911 because he was cold. More precisely, his feet were cold. He was wearing several layers of clothing but all of them were soaked. He was shivering uncontrollably. He apologized for calling but he was just so cold.

Just before the ambulance pulled into the gas station our radios crackled. The neighboring engine company was being dispatched into our area for another medical run, this time for someone having chest pain. I asked my captain if he was ok with rerouting  our ambulance to the person having chest pain. We didn't have a life threatening emergency after all. Seemed like the right thing to do.

The problem was that AMR dispatch was unwilling to swap the units. It seemed so simple. Assign the closest ambulance to the critical patient instead of the cold patient and assign the ambulance that was further out to us. They refused to do it saying that there was some protocol that they couldn't violate. Looking back on it I should have just told them that my patient had moved to the address of the second medical aid and the second patient had moved to our address.

By the time we got back into quarters we heard the second ambulance arrive on scene and our cold footed patient was toastily on his way to the ER for a dry gown and a blanket.

The Candy Man

Engine 51, respond to the Hungry Valley SVRA for a motorcyclist down. With that we were off again. This time we were responding for someone with a leg injury.

When we arrived on scene we found ourselves at the trail-head of one of the more popular rides. A man was there on the ground holding his 15 year old daughter. They had been riding all morning and she had been doing great. She had been handling some tough climbs like a pro. That is until the end of the ride.

When she pulled into the parking area she slowed down a little too much. Gravity took over and the bike landed on her left knee. The lower leg had a little inward rotation to it and she was in a lot of pain.

The rangers at the park had already placed an ice pack on her knee and were getting ready to splint her leg when we pulled up. I did a quick assessment before starting treatment. She didn't hit her head or lose consciousness. She had no history of medical problems, didn't take any medications and didn't take any medication.

I pulled out the IV start kit and assured her that she wanted me to start the IV more than some other medic or worse, a nurse in the ER. Once the IV was in I gave her some morphine. It took a couple of doses of MS to get rid of most of the pain. With that accomplished we finished splinting her leg and loaded her onto AMR's gurney.

That's almost 30 mg of morphine given out in the last couple of weeks. Just call me the Candy Man.

False Alarm

A few tours ago we had a rough first night. We were up almost the entire night. On day two some of my crew were enjoying what we call an "OSHA safety nap." While my engineer was snoring away our dispatch office received a 911 call. Mere seconds later our tones were going off.

While responding we were informed by dispatch that this was a medical alarm activation and there was no answer when the company tried to call the house. When we arrived at the home we knocked loudly on the door and announced ourselves (as if pulling up in a 40,000 pound vehicle with lights and siren going was hard to miss).

When there was no answer at the door we started looking in windows to see if we could see someone or find some way to get in to check on the occupant. At one of the windows my engineer found our supposed patient sitting in a chair. When he got her attention he asked her to come to the door. She didn't seem to right in the head. she refused to come to the door saying she didn't want to get up. My engineer answered that if we had to get up, she had to get up. I couldn't help but laugh.

Finally the patient decided it would be less effort to come to the door and deal with us than to try to ignore us. Boy was she grumpy. The 80 year old woman was just tired and didn't want to be bothered. She didn't know that she had accidentally activated her alarm and couldn't be troubled to answer her phone.

Really? Come On!

The tones went off not 30 seconds after we cleared the fire alarm call. This time it was a medical aid.

When we arrived on scene we were met by a 20 year old woman who was not in any distress at all. She just stood there and looked at us. We finally asked if someone had called 911. She said that she did, still looking at us as if we were supposed to do something amazing. After asking if we could go inside to talk to her she walked in and took a seat on the couch. He complaint? A small boil on the inside of her leg.

My captain's next question was right on the money. You want to go to the hospital, in an ambulance!? She said yes.

As the AMR crew walked in I looked up at the medic and rolled my eyes. That was all the report he needed. They insisted on the patient walking to the ambulance which she did without assistance.

Fast forward to oh dark thirty. The tones woke us up for another medical aid. This time someone was supposedly having a tough time breathing.

We arrived at a board and care home and find our 70 year old patient waiting patiently on the couch. She seemed to be breathing a little hard. I ask her what was going on and she said that she couldn't sleep. I asked about her shortness of breath and she said it had been going on for days. I clarified and found out that it had been going on for 3 days now. I asked her what had made her call for us that night as opposed to some other time in the previous 72 hours. She said that she had insomnia.

Don't get me wrong. I love running calls. That's why I go to work. But seriously?! Boils and insomnia? If nothing else it becomes blog fodder.

Patient Advocacy

What does it mean to be a patient's advocate?

The dictionary describes an advocate as "a person who speaks or writes in support or defense of a person, cause, etc."

In EMS we talk about being a patient advocate. About being the type of medical professional that will always try and do what is right for the patient. Sometimes that is respecting their wishes to not have resuscitation measures taken. Other times it is simply making sure the ER staff has heard their concerns before you leave. Every situation is different and at times it's a judgment call.

I recently read a post by a fellow blogger Michael Morse over at Rescuing Providence, where he was, in my opinion, a great patient advocate in a difficult situation. Someone left a comment on his blog tearing into him for the way he treated his patient. I think he was dead on.

You see, most of the time acting on behalf of the patient is cut and dry. You simply treat them. They don't complain because they called you and want you to treat them. However there are some times that being a patient advocate strays into a gray area. Let me give you an example, but first a little background info.

A patient, as long as he is what we call "alert and oriented" (meaning he knows where he is, what's going on and is capable of making decisions) has the ability to refuse treatment. If they are not alert and oriented then we have to assume that they would agree to whatever treatment to which your average Joe would consent. The patient loses the ability to decline treatment.

Example #1

You arrive on scene to find one of your frequent flyers. You were called because his roommate couldn't wake him up, at 1 in the afternoon. He's a 38 year old male with a history of heroine abuse. A quick assessment reveals that the patient is unresponsive and barely breathing 4 times a minute. He has snoring respirations and his pupils are pinpoint. All signs that he has had another heroine overdose. (Please assume that a thorough assessment has been done but I'm not going over everything here) The patient has a history of becoming extremely violent when he's brought out of his narcotic high.

Now there are several ways to treat this guy. If you want to start a fight, or want to give the ambulance crew a tough time, you slam in Narcan and counteract all of the heroine. This will often lead to a confrontation with the user when he realizes you just wasted his high.

Some new medics may decide to intubate the patient in an attempt to control his airway. If they go down this path there's a good chance that after they administer the Narcan the patient will rip out his ET tube and beat the medic with it.

I think the best option is to give him just enough Narcan to reverse the respiratory depression but not so much that he regains consciousness. This way you can provide adequate patient care without an altercation.

However, this is where the gray area comes in. If we reversed all the affects of the heroine the patient would no doubt become alert and oriented. If he's alert and oriented then he can legally refuse treatment. Now your patient that needs definitive care (Narcan is short lasting) is refusing to go. So do you keep him unconscious and take from him the ability to refuse care?

Example #2 

Your classic case of hypoglycemia. Someone finds the patient unresponsive and calls us. All they need is some sugar and they wake back up. 

So what's the best way to treat this patient. It totally depends on the patient.


If the patient does not have a history of diabetes you administer the glucose and then transport them to the ER. Something is causing their insulin levels to be out of whack and it needs to be diagnosed.


If the patient has a history of diabetes and just missed a meal, or something similar then I have no problem giving them some D50, then making them a sandwich and signing them out AMA. I'd like to have someone there to watch over them if possible as well. 


If 911 has been called multiple times in the last few weeks for this patient and he always signs out AMA after you administer the sugar than I'm all for getting the patient loaded up and on their way to the hospital before giving them the glucose. This way the patient will end up getting seen at the hospital where more tests can be done.


In both examples there are treatment options that do limit the patient's ability to decline treatment. Does this make it wrong? I don't think so. But part of what makes this a wonderful world is a difference of opinion. Let me know what you think. Weather you are a medical professional or not. This is more of an ethical question.

Rough Job

Warm night + alcohol + loud music + alcohol + rowdy people + alcohol + someone telling the rowdy people not to be so rowdy + alcohol = Any one? Any one? That's right, a 911 assault call.

We got a call around midnight at one of the local rented out halls. There was a large party going on with lots of drunk people. We had actually driven by it earlier in the shift and surmised that we would be back later. You gotta love how predictable this job can be sometimes.

While the crowd was getting out of hand two lowly security guards tried to keep the peace. They should have called the cops. The first security guard got knocked to the ground and then kicked in his head. While this was going on another assailant stole his Maglite. When the second security guard came to the assistance of the first she was knocked up side the head with the flashlight. Fortunately for them someone else called PD. By the time that we arrived everything was calm.

The first guard got off easy. He just had some bumps and a bruised ego. The security officer that was treated like a pinata wasn't too bad off considering. She had a good size laceration right at the hairline that had stopped bleeding before our arrival thanks to some direct pressure and a towel. She denied having been knocked out and said that her head didn't even really hurt. She refused to go by ambulance instead opting to have her coworker take her to the ER to get checked out. 

Next time, duck.

Man Up

I understand that kids whine and cry. Hey, I just went through a PALS course. That means I'm a trained professional, right?! Ok. Not quite. But I am really good with kids. And I have 3 of the little rug rats of my own. So that's where I'm coming from when I tell this next story.

We were dispatched to a child down in the street. We expected the kid to be gone by the time that we arrived on scene. When we pulled up we could see a small knot of people standing and kneeling by a kid in the street. There was an ER RN at the head of the patient holding c-spine. It really looked as if we had a critical kid.

As I walked up I noticed the 10 year old boy was laying prone with his left leg and arm slightly bent in a normal fashion. I also noted that the kid was screaming bloody murder.The story was that the victim had been racing hes scooter down the hill and lost control. Luckily he was wearing a helmet and he wasn't on a busy street.

He was complaining that he had severe pain to his left hip. We exposed his hip and found that he had road rash. During the head to toe assessment I found that he also had some road rash on his left elbow. When the kid discovered this he forgot all about the hip and started wailing like our siren. Keep in mind, there is no blood. It's a large scratch. Band aid worthy.

I know road rash can be painful. But it's not that painful. My six year old daughter wouldn't have cried that much if she had broken an arm along with the road rash. I really felt like saying 'man up' to the kid. I guess I wasn't feeling to sympathetic that day.

Seizure Sans Shaking

We responded to a board and care facility for a man having a seizure. When we arrived on scene we found a man about 50 years old laying on the couch. The man's eyes were open and looking to one side but no one appeared to be home.

The care giver said that the man had had six tonic-clonic seizures throughout the day. The reason he called was that the patient had been having a neuro-focal seizure now for about 20 minutes. I was surprised that he knew the difference between the two. The man also told us that the patient suffered from mental and physical disabilities, making an assessment all the more difficult. 

While my crew grabbed a set of vitals and started the patient on some oxygen I drew up some Versed. The seizure finally stopped after I administered 2.5 milligrams up each nostril. With the seizures stopped all we had to do was send him to the hospital.

Faceplant

A 16 year old girl was riding her dirt bike when her friends saw her head into a ditch. The girl then hit a rock at the bottom and the bike came to a quick stop. Unfortunately, she did not come to a quick stop for about a half second more when her face hit another rock.

Thankfully she had been wearing her protective equipment. Although the force of the impact did crack her chest piece and her helmet. Her face took quite a pounding.

She had an inch and a half gash on the right side of her jaw. Her jaw had probably been fractured. She had knocked four of her teeth almost all the way out and had bit her tongue, all of which caused significant bleeding, not to mention pain.

We placed her in a cervical collar and checked the rest of her out. We decided, because of the amount of bleeding in her mouth, that placing her on a backboard would lead to a possible airway compromise so we decided to c-spine her on a KED. Not a common use but it served our purposes.

Once that was done I started a line on her and gave her some morphine. By the time that AMR was ready to load her up she was packaged and almost pain free.

Just imagine how bad it would have been without the helmet.