The MacMedic

Three night shifts in a row and all of them the same. In the ED all night, busy but nothing exciting. I sure wish I could be this busy outside the ED.

The ED was rocking all night long but I spent my night in triage spending more time dealing with people ticked off by the long wait time than doing anything even remotely resembling patient care. At one point the full-timer that left a couple weeks ago stopped in to clean out his locker and spent a minute telling me about how great it was to be busy again and to work somewhere where you are spending all of your time doing EMS work instead of just a small fraction of it. Yeah, rub it in.

Another rousingly exciting 24 hour shift (not really). As usual lots of cancellations and one transport for each of us. Neither of them were spectacular calls. My partner did a hypoglycemic diabetic who had been woken up by an EMT-I after an amp of Dextrose but “wasn’t comfortable” transporting without the paramedic on board. Mine was for a gentleman who, upon review of his holter monitor for the past 24 hours had had a 6 second sinus pause at some time the previous day.

I’m finishing the shift with a feeling of accomplishing nothing.

12 hours, two calls, both of them transports, both for different reasons. the first call was for a fall victim at an assisted living facility. No ALS was required but, as happens more often during the summer, the crew was light and I needed to fill it out so that we could do the transport. I was able to do something that I don’t do very often, drive to the hospital.

The second call was for a male in his 50’s with an elevated temperature. Normally I would have wondered why call 911 for a fever but this time it was much more reasonable. The patient has ALS, more commonly called Lou Gehrig’s Disease and had a trach and was on a constant ventilator. The cause of his 103.2F fever was clearly evident when I saw the colour of the urine in his foley catheter bag. Clearly a big infection going on there. The transport itself was uneventful. I started an IV of saline KVO, drew bloods (no cultures unfortunately) and gave the patient some Tylenol under our guidelines for fevers above 101.5. I did deviate from the guideline a little bit. The patient has a feeding tube and takes nothing by mouth. the guidelines don’t really mention this situation so I winged it a little and gave the liquid Tylenol through the feeding tube with a saline flush. I don’t think anything will come of it and I think it was the right thing to do for the patient and by the time we left the ED after paperwork his fever was already starting to come down.

The ED was cranking when I arrived but slowed down to a crawl by midnight as all of the patients were either admitted or discharged. The remainder of the night was slow with patients coming in at a rate of 1 or 2 an hour. Much of the time the all of us working were falling over each other to find something to do. The charge nurse was nice enough to cut me loose at 0600 so I could get home for my duty paramedic shift at 0700.

My second night shift as the duty paramedic for the volunteer ambulance in town and my second night with no calls. this is fairly typical during the summer when the university is not in regular session. Fall is coming and with it will come a higher call volume and a new influx of student volunteers. I am actually looking forward to it since I really enjoy working with the students and helping them learn EMS. I’ll be the duty paramedic on Saturday for the say shift and we’ll see what happens then.

Another 24 hours, these long shifts are getting old (or is it me thats getting old?). 12 calls total with a single transport for shortness of breath that resolved with a single nebulizer treatment. According the the State Patient Care Guidelines this type of call could conceivably be done by an EMT-I without a paramedic at all. Of course I’m glad that they didn’t choose to go that route or I would have had no patient contact in the field at all.

I picked up half of a day shift at the local ambulance since the normal paid paramedic for fridays was on vacation. No calls but I was able to get a large amount of work done on some projects. The first was just ordering the hardware and software to update the programing in the AEDs that we have placed in the local schools and with some of the first responders. It took longer to find the right person to talk to at Physio-Control than it did to actually place the order.

The other project was a bit more time consuming. In next years budget we need to add some clinical hardware and I drew the project to get information and make recommendations. The three items that we need to get are IV fluid warmers for each vehicle, IV pumps, and some initial information on Carbon Monoxide monitors for use on patients.

Being in an even more northerly climate than I have ever been in in my career the ability to have warm IV fluid has become even more important than before. Currently we have only a few bags of fluid sitting on top of a heating pad. Not very effective and not very portable. After looking around at what was on the market I decided to recommend the Soft Sack IV Fluid Warmer by Smithworks. It looks nice and from the people I have called and asked they have been reasonably happy with them. It seemed to be the best option that I have found.

After reading several articles on “pulse oximeter like” carbon monoxide meters and the importance of CO monitoring in the field we decided to investigate what was available. The unit that seems to be talked about by most of the articles was the RAD-57 by Masimo. It looks like a fantastic unit. A teeny, tiny problem, to get 2 of them would cost almost $5000. A bit more than we have in the budget. I get the feeling that these won’t be coming in this years budget (or the next years if the price doesn’t drop).

As beneficial as the first two items would be the third is the one that has to happen, and probably should happen even sooner then the next fiscal year. In the latest version of the State EMS Guidelines it was stipulated that IV drip medications MUST be administered via an IV pump. The service chief here arbitrarily decided last month that when our current stock of premixed drip meds expired in October they would not be replaced until we have pumps for each ambulance. I can certainly understand trying to comply with the guidelines (it’s more than my full time job has done in this regard) but if this actually were to happen we would lose many of our antiarhythmics and all our vasopressors. This, obviously, is not a situation that is tolerable so this purchase has become a real high priority since I think that an emergency purchase order may have to be issued in order to purchase these before the deadline that has been set by the chief.

After talking with the most active of the paramedics I got a list of what they felt was important in an IV pump. Small, lightweight, able to calculate the drug calculations when the concentration and patient weight are entered, and the ability to handle more than one drip at a time. We tried to come up with a situation where we would need to have more than two drip meds going at the same time and couldn’t come up with one so most people thought a 2 channel pump would be ideal. Me? I would prefer to have an extra channel as a spare in case one of the others failed. I may be overly cautious when it comes to this but during my time doing CCT work for the “Big Red Machine” I had pumps fail or go into maintenance mode infrequently but more than made me comfortable.

After looking at what seemed like dozens of pumps I really saw only one that had everything that people were asking for, the Alaris MedSystem III. While some people may feel it is overkill it was the best unit I could find that met all of the needs that people felt were important. I asked the company to contact me with pricing information for inclusion in the next budget and a possible emergency acquisition. We’ll see how expensive new units are. I did manage to find some refurbished units for under $2000 each but before I recommend a refurb I want to have prices on a new one for comparison.