The MacMedic

I heard back from my supervisor who in no uncertain terms told me that intubation was most definitely part of my scope of practice both outside and inside the hospital. It seems that this particular respiratory therapist has been pushing to have respiratory therapy allowed to intubate patients.

Another 12 hours in triage. It’s kind of strange, when I first started working here I hated being in triage for any time at all. Now, I prefer it. I prefer it because it gives me the autonomy to make decisions on my own and makes me feel like I am actually doing something that requires thought and understanding of patients and their conditions.

Just because I am in triage does not mean that I don’t have to leave for other purposes. Frequently it is just a quick trip to the ambulance bay to use my finger to open the biometric lock on the replacement supplies although on rare occasions it is to take a call with the Rapid Response Team. The Rapid Response Team (RRT) is designed to respond to medical emergencies in house. Any patient who has a significant change in their status meets the criteria to activate the Rapid Response Team. At this hospital the RRT is comprised of a paramedic, a CCU nurse, and a respiratory therapist.

Initially my experiences responding to RRT calls was horrible as the orders in place didn’t allow us to do much. That has changed and we finally have a broader set of guidelines, there are still significant gaps in what we are allowed to do autonomously, that allow us to function prior to arrival of or consultation with a physician. Tonight we were called to one of the med/surg floors for a patient with respiratory distress who had a sudden decrease in his mental status. The patient was not maintaining his airway well at all and it was clear to almost everyone there that the patient needed intubation as soon as possible.

Although there was a physician in the room, one of the hospitalists, they apparently are not able to intubate so the ED was called to send a physician up to the floor to intubate. Unfortunately the ED had just received two trauma patients and the physician would come but he was not going to be immediately available. The hospitalist asked if anyone could intubate and I responded that I could. He asked me to proceed and intubate the patient. It was at this point that the respiratory therapist spoke up and voiced his objection to my doing the intubation. He preferred that we wait for the ED doc to come even if he was going to be delayed arguing that intubation was NOT in my scope of practice (his emphasis, not mine). The CCU nurse was already drawing up the Versed and Succinylcholine and the hospitalist left the room. The therapist continued to voice his objection as the meds were administered, the patient was paralyzed, and I intubated without difficulty. Reluctantly he secured the tube and started to bag the patient telling me that his boss would hear about this in the morning.

I’m not sure why he felt this was such a big problem. I have been intubating patients for over 2 decades and it is pretty clearly in my scope of practice outside the hospital. Still, knowing how hospital politics can be, I shot a quick email off to my supervisor explaining the situation and outlining the respiratory therapists objections. Better to be proactive and let her know  before she gets blindsided by a complaint from another department.

Other than that the remainder of the night in triage was quiet and unremarkable.

It sure didn’t seem like a busy shift but we spent very little time actually in quarters. My partner and I had just finished running the daily errands when we heard one of the Fire Towers calling in a smoke column to the dispatch center. The first alarm assignment rolled out the door to go search for it. It took them a while to actually find it and once they did the calls for additional forestry units went out and my partner and I looked at each other thinking that it was only a matter of time before we would be sent to standby.

We had no sooner finsihed saying that to each other and the tone dropped sending us to stage for the fire standby. For the next 5 hours we sat in the staging area a mile away from the actual fire scene. It was strange, normally the first in EMS crew would be setting up a rehab area to rehab and monitor firefighters but this time we were simply told to stay put and had little to do except listen to the activity. It was quite boring. After two hours I was pacing around the ambulance looking for something to do. After three I felt like I was starting to go crazy. By the time the fourth hour ended I was out of my mind with boredom and actually to the point of reading the HIPPA brochure. Finally we were released to go back to our quarters. I was so releived to be off the standby and swore that I would never leave quarters without a book or magaizine in my bag again.

The remaining hour and a half of the shift were uneventful and taken up with finishing the tasks that we didn’t finish during the morning. At 1900 it was time for me to change hats going from the day ambulance staff to the night duty paramedic. I’m wondering if the ngiht will be more interesting than the day was.

I feel like crap. My plan to work around the house for the morning and sleep for the afternoon would have worked really well except for one thing. I didn’t sleep well at all. I woke up with every little noise which, with the kids home on April vacation, was often. By the time 1700 rolled around and I had to get up I was pretty well wiped.

I seriously thought about calling in but decided that I would rather have the money so we could afford some of the landscaping and projects around the house that we had been discussing.

The ED was chaos when I got there more because of the staff that was working than the patient load and once the night staff settled in and the day staff went home things leveled off quite well. I did my best to the things that needed to be done, stay out of the way of the Chairman of Emergency Medicine, and make sure that my gear was set for the night.

Only one call for the night and that came in around 0100 for a pregnant woman who broke her water. No contractions yet and the ambulance canceled us when we arrived.

The night absolutely dragged. By 0400 I was having a very hard time staying awake. The clock seemed to have stopped moving. It did eventually move and 0700 did eventually arrive but it seemed to take forever.

I don;t remember much of the drive home, a fact that I find a little disconcerting, but now that I am home I am headed to bed to get some sleep.

I covered a paid day shift at the ambulance today. The paramedic that normally works Monday took a vacation day. I enjoy these shifts for so many different reasons. It’s close to home. I get to work with the volunteers. I actually get to do calls on occasion and it’s a good chance for me to get paid to work on my projects.

Today was no exception. I spent the morning and the first part of the afternoon working on the specification for our new ambulance. I was able to crank out about 12 more pages of the spec and was really happy how things were going. The paid EMT-I that was working the day shift had to leave early for his polygraph test so he could get hired by the fire department (and hopefully open a position here for me) so the afternoon was staffed with two volunteers.

The only call of the day shift didn’t come in until almost 1700. We were dispatched to a possible stroke at a home near what was formerly a major business in town. We arrived at the same time as the fire department to find a male in his mid-eighties seated on a sofa in an incredibly cluttered living room, well incredibly cluttered house to be truthful, with no real complaints. The family was relating that the patient had fallen last week and fractured a rib, was seen and discharged. This morning he was just seeming weaker than normal to them and more confused than normal. He had been incontinent of urine being either too weak to rise or unaware that he had to urinate. The patient himself seemed quite pleasant and was oriented to the usual person, place, and time but was very unclear on why we were called there, how long he had been on the sofa and who we were.

His wife was seemed pretty much equally as oriented and just as poor a historian. His exam was unremarkable with an inconclusive stroke screen and normal vital signs. There were clues that the patient had been on the sofa for quite a while. The bowl full of urine on the floor and the smell of ammonia when we stood him up to put him in the stair chair to try and get him past the clutter and out to the ambulance.

In the ambulance I started an IV and drew labs while one of my EMT partners put the patient on the monitor. A quick check of his glucose was 225 mg/dl, higher than normal but not too bad. For the remainder of the trip to the ED the patient and I chatted pleasantly about his younger life as a prominent businessman in the community and how the town had changed over the years. In this regard we was quite sharp being able to recall things from the past with remarkable clarity. Still, he was unable to recall who we were or why we were taking him to the hospital.

We turned him over to the ED staff, restocked and cleaned up the ambulance and were on our way back to quarters. On the way back I couldn’t help but think about the patient, his condition, and the conditions he was living in. I wasn’t sure if he was having a stroke of some kind, or was just suffering a sudden deterioration of his mental status due to aging or some organic syndrome. Either way I felt sad that a man that had been such a prominent figure was living in appalling conditions without anyone to watch over him but his equally frail wife. I’m not sure of it is unreasonable or not but I always seem to end up thinking about what I will end up being like at that age and worry that I will be demented (more than I already am), infirm, or alone. I guess nobody knows what old age will bring.

That was the only call of the shift and I am finished on time and ready to change hats from paid ambulance crew and to the on call paramedic for the night shift.