The MacMedic

I wasn’t supposed to be in today. I had planned on taking my dog to puppy school graduation and then spending the afternoon mowing the lawn and cleaning the basement but fate (and the fact that I can’t let a shift go uncovered) conspired against me and when the day guy called in with a family emergency I volunteered to fill the shift after I got back from puppy school.

Only one call during my shift and that one only required me to transport to qualify the crew to our organizations standards. The call was for a fall in the alzheimers unit of a local facility. The patient was, as far as anyone could determine, uninjured but the staff felt he should be transported “just to be sure”.

That was the only call during my shift and I actually crashed a little early. It didn’t last however. I had forgotten to turn my pager to “off duty” mode and heard the ambulance and duty paramedic get sent to a possible carbon monoxide poisoning. Before I could get across the room to change the setting and silence it the dispatcher updated the responding units to the fact that there were three patients “in and out of consciousness”. The duty paramedic requested a second ambulance, another paramedic and an engine company.

Since I was up already I changed quickly and headed for quarters to get the second ambulance. When we signed on the fire chief was just signing off on scene. Two minutes later we arrived on scene and I called command asking where they wanted us. The response I got back, “One step at a time 315″ was totally confusing and made no sense at all. Ah, OK. We parked just outside the perimeter of the scene and waited for some directions. The

I really didn’t start to feel like myself again until last night. I still felt a little wiped out this morning but well enough to work today. Good thing too, it was a delightfully busy day.

The day started around 0900 with a call for a post ictal female who had had a “hard partying night” and 30 seconds of seizure activity this morning. She had a history of a seizure disorder and had a seizure every couple of months but this was less than a couple of weeks after her last one. She responded really well to supplemental oxygen and had no further seizure activity on the way to the hospital. I put a saline lock in and drew blood on the way in but that was the extent of my ALS.

On the way back from the hospital we were dispatched mutual aid to a neighboring town for a fall from a ladder. It wasn’t clear from the dispatch if we were responding to provide a paramedic or if we were going to be the transport unit. It wouldn’t make all the much difference but we were curious. We arrived to find that we would be the transport unit for two patients who were in care of personnel from the local ambulance who was not on scene for some reason.

The fall from the ladder was not anywhere near as exciting as it sounded on dispatch. It turns out it was only from a few rungs up and, at worst, one patient may have had a broken collarbone. He insisted on walking to the ambulance and repeatedly denied any other injury and refused any offer of pain medications. Actually worse off than him was his wife who had been holding the ladder when the dogs gave out causing the fly section of the extension ladder to slide downward forcefully. She sustained deep lacs to both of her thumbs. The bleeding was controlled and she had no other injury.

My partner was a basic EMT who always wants experience and asked if he could be in the back with the patients. It would be the first time he priovided care to two paitents in the back by himself. Neither patient needed any ALS so I agreed and he climbed in and I started to drive to the hospital. The drive was uneventful except for listening to the second due ambulance head out for another seizure call. We arrived at the hospital and worked hard to make it an “in and out” so that we could have an available ambulance back in our service area again.

It was a good thing too, we had barely gotten back in quarters when we were dispatched for another seizure. This one another frequent flier. We arrived shortly after the fire department intermediate crew did and found a diabetic patient in bed with a glucose of 25 mg/dl. Pretty low but she was awake and trying to take glucose paste by mouth. She wasn’t extremely cooperative but we were already set up to get her down from the second floor so we evacuated her to the ambulance.

Once in the ambulance and out of the clutter of the house were able to get a teeny tiny IV established on the side of one of her fingers, usually we end up having to look around on her feet, and slowly, very slowly, adminsiter some 50% Dextrose solution which pretty rapidly brought her back to her normal (nasty) self.

By the time the ambulacne was clean, we were back in quarters and all the paperwork was done it was close to 1700 and I got home in time to have dinner with my family and go for a walk with the dog to relax after my shift was over.

The shift started a little early with a tone being dropped around 1730 for a paramedic to respond to assist the Intermediate level ambulance at a “55 and older” condo community right behind my house.

The fire department paramedic unit was on scene with an elderly male vomiting blood and was asking for paramedic assistance. It took me no time at all to get there, literally I could look into my back yard from the scene (and my wife and kids would walk right by my car on their usual dog walk after dinner). I walked in to find a male in his eighties vomiting coffee ground textured and coloured vomit which had the unmistakable smell of a GI bleed. He related a sudden on set of nausea an hour before after which he went to bed to see if he would feel better with rest and suddenly started vomiting just before the call was made to 911.

Unlike my last call there was no doubt in my mind that this was a GI Bleed and after the fire department finished starting an IV we moved him out to the ambulance and headed for the hospital. The patient stated that he actually felt much better now that he had vomited a couple of times. I’m not surprised but knew that it wouldn’t last long.

What was most odd about this call was the fact that a paramedic had been requested at all. I, honestly, brought nothing to the table that an experienced EMT-Intermediate wouldn’t. I knew the reasons, of course, it was the same reasons that causes the same fire department paramedic to call for our paramedic to transport multiple times months. This paramedic has not trust in the competency of any Intermediate and will not, ever, release an ALS patient to an Intermediate. The other reason is more a political one. He, along with the fire chief, fell that EMS is best done by the fire service (surprising since this paramedic works for a hospital based EMS on his days off) and goes out of his way to try to commit our paramedic to calls so that when a second paramedic is needed and it is delayed or unavailable he can point to it and show just how unprepared we are to fill the role of primary paramedic and EMS responder in the town. I am told that this has been an ongoing battle for years and that it is this paramedics personal crusade as most of the other personnel on the fire department want to do as little EMS as they can get away with.

It’s a little frustrating when these things happen and I suppose I could have tried to downgrade the call to the Intermediate. The problem is that he insists that if the paramedic from the ambualcne doesn’t go, he will, and the ambulance will get charged for his services. Sometimes it is easier to just roll with it than argue. In this case the decision was easy as I knew that there was another paramedic in the station already and that we woudl be all set for the next call. I made it clear to the Intermediate on the call that as far as I was concerned it was his call and he was in charge and that I was only there to be an extra set of hands if he needed them. He didn’t and I sat in the captains chair and watched out the back window as we took an uneventful trip to the ED.

The only other call for the shift came in around 2200 for a seizure in one of the dorms. It was a familiar address, we had been to the same dorm, floor, and room for a hypoglycemic diabetic a few times already this week. As strange as it seems we do see these type of calls close top the end of the school year. As students deplete their meal accounts they tend to eat less than they should and our calls for diabetic related emergencies increase.

I pulled up just after the ambulance got there but was cancelled as I climbed the stairs to the third floor by the fire department paramedic who had arrived on scene 3 minutes before me. It felt a bit odd to be cancelled so soon so the ambulance and I waited in the parking lot until the FD unit cleared the scene just to be sure.

Thankfully the remainder of the night was quiet and uneventful. I have an important meeting this morning and really needed the sleep.

I screwed up last night. Not bad, not in a  patient care standpoint, but from an organizational policy standpoint. My first call of the night was for a man in his fifties who was dizzy. The crew on the ambulance was competent and I didn’t bring anything to the table that the patient needed. So I left the senior crew member in charge to transport the patient to the hospital for what I was pretty certain was labyrinthitis.

What I didn’t remember was that the crew, while legal as far as the State was concerned did not meet the rather convoluted standards that the organization demands. I will have to fall on my sword on Monday before my mistake is discovered and people make a bigger deal out of it than it needs to be. The fact of the matter is by my not transporting with this patient I was available for the next call which actually needed ALS.

The next call was for a elderly male vomiting blood and syncopal in his garage. I headed for headquarters and picked up the second due ambulance hoping that a crew would meet me on scene. Two members signed on almost immediately responding to the scene. They would arrive before I would just because of the location of the call and where we all were coming from.

I arrived on scene and after parkign the ambulance was directed into the garage where I found the patient, a male in his eighties being propped up by one of my crew members while he vomited dark red blood and clots from his mouth and nose. It was a significant amount of blood but did not have that unique “I’m bleeding into my gut” smell so I was still unsure as to what was going on.

We moved the patient into the ambulance to assess him further where we had some better light. He related a sudden onset of a nosebleed a couple of hours before which had just not stopped and had been bleeding into the back of his throat since then. This fit with my observation of the lack of the GI Bleed smell that I noted in the garage, probably all from his nose. His blood pressure was fine but what I found very strange was the slow (in the 40’s) irregular pulse. While one of my partners put a large bore IV in I put the patient on the monitor and found that he was in Atrial Fibrillation (A-Fib) with a very slow ventricular response. I knew from his medication list that he had a history of A-Fib but even he said that his heart rate was never that slow. The patient was a retired internal medicine physician so I took for granted that he would have some idea what his normal would be. The rest of his exam was unremarkable and a quick 12 lead ECG showed nothing unusual. He vomited twice more on the way in but remained otherwise unchanged. I was still quite impressed with the amount of blood he vomited and how well he was maintaining his blood pressure.

That was the extent of the night, after getting everybody back to their vehicles and the ambualnce back to quarters I was in bed and asleep by midnight and didn’t get woken up until almost 0600 when the dog decided that he wanted to get up and go out side to “do his business”.

A night with no calls and several hours of good sleep. The only thing that would have been better would have been some significant interventions.