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 sooner....in 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.

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 MDs....you 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?

Sometimes I Just Shake My Head

The call came it at oh dark thirty. OK. Really it was about 2:30 am. Right about that time when you're really enjoying being asleep.

Dispatch said that we were responding for leg pain but had the ambulance rolling code 3. Something just didn't add up.

When we arrived on scene I found my patient sitting on the stairs by the open front door. I knelt down and asked her name and what was going on. Her reply, "I can't sleep."

I asked if she was in pain thinking that we might be there for some new onset of pain. She said that she had back pain from the 2 screws and multiple operations she had had. So I followed that question up with an inquiry about any new pain to which she answered in the negative.

I then asked a couple of more questions that might possibly lead me to understand why this woman had called 911 because she couldn't sleep. No dice. She just had insomnia that night.

Fortunately for me the ambulance showed up quickly. I turned to the medic and said, "She can't sleep." That was the sum total of my pass along to the ambulance medic. I was a little frustrated. I felt like telling the insomniac that I couldn't sleep either because of her. But that wouldn't have been very professional. I still wanted to.

For the record insomnia does suck. But calling 911 after not falling asleep for a couple of hours....come on.

Who Needs A Helmet?

Dispatch gave us an update while we were rolling. We were responding with Engine 110 for a traffic collision. Unfortunately the collision was between a vehicle and a high school student on her way to school.

Engine 110 arrived just before us. They were kneeling at the patient who was sprawled out on the street. The street was busy. It is a major artery in the city and cars get moving fast.A few feet away from the knot of firefighters there is a skateboard. Well, half of a skateboard. The other half was no where to be found.

The young woman was unconscious. The medic checked to see if she responded to painful stimulus.  She did. She contorted her body in decorticate posturing which is indicative of severe brain trauma. WE placed her in full spinal immobilization and loaded her up into the ambulance.

Since engine 110's crew only had 1 medic and we had two on my crew I road in to the hospital with the ambulance. In the back we started two IV's, placed her on the heart monitor and checked her CO2 levels. A more detailed head to toe exam was also done. There were no other injuries that were visible other than a bad goose egg on here head.

During transport the patients condition continued to worsen. She started having decerebrate posturing. Her brain was swelling and causing further injury.

At the trauma center we were met by the trauma doc and the neuro-surgeon. We gave our report and answered a couple of questions regarding the scene including probable speed of the vehicle that hit her. The surgical team whisked her away to CT for a brain scan and then I assume she went into surgery. The neurologist didn't have high hopes for a positive outcome.

She probably would have been at school the next day if she had been wearing a helmet.....correctly.

Mayday Mayday Mayday

Two days before Christmas right after lunch the structure tones went off. The computerized voice said the words that firefighters love to hear, "structure response."

That shift I was acting as an engineer and my regular engineer was acting as captain. This happens from time to time when a captain or engineer are off duty and the position wasn't able to be filled by someone of the same rank. The department will "upgrade" qualified personnel to act out of their rank and then fill in the lower ranked vacancy.

We quickly jumped into our turnout gear and hopped in the truck. Most structure fire calls turn out to be anything but a fire. Sometimes it's a lawn mower blowing l little too much smoke. Other times it's a BBQ. When dispatch states that they have multiple callers with smoke and flames showing you know you have a working fire. We had none of that this time.

As we neared the freeway (the call was a couple of districts over) we heard another of the responding units state that they had smoke showing and then declared this a working structure fire. At my department this declaration gets a couple things started. Another engine is added to the call along with another battalion chief. In the dispatch center they also start a running clock on the fire called the fire timer. It also lets the rest of the incoming units know that it's time to put our game faces on.

As we exited the freeway the column of thick black smoke was very visible. The street that we had to take took us in front of the local mall. It was a three lane road with traffic at a near stand still trying to get a look at what was going on. Up ahead in traffic there were a couple of police cars and an ambulance all with their lights and sirens going trying to edge through traffic. No one was moving for them. It wasn't until the drivers heard the wailing sound of our growler siren combined with the air horn that people started to get a clue. All doubt about what they should do was removed when they looked in their mirrors and saw big red coming at them fast and angry. Even the cops moved out of our way.

Pulling up on scene we found ourselves right behind our battalion chief. He assigned us to shut off the utilities which we did. The BC, now IC, then assigned us to back up the interior team. At the front door there were two hose lines. One went left and up the stairs the other to the right and downstairs. Both led into darkness.

My captain instructed our hoseman to follow the line up the stairs. When our firefighter got to the top of the stairs he found that there was no room. There were already too many firefighters in the deceptively small upstairs. I never made it to the top of the stairs. It was there that I heard it.

"MAYDAY MAYDAY MAYDAY"

While a house on fire qualifies as an emergency to most people to firefighters it's what we train for. That is our office. Even if we don't get to go to the "office" as often as we'd like (except maybe for my brothers in Detroit....watch Burn). When a firefighter has an emergency a mayday is declared. A mayday means the s**t has hit the fan.

When I heard the mayday the person calling it out identified that the firefighter on the first floor hoseline was lost. For my crew it was simple. We knew where the hose was and where the firefighter was supposed to be. We boogied down the stairs toward the line.

As we got close to the front door I saw a firefighter crawl out. It was the missing fireman. He had made it out even before the RIC crew could make it inside. Within second the mayday was canceled.

Afterward it became more clear what had happened.

There had been an attic collapse in the back bedroom which caused the area around to flash over. The firefighter and captain tried to make it out of the back sliding glass door but were separated. As soon as the captain lost sight of his fireman he called a mayday. The firefighter, falling back on his training, turned and followed the hoseline out.

This call served as a chilling reminder that things can go wrong. My department and more specifically my crew have gone over the events and tried to learn how to keep that from happening to us in the future. If I never hear another mayday on one of my calls I wouldn't be disappointed.

Going, Going......Gone

We got dispatched for a medical aid just after lunch. We were told that we were responding for a 95 year old male who was ill and unresponsive.

We arrived and were met at the front door by the family. The house was a mess. It was another hoarder house. Trails leading throughout the house. The family had slid their father/grandfather to the front door on a chair. As I walked up I asked what was going on while in my head I did a quick visual assessment of my patient. I could tell just by looking that this wasn't going to go well.

The family told me that the man had been unresponsive since the night before. His mouth was filled with crumbs because someone had decided to "feed" him while he was unconscious. He was breathing, but just barely. I reached out and checked for a radial pulse and found nothing. I did find a carotid pulse but it was slow and weak at about 45 beats a minute.

Something didn't seem right with the story so I asked again how long the patient had been down. I was told this time that their father had stopped responding to them this morning.

I little later on I asked a third time and was told that the old guy had only been unresponsive since lunch time.

I love it when stories change.

AMR showed up and started getting their gurney ready. I checked a BP (105/52) and a sugar (182). I also through the patient on the heart monitor (sinus bradycardia, no ectopy).

At this point, rather than staying on scene and pretending to be a doctor we scooped and ran. At the back of the ambulance I asked the medic if he wanted me to come along.....just in case.

He declined (you got to love young inexperienced medics that think they can handle everything by themselves).

I looked at the patient again and told the young medic that I was coming along for the ride.

As I walked around to the side of the ambulance the little voice in the back of my head told me to grab our Autopulse. I told the ambulance crew to wait for just a couple of seconds as I went to the truck to get the equipment. As I returned to the ambulance I could hear the medic remark that he hadn't seen the old man take a breath in a while.

Great. Just great.

I checked for a carotid pulse. Nothing. The old guy had coded.

I had the young medic help me get the patient onto the CPR device and told the driver to go. While en-route to the hospital the two of us would do everything we could to get the patient back. I was at the head of the patient so I took over on airway. I sank in an OPA and had good compliance with the BVM. In between breaths I flooded the IV line, grabbed the medications, put the patient on the StatPadz and checked the patients underlying heart rhythm.

The young medic attempted an IO but his drill died. He then got an IV established and administered the medications.

We rolled into the ER with the now dead patient. The ER quickly went to work continuing our resuscitation attempt. After 20 more minutes of CPR the MD finally called it.

Time of death 1406 hours.

Water Flow Alarm

The tones went off just about 10 in the evening. There was a water flow alarm at one of the warehouses in our district.

A water flow alarm goes off when there is a water moving inside the pipes of a buildings sprinkler system. In a monitored system when the alarm sounds we also get toned out.That way if there is an actual fire we can get there in a timely manner.

This time however was like most times. Someone in the warehouse accidentally broke a pipe.

We arrived on scene and were met by one of the supervisors. She said that one of her employees had dropped a box on a pipe and cracked it. They had already contacted the alarm company who said they would be out there first thing in the morning. Meanwhile there was a lot of water spraying everywhere.

Our game plan was to shut off the water to the sprinkler system and then just to let the entire system drain. To do this we had to find the "risers." Pipes through which water is pumped up the side of the wall to the ceiling where the piped then form a grid to provide adequate coverage in case of a fire. The problem was in a building this size (about 500,000 sq ft) there are multiple risers.

Near each riser is a shut off valve. In this case they had a shut off valve on the riser itself (about 7 feet off the ground) and a PIV (Post Indicator Valve) at ground level.

While my engineer and I did some recon to find out just how many valves we were going to have to shut off my captain looked a little closer at the pipe. He noticed that the pipe had been bent upwards causing the crack. He decided to apply a little downward pressure to see if he could stem some of the flow. Nothing happened. So he decided to apply a little more pressure. He found that he could greatly reduce the amount of water leaking.

Most of you can probably see where this is heading.

My captain then decided that if a little pressure was working so well that a little more pressure would be even better. I don't think he consulted with Murphy on this one. The pipe cracked again. This time causing even more water to cascade to the floor.

Oops.

While we went around turning off all of the PIV's we were followed by the assistant might manager. He kept offering little quips and asinine suggestions. At one point he muttered to my engineer that all firemen do is break s**t. He's lucky I didn't hear that one. I don't think I would have been able to stop myself from saying, "You're right. We'll leave." One of his suggestions was for us to shut  down the water main in the street. We had to remind him that he wasn't the only customer that the water company had.

Eventually we got all the valves shut off. The water flow slowed as the entire system drained. Neither the manager nor her assistant offered a thank you.

Oh well.

A Hug

The tones got us up just before 3 a.m. Someone in our district needed our help.....or at least they think they do. After donning my bunker pants I slipped into the firefighters seat and put on my headset. With little more than a grunt I let my engineer know that I was on board and ready to go. I was still trying to shake loose the cobwebs in my mind.

Dispatch let us know that we were just going out for a lift assist. Usually not a big deal and this one proved to be routine.

We got to the house and an elderly woman met us at the door. She walked us into her beautifully kept home back to the bathroom where her husband had fallen. His health had been deteriorating over the last couple of months to the point where he really wasn't able to walk. Once he fell he didn't have the strength to get back up.

We helped the gentleman up and into the bathroom. While he did his business we stayed and talked with the wife. We learned about the 40 years that they had been in the home. All about their successful kids that were now all around the country. A couple of times they tried to get us to leave insisting that we didn't need to waste our time waiting. We gently encouraged both of them to let us stay and make sure the husband could get back to his bed. Finally they acquiesced.

We were glad we stayed. The old man was able to use his walker and get about halfway down the hallway before his legs gave out. We caught him and carefully carried him to his bed. After assuring that everything was as good as it could be we bid our farewell.

13 hours later we were just clearing a call on the far side of our district when dispatch asked if we were able to take another call. It was at the same house we had been to for the lift assist. Thankfully Engine 110 from the next district over was close to where our call was. They said they'd take it for us.

Then dispatch updated Engine 110 saying that the patient was unconscious. Knowing who it was and their medical problems we were concerned that the old guy wasn't just unconscious but dead. We decided to head over and see if Engine 110 needed assistance.

Upon arriving we found the ambulance had already made it there too. I walked in just in time to hear my patient asking the crew from 110 where we were. I popped my head around the corner and said we were right there. I explained that we had been out of position for the call so this crew stepped in for us. Both the husband and wife were happy we stopped by.

Turns out the husband had had his BP drop significantly. He was even weaker now. His wife looked as if she was barely keeping it together. Clearly she was worried about where this downturn in health was headed. After making sure the patient was in good hands I quietly approached the grandmother of 7. I told her she looked like someone that needed a hug. She simply nodded her head and gave me a big hug.

While there isn't much we can do long term for her husband I hope that a simple hug and some kind words let her know she isn't alone in all this.

I'm sure we'll be back again.

Why Does The Fire Department Respond?

One of the questions we get quite often is why we send "big red" on medical calls. After all, isn't that what ambulances are for? Isn't that a waste of fuel/time/resources for a simple medical call?

Before I answer these questions let me just say that fire engines don't respond to medical calls all around the country. Every area has a slightly different system in place. I am going to talk about my system (since it's what I know best).

Where I work we have a private ambulance company that responds to and transports patients to the hospital a la AMR/Westmed/Rural Metro.. They are usually staffed with one paramedic and one EMT. They have, under their company's contract with the county, between 8 and 10 minutes to respond to critical EMS calls depending on where the call is (more rural locations have longer time allowances).

So why does the fire department respond to medical calls?

First off, state law in California requires two paramedics to respond to medical emergencies. Some places do that by staffing two medics on the ambulance. We do it by staffing one on the ambulance and one of the fire engine/truck. Every engine and truck in the county in which I work is staffed with at least one paramedic.

So why do we choose this method instead of staffing the ambulance with two medics and letting just the private ambulance respond?

Ambulances, especially those belonging to private ambulance companies, are spread pretty thin. Private companies are in this game to make a profit so the fewer ambulances and crews they need to staff to get the job done the better. However this can mean longer response times. Fire stations and crews are more plentiful and usually closer to any given incident (at least with career departments) allowing for faster response times.

An example of why this isn't in the best interest of some patients. There was a call in my district (on the other shift) a couple of days ago. The call came in as a lift assist. This is usually for your stereotypical "I've fallen and I can't get up" scenario. No big deal.

While on their way to the call the woman that called 911 for her husband noticed that her spouse was no longer breathing. The firefighters were on scene within a minute or so and were able to render life saving care (yes, he made it). The ambulance on the other hand took 8 minutes to get to the scene. According to Wikipedia "Without special treatment after circulation is restarted, full recovery of the brain after more than 3 minutes of clinical death at normal body temperature is rare."

Who would you want responding to your spouses untimely death?

Another reason the fire department responds is manpower. On most calls you only need a couple of people. But often you need more. CPR in progress, vehicle accidents with multiple patients, obese patients and other similar calls require more manpower than the ambulance crew can provide.

So if the fire department is going to respond why send the big fire truck and not just a small vehicle with EMS gear?

We respond with the big fire engine/truck is that we are always ready to respond to an emergency. If we were just clearing the scene of a medical call and we had responded in a small pick up truck only we wouldn't have the correct tools with us to respond to a structure fire. We would have to go back to the station and change vehicle. In a job where time matters we have to always be able to respond. No matter the emergency.

There are other methods out there such as the Squads LA County Fire use but those require more personnel. I know LA City Fire has used firefighter/Paramedics riding on motorcycles to get through traffic. But again, that requires special staffing unless you want an engine or truck crew to be without their medic for a while.

Our system may not be the best but it's better than any other EMS system I've worked under so far. I'm curious to see how we adapt to future needs of our citizens.

Ending It

I'll warn you now, this post may be a bit graphic. But it represents a part of my job and I post it so that others who may be interested in a job in the fire service or EMS can better understand what they are in for.

At the very beginning of the shift the tones went off. At times like that you hope that all your equipment was left in good shape by the preceding crew.  Especially on calls like this one.

We were responding for a full arrest. PD had received a 911 call stating that a person had hung themselves. The call was in the neighboring district (engine 110 was out on another call) so we had a longer response time than usual.

We pulled up and parked behind a couple of police cars. The officers in our city are great. They have no problem responding to critical medical calls and getting in and helping where they can. One of the officers came out and met us. He informed us that only I, the medic, needed to go in. This told us that I was simply determining death and that there was no need for everyone to go in and disturb a potential crime scene.

Inside I found another officer taking photos for his investigation. On the floor was the body of a man in his late 30's. Rigor mortis had set in and it didn't allow his body to lay completely flat on the floor. Because he was in rigor determination of death was made, 0752 hours.

Looking closer at the face of the man I could see that it was distorted. The officer stopped taking pictures for a second to explain that he had walked in and found the man hanging from the pull up bar in the doorway to his bedroom. He had used a leather belt to do it. The belt had slid up around the cheeks and the face "froze" in that position after death. The bar was to low for the man to hang completely so his legs seemed to be dragging on the floor behind him.

The worst part of this entire call was that the dead man's mother was the one to find him. She walked out in the morning and there he was. We contacted a clergyman from a local church to come and comfort the old lady. We then cleared ourselves from the call in case we were needed for another emergency but stayed with the mom until the clergyman arrived.

No Relaxing

All of the chairs were pushed back out of the way and the table had been moved near the wall. In the middle of the conference room was our patient. He was sitting on a chair cradling his left arm. 

I introduced myself and asked him what had happened. He said that during a meeting he had leaned back in his chair and stretched both of his arms toward the ceiling (I guess is was a boring meeting). During mid stretch his left arm popped out of its socket.

I asked if he had ever dislocated his shoulder before. He hadn't. He had no medical history and wasn't taking any medications. But he was in a lot of pain.

After starting an IV I gave him some morphine. My patient felt much better after that. So much so that he started cracking jokes. Hr started asking if I would write a note to his wife stating that his injury would preclude him from changing any diapers for the next 6-8 weeks.

Good luck with that one.

Better Days

My blog post "50mg of Benadryl And Some Morphine" is about one of my frequent flyers. Thankfully she hasn't been calling lately.

The other day we were doing inspections in our area and we walked by her apartment. She happened to open the door as we walked by and she struck up a conversation with us. We remarked that we hadn't seen her in a while. She laughed and responded that she was doing a little better these day. She looked like she was doing better.

Hopefully doesn't slip up. I don't want to start running calls on her again.

Vegetation Response? In My District?

At 11:30 some unfamiliar tones went off at my station. They were the tones for a vegetation fire. We have almost no "wildland" in my district to burn so we were a bit confused. Really the only places that would fall into that category are the areas right along the freeway and along side the railroad tracks. Armed with this knowledge I decided to just don my structural firefighting pants and boots and to throw on my wildland jacket.

Once in the truck dispatch informed us that we were responding for a small vegetation fire on the side of the freeway. No big deal. The biggest danger there is working along side rubberneckers driving and texting while doing 75mph. Then dispatch gave us another update. There were reports of a vehicle on fire as well.

Now I was really happy that I had chosen to use my turnout pants. In the back of the rig I swapped my wildland jacket for my turnout jacket and slipped into my BA. I was now ready for the car fire.

While getting on the freeway we could see smoke showing about a mile down the road. But the smoke was all wrong. Instead of the thick black smoke of a car fire it was the much lighter colored smoke of a grass fire. As we pulled up I realized I was way over dressed for this call.

There was a small fire about 100' across. I dropped my SCBA and stretched out the hose line on the bumper. I started at the edge of the roadway and quickly worked my away around the head of the fire. While I was knocking it down there another crew (from Engine 110) started fighting the fire from the other side. Within a couple of minutes the fire was out and we started hunting down and cooling off hot spots.

We found out afterward that CalTrans had put down some road flares to warn people of the sweeper train ahead of them. A car ran over a flare and kicked it out into the brush causing the fire. That's how the vehicle was involved in the fire.

Done With Life

The call came in as a wellness check. We were dispatched along with PD to the house of a single elderly woman. Her brother had talked to her on the phone and he didn't think she sounded ok. When he hung up the phone he called 911.

PD arrived first. When they knocked on the front door there was no answer. As they went around to the side of the house they heard moaning. They went back to the front door and kicked it in (in the past they've waited for us assuming incorrectly that we would do something different).

Inside they found that it was a hoarder house. Piles of trash, papers, boxes.....just stuff all over the place. There were trails leading to the different rooms. They followed the path that led to what would have been a living room. There on the floor they found the patient. They decided to wait for us before doing anything else.

My patient was an 80 year old woman. She was alert and oriented. She said that she was sore from laying on the ground in the same spot for so long but other than that had no real medical complaint. She did say that she was just tired of living.

Since she was done with life she curled up next to a space heater (which amazingly didn't catch the house on fire) and didn't move. She had been there for over 2 days.

The old lady let me check her vitals which weren't horrible for the circumstances. After a little talk we informed her that the police were putting her on a psychiatric hold and that she had to go to the hospital. She was amazingly compliant.

We helped her onto the gurney and sent her off to the hospital. Hopefully she gets the help she needs.

Cat In A Tree

Yes, the fire department does get calls for cats stuck in a tree. Not very often but it does happen. But what happens when your local FD fails to even try to get the cat out of the tree? Get the next best thing....an off duty firefighter.

The other day my neighbors cat decided it wanted to touch the sky. It had climbed over 20 feet in the tree. The local engine crew said that they needed the truck guys and then conveniently got a call.

I went over to investigate what was going on. Once I saw the cat in the tree I figured my ladder would reach. Maybe.

I set up the ladder and climbed up to the top. The cat was still about a foot or so out of reach. So I clmbed the tree. Just enough so that I could reach the scruff of the cats neck. I grabbed the cat and made it safely down to the ground without falling or getting scratched.

I just hope the cat didn't think that was fun.

A Shakey Situation

We arrived at the business park and were ushered upstairs. In one of the many generic offices a man had had a seizure.

We talked to the person with whom my patient was meeting and he said the guy just stiffened up, started shaking and rolled out of the chair onto the floor. Apparently the seizure lasted several minutes.

The business had their own emergency response team that was activated. I don't know what type of training they had but they did show up and check a pulse and they placed the patient on oxygen. I told them after the call they did a great job.

My patient was still postictal. A time period after a seizure when the brain is sort of trying to reboot. It can take several minutes. The person that experienced the seizure can be quite confused if they're responsive at all during this time. My patient wasn't responsive.

I grabbed a quick set of vitals, kept the guy on oxygen and checked his blood sugar levels. All were within normal limits.

At this point AMR arrived. While they loaded him onto the gurney we talked by phone to the wife of the patient. He was in town on business so no one around knew his medical history.

According to his wife her husband had recently been out of the country on vacation and had also been snow skiing. There was no medical history to speak of and he wasn't on any medications.

We couldn't rule out head trauma as a possible cause of the seizure. It also could have been something else entirely. Without the hospital and the tests they would perform there was no way to know.

After the patient was loaded up we headed for the rig. We took the stairs while AMR took the elevator. I waited for the crew at the back of the ambulance holding the door open for them. When the elevator doors opened the medic yelled that she needed me to start a line (meaning an IV). The patient was seizing again.

I jumped in the back of the ambulance and had an IV started in no time flat. But by that time the seizure had stopped. I asked if the AMR medic wanted me to ride along and she declined. I later found out that the patient seized one more time in the ambulance.

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Note about this call. A couple of weeks later the AMR medic let me know that the patient we had here had been found to have a brain tumor which was causing the seizures. He was scheduled for brain surgery.

Thank You.....I Think

We got a call the other day for a citizen assist. These calls come in from time to time and can be anything from a cat in a tree (yes, we actually get calls for this) to someone being locked out of their house. As long as there is no emergent call I have no problem going out and lending a helping hand. After all, we are public servants.

This time the service call came in from an elderly woman that lived alone in her own house. She was unable to change the batteries in her smoke detector (Public Service Announcement: If you didn't change yours when we had the last time change for daylight savings, do it now).

This old lady has been calling us to change out the batteries in the detectors for years. This time she let us know that she had been doing us a favor. Instead of calling us every 6 months to change the batteries now she was only calling us when one of the detectors started beeping the low battery alarm.

So thank you....I think.

What Do You Want Us To Do

We pulled up to the house to find a kid about 18 years old waiving emphatically. As we followed him into the house he told us his grandfather was having a hard time breathing.

Inside we found a near 90 year old man laying quietly in bed. He looked frail and sick. Really sick. Like dang near dead sick. His daughter was by his side tending to him. The man was breathing ok and had a weak radial pulse. I noticed he also had an IV in his arm.

I asked the daughter what was going on. She introduced herself as a nurse (which meant absolutely nothing to me) and said that her father had cancer of the colon which had metastasized all over his body. He had a valid DNR and the family's wishes were for my patient to be comfortable. They had made their peace with the fact that he was dying.

The daughter than informed me that she had just given a repeat dose of dilaudid and morphine to the dad. Now she was worried because her father was having a more difficult time breathing.

For those of you that don't know both of those drugs belong to the opiate family (like heroin) and both cause a decrease in the body's respiratory drive. While we do have drugs to reverse this process it also takes away any of the pain killing affects of the drugs.

By now we had the old man on some oxygen. He was still breathing adequately but he was tiring out. We asked if they wanted us to honor the DNR which they did. That begged the question, what do you want us to do?

She just kind of stared blankly in response to that question. While the daughter had realized that her father was going to die it hadn't dawned on her that in would be that day.

We explained all the options to the family taking time to make sure they understood the possible and probably outcomes of each. They then decided to have their father/grandfather transported to the hospital with the caveat that he would be kept as comfortable as possible.

The next day I ran a call with the same medic from AMR. He said that the patient had made it all the way to the hospital but not much further. When they entered the ER the doc asked if the patient was still breathing. The MD and the medic looked down at the patient and watched him take his last breath.

At least he's is comfortable now.

Even Frequent Flyers

If you work in a city long enough you start to learn that there are areas that just produce calls. We have a shopping center in our district that has more medical emergencies in it than every other strip mall in the city combined. A lot of the time it's homeless people that are too drunk to stand and someone else calls for them.

We were dispatched to Taco Bell in this strip mall for a man not feeling well.

We arrived right behind the AMR unit. While they grabbed their gurney I stepped up and talked to the manager. He said the patient had walked in and sat down about 15 minutes earlier but hadn't ordered anything. He also said the guy looked sick.

Inside I introduced myself to the patient. I asked what was going on and he said that he felt weak. He denied having and trouble breathing or chest discomfort. That was about as far as I was able to get before AMR had the gurney ready.

We helped the man to the gurney and then loaded him up into the ambulance. Inside the rig they checked an initial set of vitals which were ok. I asked AMR if they needed anything else and they said they were good.

That was the end of that call. I didn't give it a second thought, until later.

About a month went by and we ended up on another call with that same AMR crew. The medic asked if I remembered the homeless man at Taco Bell and to be honest, he had to jog my memory a bit. The medic said that 5 minutes after they arrived at the ER the man had a massive coronary and died.

Food for thought, even your frequent flyers can be really sick sometimes.

Now Is Not The Time To Panic

We got the call at 3 in the morning. My first thought when we get calls at this time of night is who is up right now?!

As we pulled up to the house a woman driving an SUV almost rear ended us. We try to park Big Red just beyond the address allowing room for the ambulance to park a little closer. The crazy driver slid right past us and into the driveway (making access with a gurney more difficult). The woman, who turned out to be the daughter of my so called patient, then ran into the house.

Inside I found a man in his late 80's sitting on the couch eating some toast. His wife was talking extremely fast trying to explain what she believed was going on. The daughter, who arrived by her fathers side just seconds before us, was trying to talk louder and faster than her mother. Both of them clearly having no idea what was going on.

I asked the women to give the information to my captain allowing my to question the old guy. He told me that he had just been released from the hospital at 8 the previous evening. He had had a 6 day stay while battling pneumonia. He said that he wasn't given dinner before leaving the hospital and went to bed soon after getting home. He hadn't eaten anything other than a sandwich all day.

My patient said he awoke and felt hungry. His stomach was growling. Somehow his wife misinterpreted this to mean he was having trouble breathing and panicked. She called her daughter who lived cross town. She jumped into her car and called 911 then tried to beat us to the house.

In the end my patient stayed at his house, eating and drinking some coffee and shaking his head at his daughter and wife.