Sunday, September 28, 2008

Stairchair surprise,

It was the kind of call that can get under your skin if you let it.
5:30 a.m.
The end of a busy shift.
Every prior patient obese or beyond.
Many of them actually sick.
Dinner was a couple Big Cups and an orange soda several hours earlier.
We had flung more stairchairs that night than an assembler at the Ferno factory.
My partner and I were exhausted, and now we were standing in the living room of an elderly woman who didn't seem to like us at all.
"I don't want to go to the hospital," she said. "They make me sit and wait too long."
"Ok," I said, "but you must have wanted to go to the hospital when you called 911."
"Damn right I did! I'm in pain! My hand hurts, and I can't walk! Can't you just give me something here so I don't have to go?"
We'd had this same conversation three times by now, and it was getting a little tiresome, but this patient was of a kind that we've all had once in a while.
No matter what you suggest, the patient wants to do the opposite.
I began by offering a trip to the hospital, to which the patient responded in the negative, exasperated that we'd even brought up the idea of an ambulance ride.
So when I asked if she would then prefer to wait until Monday and follow up with her family physician, since, after all, she'd had this particular pain for a decade and it was no worse currently than normal, she became truly offended and demanded transport to the hospital.
Finally, after about 20 minutes of negotiation in the cramped back bedroom of the musty triple decker, the patient relented.
And for the umpteenth time that night, my partner and I strapped our overweight patient into a stairchair and began the long descent down three floors of twisty, dark and steep steps.
We paused at the bottom just before heading out onto the sidewalk.
I had the bottom of the chair and as I bent down to grab the handles for one last time, I felt something on the top of my head.
I looked up and noticed that the patient was sitting back in the stairchair.
"That was a kiss for you," she said. "For working so hard."
It was the kind of gesture my patients surprise me with from time to time, and another example of why this is the best job in the world.

Persiflager's Infectious Disease podcast is a great site to keep up with the latest and greatest developments in the world of infectious disease.
The link also connects you to PACID, aka Persiflagers Annotated Compendium of Infections Disease Facts, Opinion and Dogma.
It's kind of a meta-site, full of links to other pages concerning antibiotics, pathogens and diseases.

Tuesday, September 23, 2008

Get This Book

In reading his book, Rescuing Providence, the thing that stands out most to me is Mike Morse's refusal to complain.
Not that I would blame him if he did.
A Lieutenant on the Providence (RI) Fire Department and assigned to the EMS division, the book follows Morse on a 38-hour shift in a busy urban 911 system.
The litany of calls is familiar.
The patient names may be different, but Morse could have just as easily been writing about Worcester, or Lawrence, or Lowell or a dozen other New England cities still trying to recover in the 21st century from the erosion of the 19th century manufacturing economies that were once their foundations.
What's different is that Morse obviously loves his job, and has genuine compassion for those particular patients, like the frequent fliers and drunks we all deal with, who would be much easier to hate.
He occasionally questions why he continues to work in such a busy system when relief is just a simple transfer request away.
In his book, Morse comes back with the simplest of answers -- he loves working on the ambulance.
I know Mike reads this site, so I hope he won't mind if I give his book a huge plug.
I started Rescuing Providence at 9 a.m. on a recent morning and read it in one sitting, not because it's short but because I couldn't put it down.
Along with Peter Canning's two books (Paramedic and Rescue 471), Morse's is the best I've read about EMS and I highly recommend it.
Check it out at the Paladin Press Web site , or follow the link on my blog to Morse's Rescuing Providence blog to order.
It'll be the best 22 bucks you'll spend this month.

Tuesday, September 16, 2008

Better Living Through Thin-Slicing

"What does it take to be good at something in which failure is so easy, so effortless?"
The man asking the question is Atul Gawande, a surgeon at the Brigham and Women's Hospital in Boston who also happens to be a bestselling author.
The question comes from Better: A Surgeon's Notes on Performance, Gawande's 2007 rumination about what constitutes success in healthcare, especially in the face of what he describes as "daunting expectations."
Although Gawande is a surgeon, I think his book offers profound insights for anyone in healthcare in general, and EMS in particular.
According to Gawande, the hurdles between doing a job and doing it well begin with the simplest of premises.
"For one, lives are on the line. Our decisions and omissions are therefore moral in nature...In medicine, our task is to cope with illness and to enable every human being to lead a life as long and free of frailty as science will allow. These steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act with swiftness and consistency...It's not only the stakes but also the complexity of performance in medicine that makes it so interesting and, at the same time, so unsettling."
I thought of Gawande's book over the weekend while I watched a trauma team work on a severely injured patient brought in by one of our other ambulances.
The patient had taken a huge fall and was in cardiac arrest when found by the ambulance crew.
As most people know, there are few events so certain to result in death as a heart stopped by some kind of blunt force trauma, like, for example, the sudden stop awaiting you at the end of a long drop.
The number of people who survive this kind of event is minuscule, yet my co-workers delivered this patient to the trauma team with a pulse and blood pressure, not to mention some grievous musculoskeletal injuries.
The trauma team did a similarly professional job, and the patient made it alive to an operating room that he never should have seen, if one were only to consider actuarial tables.
I thought of the innumerable opportunities for failure with this patient, beginning with the bystanders who heard his last moans and called 911, extending to the first responders who did their jobs with aplomb, and then, of course, my co-workers who got the patient's heart pumping again despite the odds and effects of gravity.
Gawande whittles down the challenge of medical success and performance to three core requirements -- diligence, doing right and ingenuity.
Diligence, he writes, "is the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles."
On the surface of things, this should be "an easy and minor virtue," Gawande writes. "You just pay attention, right? But it is neither. Diligence is both central to performance and fiendishly hard."
I think I know what Gawande is driving at here.
In Sunday School we called these things "sins of omission," those things that we do wrong by not doing.
But Gawande doesn't judge.
"Medicine is a fundamentally human profession. It is therefore forever troubled by human failings, failings like avarice, arrogance, insecurity, misunderstanding."
Perhaps the Gawande tenet most applicable to those of us who wander the streets daily in ambulances is ingenuity.
He considers it not a matter of intelligence, but of character.
"It demands more than anything a willingness to recognize failure, to not paper over the cracks, and to change," Gawande writes. "It arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions."
Gawande admits these are difficult traits to engender, and who in EMS wouldn't agree?
We are a self-reporting profession, which means not only that the inmates occasionally run the asylum, but that only the machinations of the asylum that we allow to be seen or accidentally reveal come to light.
My favorite partners are those folks who ask themselves daily how they could do the job better.
What would EMS look like if that was a question the entire profession asked itself in earnest every day?
But then I think of the work of Malcolm Gladwell, a staff writer for The New Yorker and another bestselling author, and I think maybe it's a question we're answering all the time, even when we don't realize it.
If taken to its logical conclusion, Gladwell's book Blink:The Power of Thinking Without Thinking suggests that those of us in EMS and healthcare are constantly adding to an internal data bank of experience that we draw upon every shift.
Most busy urban systems share one common trait -- a particular pride in being able to walk into a room and know without even speaking with a patient whether they're "sick or not sick."
In observing various partners over the years in these busy systems, I'm amazed at the accuracy of their split-second assessments.
Gladwell wouldn't be.
A relatively new field of study in psychology, Gladwell says it's the brain's "adaptive unconscious" that allows for these uncannily accurate predictions based on the slimmest of evidence.
Ever wondered how that medic you work with was able to take a look at a patient and know it's a head bleed or CHF or STEMI before you've even put the first-in bag on the kitchen table?
Gladwell calls it "thin-slicing," which is "the ability of our unconscious to find patterns in situations and behavior based on very narrow slices of experience."
People who work for long periods of time in high-pressure, time-sensitive professions hone their thin-slicing skills to a razor's edge.
According to Gladwell, they have to in order to succeed.
"Thin-slicing is part of what makes the unconscious so dazzling," he writes. "But it's also what we find most problematic about rapid cognition. How is it possible to gather the necessary information for a sophisticated judgment in such a short time?"
Gladwell opines that an "automated, accelerated unconscious" processing takes over, and more often than not -- and more often, at times, than people who hashed out the same decision with lots more time and lots more data -- leads us to the right conclusion.

Tuesday, September 9, 2008

Lancaster Departments to Remain Separate

It was interesting watching how leaders in Lancaster handled a proposal to merge the fire and EMS departments.
The T&G is reporting today that the merger is off, at least for now.

Monday, September 8, 2008

Charge of the Popup Brigade

I should have invested in tents. Or maybe RVs. Definitely Tyvek.
I'd be a multimillionaire by now.
It's THE hottest growth industry of the post-9/11 economy, "it" of course being the sea of baubles and toys on which billions of your tax dollars have been spent in the quest to save us from the legion of Biblical plagues that terrorists are certainly preparing to unleash on us any day now.
But I worry about more than smallpox or anthrax or panflu (and that last, technically, wouldn't be the terrorists' doing, but the money to combat it all comes from the same place).
Thumb through any magazine dedicated to fire, EMS, police or "homeland security" and you can't avoid one obvious truth:
To counter Al-Qaeda's next attack on American soil, hundreds of intrepid security and safety corporations plan to send not troops but a sea of canvas tents, rubber huts and microwave-emitting RVs driven by Tyvek-suited first responders.
These companies have amassed a dazzling array of tents, pop-up trailers, tagalongs, pullalongs, tents with shower heads, red tents, blue tents, yellow tents, tents color-coded to the type of chemical agent used, Winnebagos jammed with more electronic equipment than the Space Shuttle, and of course, my personal favorite and an example of corporate synergy so refined as to make the bean counters at DynCorp or Halliburton break down and cry, one company has come out with a radio-infested combo popup trailer AND tent, whose purpose is as unclear as the entire device itself but the ads pitching it are pretty nifty.
Hopefully, if the day ever comes that we need this stuff, it will all work as planned.
Until then, I'm buying me some shares of Camping World.

FOLLOW UP: Get ready for lots and lots of new tent designs, once this report gets out there. I believe in preparedness, but sometimes I wonder how many hospitals could be built, how many ED beds opened, how many Paramedics and EMTs put on the streets, how many ventilators bought, how many doses of flu vaccine given out, how many uninsured could be covered, how many public health ills eliminated, all by redirecting even a portion of the billions and billions of dollars the federal government has spent ensuring that we have more RVs than a Utah salt flat, more tyvek suits than a field of McMansions, and that every first responder who goes to a convention is wearing the appropriate golf shirt?
A lot, I'd bet....

Saturday, September 6, 2008


My twin 6-year-old boys had soccer practice this morning.
It was the first of the new season and we squeaked it in between rain showers, although we couldn't escape the oppressive humidity.
Watching them run, particularly the Redhead with the slight hitch in his step and who looks so much like his Mother, the last four years became like a decade, or maybe two, or three.
Hard to tell, really.

I involuntarily make the connection backwards to an ambulance call in a town 40 miles and five years away.
It was a September day, perfectly blue and sunny, and I was working at my part-time job at a non-transport ALS service when we got a call for a child with a pitchfork in his head in a nearby town.
We intercepted with the fire department BLS crew downtown.
The EMT in the back jumped out as we approached the ambulance's side door and didn't say a word.
In fact, I never saw him again on the call.
He knew how sick his patient was and so he went right to our truck to drive.
He also knew there wasn't much he could add to the scene we were about to encounter.
When my partner and I got into the ambulance we found a 4-year-old boy in c-spine immobilization with a non-rebreather oxygen mask strapped to his face.
He had a bandage over the top part of his head, and you could see a half-dollar sized patch of blood through the gauze.
A small three-pronged gardening pitchfork sat on the tech bench.
I'll never forget how two of the prongs were encrusted in mud, while the third gleamed as brightly as the day it was taken down from the hardware store rack.
Somehow we discovered that the boy had been playing with a friend, and for some reason the friend had plunged the pitchfork into our patient's head.
While waiting for the ambulance, the patient's mom had removed the pitchfork and the EMTs had had the foresight to bring it with them.
The boy was seizing violently, or "to beat the band," in the EMS vernacular.
We didn't waste any time in starting transport to the hospital.
En route we got a couple IVs going, administered one drug to stop the seizures and a few others to sedate and paralyze the little boy so we could put a tube into his trachea and breath for him.
A helicopter met us at the hospital and took him to the major children's hospital about 30 miles away.
I was convinced the patient was going to die.
I couldn't imagine the infection potential of the dirt and mud that had found its way deep into his brain; I could definitely imagine the trauma the pitchfork prong caused as it made its way into the most valuable real estate in the human body, into places where our true selves are secured.
While I'm convinced there is such a thing, I don't know where the soul resides, but I know that this poor little guy had just had a sharp pointed object rammed through the machine that gives motion and action to the soul's desires.
I wasn't optimistic.
But children are wonderful, confounding creatures, and they never cease to amaze me with their ability to do the unexpected.
This little boy survived first, and then thrived.
The neurosurgeons at the hospital performed miracles; the nurses on the neuro floor made sure those miracles stuck, and had a chance to cement themselves.
A year later, I was met at the ED entrance by this little boy, who now walked with a slight hitch in his step, which I barely noticed as he came forward to give me a hug.

I remembered the names of those surgeons, not because I ever thought I'd need them, but because I thought their work was amazing, worthy of the kind of fame we reserve for rock stars and actors.
I thought my admiration would remain academic, third-hand.
Then my little redhead starting getting dizzy.

Medulloblastoma is a malignant brain tumor of the posterior fossa.
That's the part of the brain, kind of near the brain stem, that controls balance, among other things.
We learned this on Nov. 8, 2004, when a CT -- in the same ED where the little boy with the pitchfork injury had thanked us for helping him out -- ordered by an ophthalmologist investigating the source of my son's swollen optic nerves revealed a large mass in the back of my son's brain.
My little redhead, 2-years-old at the time, ended up in the same children's hospital, on the neuro floor no less, and was promptly readied for surgery on Nov. 10.
I liked the date.
Nov. 1o is the Marine Corps' birthday, and as a former Marine I couldn't imagine a better day to start a fight against brain tumors.
The day before the surgery my wife and I met with the woman who would be operating.
I knew from my follow up on our little pitchfork patient that this woman had also been on the team that had saved his life.
As the ICU nurse who cared for my son put it in the hours after that Nov. 10 operation, this woman is a miracle worker.

I won't bore you with the details of the next two years of treatments.
Suffice it to say there was lots of chemo, radiation treatments, a stem cell transplant, more than a few brushes with death.
He lost his red hair and his appetite. More than a few other kids we met in the same fight lost their lives.
My little redhead is currently tumor-free, although we know there are no guarantees.
But today I watched my little boy play soccer with a slight hitch in his step, racing around a small grass field against opponents who will sit next to him in his first grade class on Monday and joke about how much fun they had on Saturday, and I couldn't help thinking that some miracles don't always end.
Sometimes they go on and on, even playing soccer with a slight hitch in their step.

Wednesday, September 3, 2008


Just a couple quick items to follow-up on things CMM has blogged on earlier:

It seems North Brookfield EMS has gotten its contract with the town. According to the Telegram, the deal is for a year and provides the service access to $25,000 that town voters approved earlier this year.
Ominously, though, it sounds like the deal would allow the town to put up its own ambulance with town employees (I assume they mean the Fire Department) and break the contract with just a month's notice.

In Gardner, the City Council has decided against signing-on with a company that would collect money from at-fault drivers to recoup the costs of fire and police responses to the accidents they cause.
Rather than defeating the proposal by official vote, the city council simply removed it from their calendar, achieving the same goal.
Cost Recovery Systems, of Dayton, Ohio, is a company that promises to recoup the cost of sending fire and police vehicles to accident scenes by targetting the drivers deemed at-fault in the accident and sending them a bill.
I'm sure a good chunk of the money ends up in Cost Recovery's pockets.
A couple other communities in the state have or are nearing deals with this outfit.
I applaud the Gardner City Council for steering clear of this whole mess.
Money is good, but at what cost?
To me, it's a pretty thinly veiled attempt at allowing police and fire departments to start billing for services that have traditionally generated no revenue.
I couldn't agree more with City Councilor Kim Dembrosky, who said after the move was defeated that “sometimes people say that government goes a little too far. I think this would have been one of those cases.”