EMT Change of Scope

The state I live in has just decided to remove Pulse Oximetry from the EMT-B and EMT-A scope of practice. (Click the link if you want to know what it is.)

This issue has really upset a lot of my coworkers. I understand the logic that if a pulse oximetry reading comes back unusually low then the patient should be cared for by a Paramedic rather than a Basic. But, a Basic can give a patient Oxygen and a Pulse Ox is how you can measure the effectiveness of your treatment. Plus, we all are trained to understand there are situations where the reading should not be trusted. (Those suffereing from Carbon Monoxide poisoning will read higher than they actually are.)

What I am worried about is that an over-reaction will occur and EMT-Basic's will not even be able to get this information as part of collecting vital signs. It's non-invasive and currently we tend to rely on your Basic's to collect this informaiton for us when we first arrive. This allows the Medic time to collect more of the "big picture", interviewing the pt, etc.

I am really wondering how this is going to play out...

some good moments

I had two patients recently that thanked me for what I had done. I've had other people say thanks..but these two really seemed to mean it.

I also had a senior medic compliment me on my IVs. This really felt nice because I really stress about this. I had so much trouble as a student learning this..really I know HOW to do an IV. I just had A LOT of trouble being conisistant. So, though my hands do still shake a little, I am not letting it bother me and I am able to get a good IV the first time almost every time. (There are always those patients that are near impossible to get IVs on.)

Anyway...I remembered this post from the past:
http://midwestmedic.blogspot.com/2005/09/i-am.html

My community has had some tragic events recently and the fire department and police were recognized in the media. The hospitals were also focused on greatly. But, again the medics and emts were not really metioned at all..even those whose homes were barely missed yet will out there saving lives. I am not sure this is the fault of the media...it seems like my agency might have missed an opportunity to show the public what we do. I don't think we even designated a public information officer to help coordinate information to the public...never mind public relations.

For Mom

This is from another blog I read, but it did make me remember the times I have visited my Mom. I do not agree fully with this list, but it is a good list none-the-less.

"Since anyone remotely proficient with a computer becomes the official household IT person when they go home for the holidays, Top 10 things to do for mom's PC over Thanksgiving"

11 runs in 12 hours...

OK. Last night did not fit the slow November mold. Most of the runs were no big deal stuff. There were a couple of chest pains but over all it was just sick people who were not following doctor's orders and think that going back to the hospital AGAIN will some how cure them.

Looks like cold and flu season is starting. My shift's number one dispatch code has gone from the usual "difficulty breathing" to "Sick Person".

Survival until discharge

My partner and I tried to visit our cardiac arrest patient from last week. The problem we had was a good one...she has already been discharged from the hospital. I wish I knew if she had all her mental capabilities restored. I'm wishing her the best.

short notes

November is the slowest month at my service. This is normal and is expected. Two nights ago, I only had two runs in 12 hours. Last night, I had 6..one of them a refusal. The whole service has only been having 50-60 runs in 24 hours. This is nuts compared to last month when we had a day with over 100. Mind you, I'm not complaining at all. Just a crazy change of pace.

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I really hate having to work two jobs. I got off the ambulance at 0600 this morning. I started at the computer job at 0700. The thing is, I like 99% of the people I work with there, it's just all the repetative questions about things like "how do i find this web page". But, what really gets me is the amount of stress some people get over things like paper jams. I suspect they do not like my "hey, it's not like somone is dying" attitude. But, really, there is a big difference. I fix the paper jam and move on. What was that? 15 minutes were they had to walk a little futher to get their print out?

I am so ready to quit. Right now, I am thinking it will be the end of January...

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Update on my first code:

She's off the vent..out of ICU and talking! I got this update last night. Obviously, the hospital had a lot of work on their hands and the patient had an angel watching over her. I do not work again until Friday. Hopefully, my partner and I will have time to check on her at the hospital.

It would be nice to actually have my first code as a medic actually survive to discharge!

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Thanksgiving: Not my favorite holiday. I honesty feel trapped at the realtives for hours longer than I want. The thing is, my wife LOVES the long holiday stuff. I try my best to breathe as little second-hand smoke as possible and not swell up from all the cat dandur. I do love tryptophan... it gives a good excuse to nap..even if it isn't the cause of the mid-day slumber. (article)

This Thanksgiving will be different..as will Christmas Eve with my wife's uncle, my mother-in-law's twin, passing away yesterday.

I expect to be there from noon to evening...and I'll not complain...i don't need to..my wife knows how I feel. But, I'll be there for her. That's why I do it evey year anyway.

Seven Long/Short Weeks

From the wife's blog:

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Seven Long/Short Weeks
Current mood: drained

Seven weeks.... 49 days... that's all it lasted.

My uncle passed away yesterday. Seven weeks exactly from the time he was diagnosed with cancer. Seven weeks....

My mom got a call from my aunt on Monday. She needed her to come down there. When Mom arrived, my uncle was sitting on the edge of his bed. He had been for a couple of hours. Just sitting. His pain too great to move. With the help of hospice (wonderful organization, by the way!), they finally got him into a hospital bed in the living room. They catheterized him and informed my aunt and mom that this was it. They expected him to pass by early Tuesday evening. My mom spent the night.

Yesterday was a waiting game. Every time my phone rang at work, I jumped. At 3:30, my sister called me. My uncle's suffering was over. He had passed away 15 minutes earlier. Mom wasn't doing so well and I felt the need to go be with her and my grandmother. I finished up the imperative items at work and left about 25 minutes later.

I entered the front door. There, in front of the fire place, was the bed and my uncle. My mom was standing just past the entry way. I hugged her and told her I loved her. She had hyper-ventilated, she told me...and was so embarassed that she fell apart. I told her it must be the twin thing - she was probably trying to breathe for the both of them.

In the kitchen, Grandmama was talking with my aunt's mom. When she saw me, she sobbed. I tried to console her - but what do you say to someone who just lost a child? Doesn't really matter how old that child is...burying your child does not fit what we think the natural progression of life should be.

The funeral home staff arrived a short-time later. We were asked if we wanted to say our final goodbyes. My mom was first. I was back holding onto Grandmama. How she didn't collapse is beyond me. Grandmama leaned over, told him she loved him and to be watching for her when God called her home. Tears fell freely from my eyes. Can't imagine telling that to one of my children! We left the room and let the funeral home do their thing.

The best part of all this is that his pain is gone. He was right with God. There was no question where he was going. Our sorrows will eventually lessen. We will miss him, but the pain will be softened. And tomorrow, tomorrow on Thanksgiving, we will be thankful. Thankful for the memories we have and for the life we shared with him. And my uncle? He will be having the best Thanksgiving he's ever had!

I love you, Ronnie! Save us a spot at that Thanksgiving feast!

Uncle Ronnie
June 18, 1943 - September 22, 2005

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if you could just pick up and move...

Where would you go?

I've lived in a number of places during my not-so-long life. Luckily, a few of those moves included moving to places that most Americans just dream of vacationing. Plus, some of those moves went quickly from planning to reality. But, back then I was young, single, and everything I owned could fit into my 1985 Ford Tempo (plus a carrier on top).

Any future move would be a much bigger deal.

My wife was born and raised in the town we currently live in. She has joked in the past that she would move if it meant she could be a stay-at-home mom wherever we went. I pretty much took that as her way of saying my dream of moving is as likely to happen as her dream of being a stay-at-home mom.

As I suspect with any family, the children, jobs, and home are the main issues if we ever move. Our kids are 21, 15, 6, and 5. The 21 year old is about to get married. Our 15 is in high school and I agree that we should not move until she after she graduates. She's doing well in her high school and I am not sure she would handle a move that well...the whole teenage "you ruined my life" routine is not something I want to deal with. Our younger ones, 6 and 5, are just entering their school age years and though I am sure they would miss many things I believe they would find new friends easily and adjust just fine.

Jobs? My wife works for one of the top 5 employers in our area and has slowly worked her way into some decent pay. Moving could be an impact on her employment. Her employer has "branches" in other areas, but they are not quite the same job and not always available. This goes back to her stay-at-home mom argument.

My job, heck, I am in EMS. Nicely, there are Paramedic jobs all over the place. Sadly, some of the areas I like only have volunteer services. The thing is, I like rural areas...makes it even harder for jobs. This is one of the few reasons I would consider bridging over to nursing. A LOT better pay and jobs almost everywhere. But, to stay sane, I really would only consider a flight nurse position...but then I would really prefer to be a flight medic.

House? Yes, there are homes all over..but where we currently live the home prices are MUCH cheaper. This area has a very low cost of living and moving OUT of this area as opposed to those moving IN, have a lot harder financial burden. A family of four can easily find a home (not new, but nicely maintained) for around $100,000. How many areas can say that?

Why am I think about this tonight? Why am I bothering to blog about this?

I just comes to mind now and then, but there have been to recent things I have seen online that made it come out of the depths of my mind.

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Anyone consider moving to Kalamazoo, Michigan? I have not until I read this. Mind you, I would definitely check out the school districts first...but look at this for a long term bonus for your children: The Kalamazoo Promise.

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I took this test a year or two ago and got predictable results. But, somehow it has floated around again and someone forwarded me another email about it. It's an interesting survey that matches you with locations that fit your criteria and how you describe yourself, your likes/dislikes, etc.

http://www.findyourspot.com/

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Where would I move? I personally like rural areas but mostly small towns and those resort communities where the population quadruples in a certain season. I can handle the crowds short-term. But, I tend to like the folks who are there when the place is all closed up. I am sure there are towns like this all over the US. But, I tend to favor the northern states because I like the transition area from Hardwood forests to Boreal (northern evergreen) forests. Also, since I grew up in Michigan, I do like having water nearby. I don't really care about beaches. It's more the water, rivers, and lakes I like. Maybe I would like New England, but I have yet to visit there. Currently, I prefer the "pinky" of Michigan....http://www.mytraversecity.com/. And my current "favorite place on the planet" is Isle Royale National Park in Lake Superior.

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So, back to my original question...

If you could just pick up and move, where would you go?

I don't try to let reality get in the way of thinking where I would go, so please don't let it stop you either. Please post a response and let us know. Or at least go to the Find Your Spot site and let us know if you find any of the results interesting.

Katrina Mental Aftermath

An NPR story. RealAudio or Windows Media Player required.

EMS workers dealing with the increased level of suicide attempts in their area while also dealing with their own lives.

http://www.npr.org/templates/story/story.php?storyId=5014682

Highly recommended story.

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This makes me think of Critical Incident Stress Debriefing in general. After the recent trailer park vs. tornado incidient, the local hospitals and fire departments had CISD within 24 hours and again over the following days. Did the ambulance service? No. None. They have a 1-800 number we can call if we choose to get help and all the crews were invited to attend the other CISD meetings. This just does not seem right to me. There is no reason to be superman. CISD is a wonderful thing for most people. Why would an organization that supposedly understands issues like this would not even offer CISD? I don't know the answer to that.

We're not in Kansas...

But, it may be hard to tell.

Three tornado warnings in my county today. Two during the day and one just after sundown.

There were a three confirmed tornados in the area from what I can tell so far. Luckily none were near my home or actually in my city. But, they did serious damage in nearby towns. Sadly, the picture above is by far the smallest of today's tornados. Also a lot of wind damage in general all over the area. One of the mobile homes that survived the tornado last week was struck by lightning today too. The fire was put out quickly.

Temperatures have really dropped. November should be closer to normal now. At least, I hope so.

Just think of the anxiety level in this town...lots more anxiety related runs.

Tornado coverage

Here are some links I copied from the local newspaper's website.
Tornado Aftermath, etc.

•SLIDE SHOW 1
•SLIDE SHOW 2
•SLIDE SHOW 3
•SLIDE SHOW 4
•SLIDE SHOW 5
•SLIDE SHOW 6
•SLIDE SHOW 7

Sad

For those of you following this. My wife's uncle is getting much worse. Seems is wasn't Colon Cancer but had spread there..along with the liver, and lymph nodes. Maybe it started in the lungs, but it really is not important anymore.

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Here is today's post from my wife:

Final Farewell
Current mood: numb

I said what I believe to be my last goodbye to my uncle yesterday. Hospice has been coming in and last Friday, they changed his life expectancy from another 5 months to 2 weeks. Big change there. It was a devastating blow to the family...although in my heart, I already knew it wouldn't be 6 months to begin with. Cancer, especially in the liver, does not wait that long.

So, yesterday after church and lunch I took the kids on a drive. Drove them around to see the tornado mess...still floors me how bad Newburgh is... and decided to stop by and see my uncle. Two weeks will pass sooner than I realize. What I didn't expect was the drastic change from last week to this week.

Last Saturday he was weak, but still able to move about pretty well. He was talking to us and carrying on conversations. Yesterday, just the mere act of breathing was labored. He sat quietly in his chair. He stared blankly at the floor...glancing every once in a while at the cigarette in his hand to make sure the ash hadn't fallen. His medication is increased, but even Hospice said that he's so stubborn, he'll keep his mind until the last breath. His eyes were very dark and sunken. His skin yellow. His body thin and frail. I'm not sure how much weight he's lost in the last month...but if I were to guess I'd say probably 40 pounds... 40 that he really didn't have to lose.

He had finished a popsicle about 5 minutes before we arrived. We hadn't been there long (maybe another 5 minutes) when he had to get to the bathroom to throw it up. Nothing he eats stays down. Nothing. I just sat there by my cousin...sad. She said she didn't believe he would even make it 2 more weeks. He's been deteriorating at a rate that's hard to believe. It's really the best for him...less suffering...less pain. But it sucks! Apparently he still has some humor left in him. He told my cousin that he's ready and ok to die...it's just getting there that's killing him! -soft smile-

By the time he's coming back out, I decide it's time we leave. He needs his rest. I hug him as he passes me. I tell him, "I love you, Uncle Ronnie." to which he responsds, "I love you too, Dee." And that's when it hit me...I knew I had just seen my uncle for the last time. That was our goodbye.

I broke the rule. I cried. I cried for my sorrow and my loss. Yet he'll be rejoicing soon...so these tears are for me, not him. He'll be fine. -smile-

I love you, Uncle Ronnie! I'm going to miss you!!!

******

My first code...

First, I must say I am spoiled working on a double Medic truck. It was just nice to have a partner that also knew the protocols and could handle half the work at the same time.

I do not have any notes in front of me at the moment, so here is the short version of what happened...minus a lot of details.

0130: Call comes in..man witnesses his wife's arrest. Due to an earlier heart attack, a local hospital had given this family an AED as part of a pilot-program. No shock was indicated and the husband initiated CPR. Pt is a 54yo female with unknown history other than the one heart attack.

0139: Fire and EMS arrive on scene. This house is on the far edge of our county and I drove WAY too fast to get there. Getting there at the same time at the fire department is rare, they must have had a hard time waking up. Of course the pt is in an upstairs bedroom down a narrow hallway.

We slide the pt from beside the bed to a spot in the room where we could actually get all around her. The pt's is warm, dry, and blue from the nipples up. We attach our Defib pads. Fire starts CPR. Another firefighter attaches the monitor leads.

Pt is Asystolic. My partner intubates the pt. I apply chricoid pressure while looking for an IV site. Tube goes in fine and I start an 18 guage IV in her right arm. Gave two rounds of Epi & Atropine then gave 50meq of Sodium Bicarb.

Pt now in V-Fib. Shocked the pt three times with persistant V-Fib. Amiodarone 300mg. Shock. Pt now in a very ugly looking V-Tach....with a pulse! Pt even takes a breath. Not breathing fast enough..so Fire is still assisting ventilations. Pt is not so blue at earlier. While hooking up an Amiodarone drip pt goes back into V-Fib. Also got another 18 guage IV in her left arm while setting up drip.

Shock. V-Fib. Amiodarone 150mg. Shock. V-Fib. Sodium Bicarb 25meq. Magnesium Sulfate 2G. Shock. V-Fib. Epi. Shock. Effective CPR to circulate drugs between shocks. After the last shock, the pt's rhythm changes to a very pretty looking Sinus Tachycardia with a pulse of 115bpm. Pt again takes a breath but we still need to assist respirations to keep a good rate. Pt now pink instead of blue.

Move pt to Long Spine Board and verify tube placement. Now the fun of moving down the hallway, down the staircase, out the foyer, over some landscaping bricks by the porch and onto the cot. Verify the tube placement again and pt still has Sinus Tach pulse of 115. Lines all still attached and flowing. Of couse, it now starts to rain. Quickly move into the truck and go en route to the hospital. Pt stays in the same rhythm and rate the rest of the time we are with her.

The Pt's pupils were fixed and dilated the whole time. I am not fooling myself on this. People who we meet in Asystole tend to either never make it to the hospital or if they do, they tend to not live past it. But, by the time we left the ER, the whole family was at her bedside and the doctor was explaining the odds and likelihood of things to come.

My thought on the whole matter is that we at least give the family time to say goodbye, be together a little longer, and maybe even hold onto a little hope that the pt's condition may improve.

It's the least we can do. The whole thing from 911 call to arrival at ER was almost exacly an hour. We cleared the hospital at 0249. We took some vital signs and such along the way through this. The pt had a bp of 100/60 in the ER.

PS- Thank God for a great Fire Engine crew. Between them they did perfect CPR, knew how to spike an IV bag, and understood how to move and ventilate a patient without dislodging an ET Tube.

*******

I'm too tired to proof read this post right now. I've only slept 4 hours today. I'm glad I do not work tonight. Another big thunderstorm, I'm sure we'll have some more anxiety attack patients. I think I got all the major points typed out correctly in the post above, I'll check later. Until then, this is good sleeping weather.

Rare nighttime tornado picture

Photo from a security camera at Deaconess Women's Hospital. It was only visible for a moment thanks to some lightning. Scary enough, this was likely the moment when it was hitting the Eastbrook Mobile Home Park.

For the very short video clip, click here:
http://streaming.news25.us/launch.asp?video=tornado

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Emergency rooms prepared to handle disaster victims
The doctor interviewed first in this article is one of my service's two medical directors.

What were you thinking?

The call comes in at 5:45am. I get off at 6:00am. The next crew is not in yet and the all other trucks are on runs already. The call is at a nursing home at the very far edge of our area. Off we go. My partner and I are both medics, so we switch off on "who's run" it is. We both do our medic skills, but only one is "in charge"...and has to do the paperwork. This is his run. We are dispatched for a Breathing Difficulty.

80yo female. Earlier in the night she had shortness of breath and jaw pain. The nurse at the nursing home gave her three nitros (one at a time) and the pain went away. The pain came back later, they gave her two more nitros and the pain is still there. They call for us. The pt has no significant medical history other than dementia.

We get there and do our thing, get a report for the nurse while walking down the hall, get vitals, move pt to cot, etc. Pt is awake and talking as normal for the pt. Only complaints are jaw pain and shortness of breath. I'm starting to think possible MI (heart attack)...

On the way out to our truck, the nurse wants us to wait for her to finish her paperwork...quite a bit left. I told the nurse we would be in the truck and she'd need to bring it out to us there.

In the truck, we have the pt on O2, hook the monitor up, start an IV and draw blood tubes for the hospital. My partner was unable to find any good veins on his side of the pt but I did and was able to get an 18 gauge in her right anti-cubital area (inside of elbow). After getting the IV, I see what the monitor says (my partner placed the monitor while I did the IV). She has S-T elevation in leads I, II, and III. There are the only leads available to me. I am still thinking possible MI.

I get out to start heading to the hospital, my partner does not need me anymore and it would be best to start moving. The nurse gives my partner the paperwork and we are off.

On the way there my partner does not seem to be doing much, if anything for the patient. But, maybe I am missing something because I am trying to drive in morning traffic.

We get to the hospital, get the patient in the room. He gives his report while I am out getting the truck cleaned up and cot back in it. When he is back out he calls dispatch and tells them we are available with a Retro of 6 (Difficulty Breathing). Mind you, the Retro-code is how we tell dispatch what the run really was..a check for their dispatching to see if what they tells us we are going to is what we really get. Now, I am shocked. Was I the only one seeing a possible MI here? Luckily, I saw the ER nurse after that and they thought MI too and were caring for the patient properly. Ends up my partner did nothing other than O2 for her. Seems her jaw pain wasn't severe and he did not connect any of the dots. He was going down some sort of breathing difficulty protocol in his head...she did not have wheezing...just short of breath..slightly panicked breathing...ummm..hello??? Could it be because of referred MI pain to her jaw. It's common in women to not have "classic" substernal chest pain with an MI. Heck, the nitro relieved the pain earlier in the evening..should that have not been a clue?

I am going to stop ranting now..I need to get to work. My partner has been a medic for about one year...this is the second service he has worked at..he has been in this service less than 90 days. I was hoping to be partnered with someone experienced...now I am worried.

Anyone else see a possible MI?

To my partner who hopefully never reads this blog:
What were you thinking?

*******
PS - I know I am leaving a bunch of details out of this...some may even be useful for you to form an opinion, but this run actually happened some time ago and this is all I have left in my memory.

Thief in the Night

From my wife's blog:

Current mood: sad

(My son) and I had dentist appointments Friday afternoon. My dentist office is about 1.5 blocks down from where the tornado hit Newburgh. (Just to the east of Evansville) What I realized today is that the media has not totally represented the devastation this monster brought. Although their focus has been on the trailer park in Evansville...as it should be with the number of fatalities as well as the number of homes destroyed...there hasn't been much mention of the destruction this fiend has left behind in this enitre community. Truly, a thief in the night!!

Beautiful one and two-story homes...gone. $150,000 - $250,000 brick and mortar homes...vanished. Heavily wooded areas...exposed. Houses 1/2 there; the left side of the home is standing, but maybe the right is gone or vice versa. Swing sets mangled around trees or on top of cars. Limbs and toys and papers strewn about. And this is AFTER the first parts of the clean-up efforts.

But there is so much more of an impact that we never think about. Newburgh is a small community. Businesses are feeling the indirect effects of this killer as well. The access to their business was temporarily closed. And now...who has time or money to frequent these mom and pop stores? We need the big guys...Home Depot, Lowes, Contractors, etc. Who has the money to go out to the little restaurants? The daily income they are losing will be felt well into 2006 if not farther. Yes, this twister has taken quite a toll on the place I call home. It brings tears to my eyes.

Our local radio and television stations sponsored an impromptu telethon Wednesday. (Thanks to all the wonderful staff of those venues!!) Our loving community - families, business, etc. - generously donated $1.25+ Million to help in the relief efforts. I live in a GREAT place!! Seems like a lot of money, but only a fraction of what it's going to take to rebuild and re-establish. There's a long road ahead for all involved. Please keep all these people...family, friends, neighbors...in your thoughts and prayers!

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A further note from me. Of the 1.25 Million, there was one single donation of $200,000 from the near by Toyota plant. Very cool.

gone so long

Sorry I have been away from here so long. Two jobs, family activites, life..all keeping me from being online very much.

I have things to post..I'll try to get some different posts up soon.

First, I'll copy/paste one from my wife's blog...it will give away more than I like about where I live, but it's on an important topic that I will likely not blog about myself.