Friday, August 29, 2008

Planting The Left Foot

I was thinking today, as I looked at the flattened toes on my patient's left foot, about the powerlessness of words at certain times.
Fortunately, there's a unique vocabulary that goes along with the art and science of caring for the sick and injured.
Heart attack patients "circle the drain."
When the drain is empty, they "code."
Congestive heart failure patients who are in acute distress are "full to the gills," while an equally troubled asthmatic or COPD patient is "tight as a drum."
The ambulance is a "bus,"a significantly hypoglycemic patient is "gorked," and a car rammed high-speed into a tree, trapping its occupants, is a "pin job."
And, of course, limbs that get run over by heavy industrial equipment are "pancaked."
Today's patient is a middle-aged guy who has worked in a factory for 30 years.
"Without an injury," he proudly notes.
"Until today!" we say in unison.
It gets the patient laughing, enough that he cheerfully says that he thinks the injury might help his golf game by forcing him to plant that left foot more.
His toes are flattened into gelatinous stubs.
There is not even the slightest suggestion of boney formations left. It's as if the four toes have become the necks from those steamed clams everyone eats on the Cape each summer, with only the big toe miraculously escaping serious harm.
We splint the limb and give him fentanyl for analgesia, and since we're about 40 minutes by ground from the surgeons who have the only shot at saving what's left of the patient's left foot, we send him by helicopter to save time.
Throughout the whole ordeal our patient stayed calm and kept his sense of humor, no small task for someone who, in an instant, is now forced to perhaps say goodbye to an important piece of anatomy.
This is the second time in a couple of weeks that I've really been impressed with a patient.
In the urban systems in which I work, I've had patients call 911 to get a prescription refilled, or because they're convinced that an ambulance ride means faster service in the ED.
Earlier this year I had one of our frequent fliers call 911 demanding to be brought to the hospital for a pregnancy test.
But patients like today's prove that one piece of vocabulary to describe our patients needs no improvement.
It's quite enough to name it for what it was.

Saturday, August 23, 2008

Podcast Education; How Much For That Speedy Dry In The Window?; Blog Loss; ECG ABCs Course

Looking for ways to keep up with some of the current research in EMS and related topics?
The Web offers plenty of opportunities and from time-to-time I'll try to spotlight ones I like.
For today's installment let me direct you to
The site allows you to listen to talks by physicians and national leaders in trauma research via audio streaming on several dozen trauma-related topics, everything from shock and spinal cord injuries to the current state of research into fluid resuscitation.
You can also download the lectures to your mp3 player for listening later (Apple iTunes actually has a pretty remarkable selection of mp3 medical lectures available for free on its site -- but more on that another time).
The interface is easy to use, the audio is excellent quality, and you would be hard-pressed to find a better source of cutting edge information on trauma care, current practices and future developments.

I don't know how I feel about this idea making the rounds in Winchendon.
I can see the rationale for charging at-fault drivers for the cost of the emergency response to the accidents they cause, but something about it doesn't sit well with me.
I mean, why not start charging anyone who calls 911 and sends an ambulance, police car and fire engine out the door?
Should we start charging patients who call 911 then refuse to go to the hospital? How about hypoglycemics who refuse to go to the hospital once EMS corrects their low-blood sugar with an IV and amp of D50?
I don't know if I like the sound of any of that.
My feeling is that we're a public service, and the public shouldn't have to worry about how much it might cost them to call us.
This will bear some watching.
FOLLOW UP: Here's the Web site for the Dayton, Ohio-based company that is mentioned in the Telegram story. It sounds suspiciously like a way for police departments to finally bill for some of their services, and for fire departments to bill for something other than inspections and ambulance runs.

I'm sorry to say that one of my favorite blogs may be no more. The Boston EMS paramedic who wrote Other People's Emergencies announced this week that he was suspending his blog for the time being due to his activation in the armed forces, and that in all likelihood the blog is done permanently.
That would be a huge loss to his readers, but the blog remains up for now, and I highly recommend following the link above to read his archive. Let's hope this is just a temporary interruption.

This course comes highly recommended by a friend of mine whose acumen at choosing excellent courses is legendary.
"The ABCs of ECGs: Essentials for Frontline Clinicians" is being held on Nov. 1 at the InterContinental Hotel in Boston, and is a continuing medical education event sponsored by Harvard Medical School.
The course announcement claims that there will be something of interest to every level of provider here, and some of the topics covered during the day are definitely relevant to EMS, for example:
"Basic Principles: How to Read an ECG"
"Artifacts, Lead Misplacements and Normal Variants"
"Avoiding ECG Fumbles and Errors"
"Bradycardia: Causes of Pauses"
"Metabolic Abnormalities and Drug Effects/Toxicities"
The course costs $170 for everyone except docs, who get to pay $350.

WEMS Names New Deputy Chief

UMassMemorial/Worcester EMS officially named Monday Night Group Shift Captain Michael Hunter as the service's new Deputy Chief.
DC Hunter was named to the post late last month and replaces former DC Ed Ramstrom, who has decided to go back on the road as a street medic after nearly six years as deputy.
With an EMS career that has spanned 26 years, the last 16 at WEMS, DC Hunter brings to the table a strong commitment to professionalism and patient care.
A North Brookfield native and current Holden resident, where he lives with his wife, April, a nurse practitioner, DC Hunter first became an EMT in 1982 and volunteered for the former North Brookfield Rescue Squad (now North Brookfield EMS) and the town fire department for a dozen years.
He completed paramedic training in Brattleboro, Vt., in 1983, and by 1984 was a nationally registered paramedic working at a non-transport service covering 10 towns out of Marlboro Hospital.
That service shut down in 1989 and DC Hunter went on to serve as the ALS coordinator for the original Marlboro-Hudson Ambulance and its successor after a merger with Ruggerio.
In 1992, DC Hunter was among the first group of medics hired by WEMS after it became part of UMassMemorial.
DC Hunter is a strong proponent of the Prehospital Trauma Life Support program and a member of its Executive Council, teaching at numerous conferences here and abroad, including his recent trip as part of the first PHTLS course taught in Muscat, Oman.
In an email exchange with Central Mass Medics, DC Hunter elaborated on the personal philosophy he intends to bring to his new position, and the future challenges he sees facing EMS as a whole.

CMM: What principles guide you, both as a medic and now as Deputy Chief?

MH: I always try to remember a few key phrases at work and in my personal life. One, loyalty above all else, except honor. Two, lead from the front and, finally, three, actions speak louder than words.

CMM: It might be a bit cliche to say it, but EMS seems to be at a crossroads today. It seems like the industry -- for years in the shadow of more-established brethren like the police and fire services -- is on the cusp of something, but it's hard to tell whether that something is a leap forward or backward. What do you see as some of the challenges facing our profession?

MH: At a national level -- and locally -- recognition is a huge problem. With recognition comes respect. We need to continually build positive relationships with the media, political leaders and the medical community. We need to become involved in committee work at the local, state and national levels. We are the experts in our field, and our opinions and thoughts need to be heard by the ones making global healthcare decisions. We also have a duty to educate the public and we need to advocate for public health. There are many places where our voices will lend credibility and depth to healthcare issues. Seatbelt use, car seat compliance, bicycle helmets, stroke and cardiac disease awareness, elder care and referral to services are just a few examples of worthwhile causes. Through our involvement in these issues will come recognition and respect.
We are also a young profession and our leaders are still developing. We all need to remind ourselves to look backward and help bring the new group of providers along. The newest members of our profession should not have to make the same mistakes we did. It's not a rite of passage. I think we all should also remember that involvement in medicine, especially in a young profession like EMS, is a dynamic process. We must all be "life-long learners." Too often we find ourselves basing decisions and actions solely on tradition. We must all be willing and eager to learn new technologies, theories and ways of working smarter. If we don't, we're doomed to make the same mistakes of those before us. Tradition and folklore have a place in the EMS society, but must be kept in perspective and we must not be rigid in our resistance to change.

CMM: Deputy Chief is a demanding position, especially at a service as busy as WEMS. How will you approach your new duties?

MH: I feel that four principals are paramount for my new position, and I try to adhere to them with every decision and action.
One, leadership. Leaders choose to lead. They must understand the consequences of their decisions and accept the responsibility of their failures, and successes. Leaders also lead from the front.
Two, respect. We should treat everyone as we would expect them to treat us. This holds true at many levels -- patients, peers, supervisors, subordinates and the general public. Putting on a uniform implies a position of authority, and with that comes the responsibility to act accordingly.
Three, communication. It is much easier to lead if everyone knows the direction we're going. The goals and expectations of a project or action need to be understood by everyone involved. Communication involves at least two parties, and the best ideas don't always come from the top down. It is important to remember that you cannot listen if you're constantly speaking.
Four, evaluate. We should always step back and evaluate every decision we make or action we take. This goes to life-long learning. Is there a better or smarter way or doing what I just did? Was my action in the best interest of my patient, partner and service? It goes to what Einstein said about insanity -- that doing the same thing twice but expecting a different result is a sign of insanity. Older medical professionals embrace mortality and morbidity rounds as learning experiences. EMS tends to embrace defending our own actions, even when they are proven to be less than correct -- or even deleterious -- to ourselves, patients and reputations as healthcare providers.
The medics, physicians and communication specialists of WEMS are a great and diverse group of individuals. They each bring unique strengths, backgrounds and experiences to the table. One of the strongest bonds the members of WEMS share is the desire to be the best and provide the highest possible level of care and service to the population we serve.
It is an honor to have been chosen as Deputy Chief and I'm looking forward to learning and growing into this position. WEMS is a great place. I'm very happy to be here and will do the best I can to keep it a great place.

Friday, August 22, 2008

Courage Under Fire

The patient was a teenager, but he looked like he was 12-years-old.
In the 45-minutes I was with or near him, he passed out four or five times.
His normally-beating heart was betraying him, his atria quivering when they should have been contracting in synchrony.
It's not the sort of thing a young man's heart typically does.
We started two IVs on him; the ED added a third.
His heart rate never dropped below 130 beats per minute, and twice -- once when we moved him over to the ED bed and another time for no good reason -- accelerated to 280 plus.
Eventually, the ED threw the drug box at him -- Amio, Mag, Versed.
Before the cardioversions began they even gave him some Etomidate.
Anesthesia came down with their bag of tricks as the docs considered intubating him, but this kid was tough.
He maintained his own airway and defied our system's plans to take away his ability to breath unaided by machines or people, probably the most basic proof we have that we're alive.
The docs shocked him 5 times. A helicopter was called, and by the time they took him to the city he was doing much better.
As they wheeled him out the door I tapped him on the shoulder and told him to hang in there.
He nodded, but it seemed like he was already dealing with his condition better than any of us.
Today was a bad day, but not the worst for this young man in his brief life.
Diagnosed with a form of bone marrow failure and chronic anemia when he was just a few months old, the patient's disease has left him with an alcoholic's liver and a 90-year-old's heart, and he bears a 12-inch half-moon scar down his abdomen from where they'd removed his spleen at one point.
And despite all this, despite having a million and one reasons to complain, to feel sorry for himself, to do any one of the legion of things I might do if faced with a similar path, our patient was calm, almost stoic.
He answered questions and described his condition with the maturity of someone three times his age.
I don't know that I've been more impressed with a patient.
We hear a lot about courage and heroism.
Most of it is crap.
This kid was the real deal. He knew how sick he was, better than us -- better than ANY of us there that day, and he was the calmest one in the room.

The patient has what's known as Diamond-Blackfan anemia.
If you haven't heard of it, don't sweat it.
There are only 500 cases in America.
The condition is a member of the family of inherited bone marrow failure syndromes (IBMFS), and according to it's incidence in the U.S. is somewhere between 2 and 6 cases per million people.
It usually appears first in early infancy and is marked by a pure red blood cell aplasia, which means that the patient's bone marrow lacks any red blood cell precursors.
About a quarter of those cases result from gene mutation; the other 75 percent, apparently, appear mysteriously.
The treatment generally includes lots and lots of transfusions, which can lead to cardiac arrythmias, congestive heart failure, iron overload, stunted growth and infections.

For my partner and I, the acute dilemma was twofold.
The patient presented with a rapid AF in the 150s, but also threw pretty frequent runs of Vtach.
It was a unique ECG strip, to say the least.
His pressure was Ok, 124/70 bilaterally, but he was able to tell us that he has had episodes of acute hypotension with Dilt.
So we worried about dropping his pressure.
The Vtach was problematic, too, because we worried about giving Amio due to the hepatic issues, what with Amio being excreted mainly by the liver.
We ended up contacting med control.
The online doc, having already spoken to the city specialist who treats this young man, told us to give a little fluid but, as long as he continued with a stable hemo status, otherwise just observe.
Given how complex his treatment course in the ED became, I'm glad this is the course we took.
Sometimes less is definitely more.

Even as I write this, I wonder how this patient is doing.
Unless we return to his house, I doubt I'll find out.
And if we have to return to his house, it can only mean that things aren't going well.

Wednesday, August 20, 2008

North Brookfield On The Ropes?

From the Things Are Tough Everywhere file, this story about the financial woes of North Brookfield EMS.
I hate to see these third-service non-profits have such tough times. My first job as a Paramedic was with New Britain EMS in New Britain, Conn., a third-service non-profit with loose ties to the former New Britain General Hospital (it now has some new convoluted name that I can't even begin to remember).
I loved every minute I worked there.
There are numerous examples of such services thriving here in Massachusetts -- Spencer Rescue and Webster EMS come immediately to mind -- but obviously the financials can seem insurmountable.
On an editorial note, and although all I know of the proposed contract with the town is from what I read in the paper, I'd have to agree that it would be cost-prohibitive for a town with a call volume as low as North Brookfield's to insist on TWO 24/7 dual medic trucks dedicated solely to 911 calls.
Frankly, I don't know how they'd pay for it.
I wish North Brookfield EMS all the best.

Monday, August 18, 2008

Some Blogs I Like

I like blogs.

Actually, I LOVE them. It's like they exist in real-time, and speak directly to their readers, unlike what most Web sites have become these days -- marketing tools meant to tease you into buying something; hopelessly out-of-date, at least by 2008 standards. I mean, who wants to linger at a Web site that was last updated 8 months ago?

So here are a few of my favorites. One of the best things about each of these blogs are that they link to dozens of others, each of which links to dozens of others, and so on, until suddenly you realize there are tens of thousands of people writing blogs just about ambulances and EMS, which is pretty cool.

Wormtown Medic. Written by a co-worker, it's a new blog that focuses on Worcester EMS in Worcester, Mass. Anyone who knows its author, Rod Witkos, knows it will be opinionated, insightful, definitely funny and a must-read worthy of a Bookmark. For those of you wondering about the title, "Wormtown" is a city nickname that has stuck around for a few decades despite some opposition among more sensitive residents. I always liked the name.

Rescuing Providence is a blog written by Lt. Michael Morse of the Providence Fire Department.
This is a great blog written by a guy who chooses to work on one of the busiest ambulances in America despite having the option not to. Inspiring to those of us who don't feel the need to apologize for being passionate about EMS. Another must-read.

Other People's Emergencies focuses on Boston and is written by a veteran Boston EMS medic.
This blog captures the experience of urban EMS in all its facets like few others I've come across. No war stories, just clear-eyed observation underscored by keen analysis of the day-t0-day life of an urban Paramedic.

Random Acts of Reality is a blog written by an EMT for the London Ambulance Service. Well-written and funny, it also goes to show that a 3,000 mile gap doesn't mean much when it comes to EMS. The things that make the job great and galling are universal, it seems.

Brick City Blues covers the daily (and nightly) grind of working for University EMS in Newark, New Jersey. This is definitely an intense place to work, on all fronts, and the medic who writes it pulls no punches. Although in the news recently for all the wrong reasons, this is one of the nation's best EMS services and the blog is a joy to read.

Not Just For Firefighters; Down With The Stairchair

Thanks to Rod from Worcester EMS for pointing out this link.
While sponsored by a group attempting to tackle health problems amongst firefighters, I think they could easily have been describing anyone who makes a living responding to emergencies with lights and sirens.
We work so hard to help those around us that it's so easy to forget about ourselves.
Although there have been some EMS initiatives, the fire service is really striving to address those things that make heart disease the most prolific killer of public safety personnel.

In perhaps a more EMS-centric vein, recently posted an article about back injury prevention.
This is where I find the state's declaration that we stair-chair EVERY patient to be not just ridiculous, but downright career-threatening.
Can someone please tell me why I should risk a career-ending back injury stair-chairing a Section 12 patient with no physical issues whatsoever?
With all the talk about selective c-spine immobilization and the recent research questioning the wisdom of backboarding everyone who calls 911, I think we need to look at stairchairs the same way we look at surgical airway kits -- something only to be used when needed and appropriate.
I want to do this job until I retire, and I need all my discs and vertebrae in their proper location and functional.

Here's an interesting .pdf file about expanded scope Paramedics, an idea that was in vogue for a brief period a couple of years ago. I'm always intrigued by ideas like these, but we work in Massachusetts. I'm not holding my breath...

Sunday, August 17, 2008

Flophouses, Foyers and Lobster Trap Hearts; Plus, Does Your Doc Throw Stuff?

I worked a shift today at one of my part-time jobs, a non-transporting gig based in one of Massachusetts's most economically depressed cities.
This job is usually a good jolt to the system because in addition to this city, the service provides ALS to a couple of the state's nicest -- that is, wealthiest -- towns.
The juxtaposition can be jarring.
One call you're intubating a cardiac arrest in the fetid bathroom of a flop house and trying not to think about what the gooey stuff is that you're lying in, and the next you're evaluating the chest pain of an elderly matriarch -- whose relatives skippered the Mayflower -- in the foyer of a brick mansion that itself is bigger than your own home.
I make no judgments here about either of these patients. They both get the best I have to offer.
That's the great thing about being a Paramedic.
We don't have to worry about who these people are -- the sick and injured who call 911 or have it dialed for them.
No matter whether you're the alcoholic homeless guy at the local wet shelter who had his nose broken in a fight with another alcoholic homeless guy from the local wet shelter, or the CFO of a Fortune 500 company in flash pulmonary edema, all we have to do is treat you.
Throw in a little humanity and you're on to something...

Doctors take the hit in this article, but none of us in the field are blameless.
For me, the dangerous hour is 3 a.m.
Certain decisions that seem completely justified or rational in the middle of the night -- like throwing discarded pizza and Chinese food containers against an EMS charting room wall instead of actually asking the ED nursing staff to stop using the only table in the room as a trash bin -- will almost always be revealed during the daylight to be really, really stupid.
I've noticed that some people in healthcare seem to equate personal competency with a license to treat the rest of the field like fools or little children.
I don't know where this comes from.
Mostly I think it's a form of amnesia.
When you forget where you came from it becomes even easier to forget where you are -- a small part of a big team trying to alleviate suffering and cure illness.

For those of you who might have missed it, there's a bit of a Rennaissance happening at Spencer Rescue over the last year or so. This article in the Telegram makes reference to Spencer Rescue's pact with Paxton, and is a great example of how a little cooperation and innovative thinking can bring good things to all sides.

I don't know much about how EMS operates in Upton, but it seems changes are afoot. Although maybe unrelated to anything going on in nearby Upton, EMS in the Milford area has undergone a sea change lately, what with the sad demise of the 2181 non-transport service out of Milford Regional Medical Center. I'm not sure who's stepped in to make up for the loss of ALS coverage, other than AMR now owning the entire operation in Milford itself. Uxbridge Fire Department has been making strides to get its ALS program running, while Events and Alert Ambulance are still in the area. I'd love to hear from people who can explain where everything stands down there.

Does it seem like we respond A LOT in the course of a week for patients complaining of possible reactions to antibiotics?
It seems we're not imagining things.
A recent study found that nearly 20 percent of all hospital evaluations for adverse drug reactions involved antibiotics, affecting nearly 150,000 people.

Here's something for the Medical Oddity of the Month Club, courtesy of George, a partner of mine at the part-time job I wrote about earlier who works full-time as an RN in a cath lab.
George is one of my favorite partners of all-time, mostly because despite having over two decades on the streets as a Paramedic, George still approaches the job with a sense of wonder and a desire to learn.
I hope I have half his intellectual curiosity when I've been a medic that long.
So anyway, George had to give a little mini-lecture at a meeting of the cath lab staff on the subject of takotsubo.
Also known as Transient Left Ventricular Apical Ballooning, it's basically a deformation of the left ventricle resulting from extreme psychological or physical stress.
The name is derived from the shape of traditional Japanese lobster traps, which the stricken heart resembles.
It's kind of rare, but not unheard of. George has himself seen two of these cases in the cath lab, where he's been for less than a year.
I don't know how knowledge of this will help you directly in the field, since it's not something we'd be able to discover and even if we could, there's nothing to be done about it prehospitally.
But I'm not adverse to knowing stuff just for the sake of knowing it, and takotsubo is pretty interesting, so if you feel the same way, then bon appetit.

For those of you willing to send it along, one of my main goals for this blog is to be a resource for EMS and related news for central Massachusetts.
I'm not looking for gossip and I have no agenda other than spreading the word about goings-on in our part of the prehospital world.
If you have anything of a newsworthy nature -- and my list of things that might be considered newsworthy is pretty broad, everything from new vehicle purchases, contracts, hirings, open positions and whatnot to attaboys and award announcements -- please feel free to email it to me and I'll be sure to get it in the blog.
Also be sure to spread the word about Central Mass Medics.