The MacMedic

The weather last night was perfect. Cool enough that I was comfortable with just a light fleece jacket and delightfully clear. I did not, however, get to spend much of my free time along the shore. Too much work that needed to be done in station for “joyriding” and by the time I was finished with that work my energy level was starting to ebb and I just wanted the night to be over so I could head home.

Only one transport last night but it resulted in me getting grief from the physician at the ED that we transported to at the university hospital down the coast.

I was only partially done with my beginning of shift checklist when the tones dropped to respond for a woman in her mid fifties with respiratory distress. I arrived a few minutes after the ambulance and found the patient in care of the BLS crew and the police officer/first responder. She did appear to be having some difficulty breathing but the problem seemed more related to the severe pain she was having at the site of the epidural she had had during a hospital stay that ended only a few hours before.

It took me a minute or two to get the story straight but once I did it made much more sense. I had never encountered epidurals used outside of the labor and delivery suite. What I learned tonight was about a new pain management technique that was being tried. The patient had a history of chronic pain after a fractured scapula in an MVC a few years ago. They tried a new procedure (or at least new to me) and placed an epidural at the base of her cervical spine and spent twenty-four hours infusing low dose ketamine (an anesthetic) directly into her spine.

After the procedure her epidural was removed and she was discharged home. Her car ride home was a bit more than an hour and by the time she arrived back home she was in tremendous pain at the sight of the epidural and radiating out to her arms. My exposure to epidurals in other settings made me aware that some discomfort and numbness in the distal extremities was possible. I had never seen a post-epidural patient in this much discomfort.

Being based at the freestanding ED in the southern part of the county I knew that we had limited support and that the possibility existed that this patient might need resources that would not be available there. I gave the ED a call by phone and talked to the attending physician for advice. She agreed that the patient would probably be better served at a facility that had the availability of an anesthesiologist at least as well as a physician that was more familiar with the procedure that was done. She agreed that I should treat the patients pain and transport her down the coast to the larger facility there.

The patient was clearly uncomfortable with tears streaming down her face and a difficult time getting a full breath. Before we even started to transport I put an IV in and started to administer morphine to the patient. I started with 2mg doses in the IV and repeated them for the duration of the transport with some reduction of her pain, down to a 6 out of 10 from the 10 out of 10 that she started with. During transport the patient ended up getting 10 mg of morphine (pain medication) and 12.5 mg of promethazine (an anti-nausea drug)

I called in with a radio report that was pretty specific on what we were transporting and what was done but I knew that I would end up repeating my verbal report at least a couple of times when we got to triage so that they could decide where the patient should be placed. I was not wrong.

The triage nurse looked at me like I had sprouted another head when I described the procedure that the patient had undergone and why and looked at me skeptically when I related my efforts at pain management and their results. Eventually we were directed to a treatment room and the doctor followed the stretcher in and listened to my verbal report. I could tell from the look on his face that things were going to start going downhill. After she had been moved over a different doctor came into the room and I ended up repeating the report again.

“We generally don’t treat pain with morphine here.” Here it comes. I explained that I had limited resources and the only pain medication that I had was morphine. “Why so much?” OK, pain medication titrated to relief as long as vital signs and mental status remain stable. I kept looking for a way to turn the conversation to something positive and asked what he would have preferred that I had done. After some hemming and hawing he told me that he would much rather have seen me use Fentanyl (a different pain medication). I agreed, it would have been effective and maybe even better than the morphine that I had used but that was a drug that I did not have available. “That’s why our paramedics down here don’t worry about pain management.”

I was simply not going to get into that discussion. It was not “my” hospital, “my” medical direction physician, or even really “my” problem. I had followed my treatment guidelines and had reduced the patients level of pain. I did what I was supposed to do. I was a little shocked by the implication the paramedics “down here” didn’t worry about pain management, I had always thought that reducing the patients pain was one of our primary jobs. What do I know?

This ended up being the only call that I did for the night, outside of a few cover assignments. All in all, not a bad night.

It’s a good thing that the night wasn’t bad, the day promises to be less than great. The people buying our house are scheduled to have the house inspected today. Our realtor says that it shouldn’t take more than two and a half to three hours which is perfect timing to get me to bed after getting my youngest to school. I’m hoping that I can grab a nap this morning before she goes to school but we’ll see.

Total calls for the night: 4 
1 ALS transport 
3 Cover assignments

Milage for the night: 76

Music for the night: “The Complex” by Blue Man Group

Back to work tonight but I am not feeling like I want to go. It’s not that I don’t want to go to work, I still love my job, but I am starting to feel time pressure with all that needs to get done before our move and I just want to feel like things are back under control.

I “went public” with my resignation and upcoming move out of state on a couple of the internet mailing lists that I administer. I have received about a dozen messages either on the lists themselves or privately from people wishing me well and promising to keep in touch. My original intent had been more focused on starting the transition to new list moderators so that I can have them up and running by the end of November. I’ll continue to host the mailing lists, websites, email services, and blogs on my server and handle the technical aspects of them but the day to day administration regarding content will be passed on to the next victim new moderator.

Surprisingly I have received a couple of dozen messages from members of the lists wishing me luck in my move and telling me that I will be missed. It’s nice to get positive feedback like that but it doesn’t make my imminent departure any easier for me.

Tonight should be a delightful night. Temperatures are supposed to be in the high forties with low humidity and clear skies. A perfect night to be down along the shore.

OK, so I am the bringer of chaos, I walked in, changed clothes and before my shift had even officially started was out for the person crushed between a motor vehicle and a house. The day shift decided that he would tag along, officially it was still the day shift and who can pass up a good trauma?

For the fourth time in three shifts for me the helicopter had been requested before I had even signed on and as I drove down the highway I was seriously considering asking for a finders fee from the flight crew.

We arrived just after the rescue and before the ambulance to find a male in his late forties supine on the ground next to a pickup truck and the wall of the house which had some crush damage to it. He was awake and alert complaining of right sided chest pain and head pain. He had some abrasions on the right chest wall and a laceration on the right side of his head.

The fire officer related the situation. The patient and a friend had been trying to move a large slab of rock in the front yard using a 2×4 and the plow frame on the pickup. With the friend driving the truck and the patient guiding the rock into place things had been going fine until the 2×4 splintered and the truck lurched forward pinning the patient between the bumper and the house. The truck had been backed away quickly and the patient lowered to the ground prior to the call to 911. He was unresponsive for a couple of minutes and was just regaining consciousness when the first responders arrived.

We found him alert and oriented with alcohol on his breath. While I ran through a thorough assessment the day shift paramedic put a couple of large bore IV’s in place and the rescue was preparing to board and collar the patient. By the time the ambulance had arrived the patient was ready to move to the landing zone which was a couple hundred meters down the road in an open field.

The helicopter was landing as we left the scene and as soon as we stopped moving at the landing zone the flight crew was entering through both doors of the ambulance. They made a quick reassessment, switched over to their monitor and oxygen source and were back in the aircraft and lifting off with in 5 minutes.

This had to be one of the shortest trauma calls that I had done in a long time. From time of call to return to service was less than forty minutes. It was clear to me that this department had been extremely well organized and that this whole procedure was planned and rehearsed ahead of time. I was pleased with the way things went and very happy with the short scene and total time on task. We were back in service a little after 1930 with an 1854 time of call. Not bad.

Working with another paramedic was an unusual experience for me, we so rarely ride with dual paramedics that it is something that I have not been used to. My understanding of the systems where I am moving to is that they are quite frequently dual paramedic systems so I guess I had better get used to it.

The night was steady for the next several hours but with only a single additional ALS call done in Medic 1’s area while he was tied up with a maternity call. All I can say about that is better him than me. Mine was a diabetic with what he felt was a hypoglycemic episode which he had treated with oral glucose prior to EMS arrival. It was still an ALS transport just as a precaution because of his age, history, and presentation with atrial fibrillation with a slow ventricular response.

Things finally slowed down around 0200 and I had no choice but to crash on the chair in the office for a couple of hours, I was seriously running out of steam. I slept fairly well and felt quite a bit better when the tones woke me up for an assault in a nearby town in the next county. No need for ALS and I was cancelled pretty much as I drove up to the scene.

In general it was a pretty good night but I am glad that it is over, I really need a solid few hours of sleep so that I can feel rested and refreshed.

Total calls for the night: 9 
1 ALS turned over to the air ambulance 
1 ALS transport 
1 BLS downgrade 
1 No Medical Emergency 
1 Unable to intercept 
4 Cover assignments

Milage for the night: 104

Music for the night: “Live at the Montreal Jazz Festival” by Diana Krall

The night started out with a bang and just kept going. I don’t think that I took a breather until almost the end of the shift.

I wasn’t even in yet and the dispatch center was looking for a paramedic to respond to a car versus motorcycle crash in one of our towns. Pulling my car into the first available parking space I sprinted across the parking lot (not a pretty sight I can assure you), met the day shift paramedic as he was unloading from his last call and we made the change on the fly.

One of the towns we cover was having a large agricultural fair going on and this accident was in the same town but south of the fair location. Medic 7, the unit dedicated to the fair had been chopped by the EOC to respond and he was requesting a second paramedic to respond to help him. Two medical helicopters had already been requested with the landing zone set for an open field a short distance from the scene.

I arrived just as Medic 7 was turning his patient over to the first flight crew and went into the ambulance to assess the other patient and prep for the incoming helicopter. Medic 7 had already put an IV in during the time that he was waiting for me to arrive and done an initial assessment. With the assessment of the BLS crew I repeated the assessment and found that, while the patient had a major head laceration and a probable wrist fracture. His vitals were stable but he was unsure if he had lost consciousness when he was struck by the other vehicle and launched of the motorcycle.

All in all I thought that he needed to go to a trauma center but we probably could have gotten away with transporting by ground. We could have had this been any other time of year. With the fair drawing thousands of additional vehicles to the area the roads were heavily congested and it would mean a significantly longer transport time. Transport by air it was.

Unfortunately, the biggest problem we have with the flight program in our state is communications. Getting an accurate ETA is exceptionally difficult and today was no exception. At one point we had three different ETAs and locations for the aircraft ranging from still on the ground at their base to in the air and 4 minutes out. The true ETA and location was somewhere between the two extremes.

Finally they arrived and I found that the lead flight nurse was an old friend who I had worked with for many years earlier in my career at the ED where Medic 2 was based. The new flight nurse she was training and the respiratory therapist were doing their assessment and she asked me what was new. I gave her the micro-squirt version and was asked if I was considering applying to the flight program in that area. I replied that I wasn’t because I felt that I was too large and too heavy only to have the RT shoot over his shoulder “don’t bet on it”. They departed with my friend offering to act as a reference for me when I was applying for jobs.

With both patients in the air and headed for the trauma center north of us I collected my equipment and headed back to my station through the heavy traffic. It took me close to half an hour to arrive back at the ED to restock supplies and put new batteries in my monitor.

Just as I finished the next call came in. “Head on motor vehicle crash, multiple calls reporting serious, helicopter requested” way at the northern border of our service area. Shortly after I signed on the call went out for an additional ambulance with the report of three patients. I requested that another paramedic be added to the assignment as well and Medic 3 was dispatched from his quarters

Arriving after the first in engine and the rescue I found that the scene was fairly chaotic. A severely damaged SUV was closest to me with the rescue crew working with heavy extrication tools to force entry. A volvo station wagon was further down the road with personnel around it but access already gained. I was directed to the SUV where the patient was reported to be unresponsive and severely injured. Medic 3 would be second in paramedic and go to the other vehicle.

The only patient in the SUV was a male in his forties entrapped around the legs in the drivers seat and laying across the center console and into the passenger seat. A firefighter had already managed to squirm inside through a broken window and was keeping his airway open and stabilizing his cervical spine at the same time. He reported to me that the patient still had a pulse and was breathing about 12 times a minute. I could see that he had a large abrasion on his scalp with an obvious deformity. Reaching through the broken window I could examine the upper body and see that aside from the head injury the patient had deformities to his chest and what appeared to be a huge laceration the upper right bicep with a accompanying avulsion and significant abrasion to both the skin and the underlying tissue that left no guessing that his arm had been outside the vehicle at some point during its rollover and skidding across the road. His pulses were present at the neck his breathing while noisy was present and seemed to be adequate for the moment.

Disentanglement was proceeding at a good speed and in a couple of minutes we were able to get the passenger side of the vehicle open and extricate him onto the long back board. I could hear the helicopter circling overhead evaluating the landing zone that had been set up in a nearby parking lot and I could also hear that the patients respirations were becoming much less regular and much more noisy. I tried to open his mouth to put an oral airway in but his teeth were jammed together and his jaw clenched so tightly that I couldn’t even move it. His heart rate was climbing he was deteriorating rapidly. With the help of an off duty ED nurse from the trauma center I was able to get a good line in place and draw up the medications for Rapid Sequence Intubation (RSI) where I would paralyze the patient so that his jaw could be moved and I could intubate him.

The medications were administered and his jaw was still clenched, it took over a minute for the medications to take effect and during that time the patients heart rate started to fall gradually. After the first intubation attempt I gave the patient some atropine to bring his heart rate back up.

The intubation was a nightmare. His moth was full of vomit and a brown liquid that smelled so heavily of alcohol that breathing it made me feel lightheaded. We suctioned him almost continuously for thirty seconds to clear his airway enough for another intubation attempt. I viewed the cords and with the assistance of the ED nurse who provided cricoid pressure (pressure on the larynx that moves the vocal cords down into view and blocks off the esophagus to reduce vomiting). The tube passed easily, too easily as it was because when I removed the stylet and the bag mask was squeezed a single time vomit started to flow up the tube. I pulled it quickly and went back to the suction.

At the same time the flight crew arrived which gave me an additional set of trained hands which I desperately needed. The patients heart rate was continuing to fall and I had just ordered CPR to be started as I could no longer palpate a pulse at the neck. The monitor showed electrical activity but there were no pulses that we could feel. With the flight crew starting to manage the impending cardiac arrest I was freed to focus entirely on the airway.

After more suction, more cricoid pressure, my throwing myself prone on the ground, and a lot of concentration I was finally able to get a view of just the bottom edge of the vocal cords. With a little manipulation I was able to get the tip of the tube to that point and started to pass it. I met a lot of resistance once I got the tip beyond the cords. It almost felt like the tube size was too big but I was using an average size for an adult male. It felt like minutes before the tube passed beyond the cords and I was able to secure it. I know it was only a fraction of a second but since I was holding my breath at the same time it felt like much longer. (I had gotten in the habit of holding my breath while intubating long ago, the reason being that if I feel like I need to breath the patient needs to breath as well and I need to either finish placing the tube quickly or terminate the attempt and breath for them for a while.)

With the tube passed and the flight respiratory therapist securing it to his satisfaction I listened to breath sounds to confirm placement. Problem. Breath sounds were present on both sides but so were sounds in the stomach area. We hooked the capnography onto the tube and had good waveform. Frank blood was suctioned from the tube and now there was some misting on the inside of the tube as the bag was released and the patient exhaled.

Things were looking pretty grim and I was surprised a little when the flight crew called for the patient to be moved back to the aircraft. I honestly was thinking that at this point the patients injuries and condition was incompatible with life and that they just might call the trauma center for permission to terminate all resuscitative efforts. Instead they were making ready to load. Even if they transported the patients probability of survival was extremely slim. My suspicion was that his injuries were so severe that had the crash happened on the doorstep to the operating room it would still be highly unlikely that he could survive them.

With the aircraft airborne and heading north again I went back to the scene to see if anything else needed doing. Medic 3 had already left the scene with two patients ALS by ground to the same trauma center and the police were already busy measuring and marking the scene.

I was a little disturbed when I got back to the SUV and found that the shoulder of the road was littered with children’s magazines and that there were two car seats in the back seat configured for small children. The police and fire department had already done a thorough search of the area to make sure that there were no children ejected out into the bushes for us to miss. I whispered a silent prayer of thanks when they reported that nothing was found.

By this time I was already tired and drenched in sweat. I needed a cold drink and a clean shirt at least and preferably a hot shower to go along with that. I settled for some lukewarm water from the rescue and a towel from one of the remaining ambulances. It wasn’t even 2200 yet and I was ready to go home.

Things didn’t slow down much after that, although I didn’t have need to see the flight crew again after three times in twenty-four hours (I was beginning to wonder about referral fees). The calls kept coming. It was almost 0600 before I was able to park the vehicle for the final time before 0700 and start to work through the remainder of the paperwork that remained.

I was pretty happy that morning was approaching even though I knew that officially I had no relief. I was hoping that one of the other paramedics would decide to come in even for just a few hours to cover. In the end I was there until a little after 0900 due to the mountain of paperwork that I had to get through. I would have stayed linger to provide coverage until I reached my 16 hour threshold but I could barely stay awake.

My bed was calling.

Total calls for the night: 11 
2 ALS turned over to the air ambulance 
1 ALS transport 
2 Cancelled enroute 
1 Cancelled upon arrival 
1 Unable to intercept

Milage for the night 247

Music for the night: XM 73 Beyond Jazz

A half day of school for the kids today so that the teachers can have a “Professional Development Day”. For me this is a good and a bad thing. It’s good, since my youngest, who goes to half day kindergarden in the afternoon, went to school earlier than usual. The bad part is that the three of them got home a couple of hours earlier. The end result is that I got to sleep earlier but didn’t get to sleep as long. I had hoped that I would have been able to doze on the sofa for a while but that didn’t happen.

My oldest had decided that she wanted to play a musical instrument in the school band and today was the day that the instruments arrived. There was no way that I was going to get much sleep with a new (untrained) trumpet player in the house.

The end result is that this is going to be a pretty awful night especially since before I knew it was a half day of school I had agreed to come in a couple of hours early.