Monday, October 20, 2008

To Fly, or Not to Fly?

That is the question.

There's been a lot of talk on various sources about the pros and cons of HEMS. Don't get me wrong. I'm all for it in the right circumstances. I have flown several patients out myself. Five, in fact. In the 10 years I've been an EMT. Three were peds cases, two were adult traumas. In all 4 cases, I had (as did the medics with me) every reason to believe that time was of the essence. Both peds cases were head injuries, and while one of them could have been driven, it was rush hour in the metro area, and getting to the Big Children's Hospital would have taken over an hour, if not closer to 2 hours. The second peds case I flew was a status epilepticus secondary to a fall down the stairs. The third was a toddler who had been 'run over by a car' and while he didn't appear to have any obvious injuries, there was a large patch of hair missing from his head, which lead both me and the medic to believe the by-standers story that it was his head that was in contact with the tire. How much? Who knows, but I'm not really one to take chances with a toddler.

The first kid actually ended up only having a moderate concussion and depressed skull fracture (after pulling a fully loaded bookcase on himself!) and spent 2 nights in hospital, only because mom wanted him to stay the second night just in case. They stopped by about a month after it happened to say thank you, with cookies. Lucky kid.

Both adults were head injuries from an MVA, with altered mental status and other injuries like bilateral humerus fractures or a femur fracture, etc. In one case I was driving home from work and came on scene before the FD. Luckily, I knew the Lt on the engine, and when I said that the guy was going to need a helo, he listened to me. Granted, the guy could have gone by ground, but again, it was rush hour and even with lights and sirens, it would have taken over an hour to get to the Level II trauma center.

I got my EMT certification in a state with a lot of rural areas, and I happened to work in a semi-rural area (some small cities, with LOTS of emptiness and the closest trauma/burn/anything bad center was about an hour away on the state turnpike). The closest helo was about 45 minutes away by ground, and had to be called special by the county to the state in order to get them going. I can't remember EVER flying someone when I was up there. Granted, I didn't have much of a chance to most of the time, but the mentality up there was to get a good assessment and learn to deal with a lot of shit yourself, because the helo was only for REAL emergencies. Good, bad, or indifferent, that was the way it was.

Then I move to a smaller state with a much higher population, in one of the most populated areas in the country. The HEMS around here is run by the state. No 'helo shopping' around here. And a federal police service has medics on their helos, so they can help out when we need them to. Their AC are also larger, and can carry more people/patients. I see a lot more patients being flown to various places here than I ever saw in Rural Area state. One would think it would be the opposite, with my primary call area being within spitting distance of 3 hospitals, one of which is a Level II Trauma center, and within an hour (in good traffic) of 3 Big City Hospitals. I've had an opinion about this proliferate use of HEMS when you are so close to relatively definitive care, and a recent call I went on before my surgery only cemented that belief.

My EMT instructors HAMMERED us on assessment. How can you decide what is best for the patient when your assessment is lacking? And in areas where the closest hospital may easily be an hour away, assessment is key. Continuing assessment is also key. And by having a good assessment, and KNOWING your assessment is good, you have confidence. Confidence that you haven't missed anything glaringly obvious, and confidence that what you write on your run sheet will stand up.

When you lack confidence in your abilities, you are more likely to call for someone with more skills to help out. This can be a good thing sometimes. But when that someone is a flight medic who comes on a big whirly bird, this can be a bad thing. The flight medic is unlikely to refuse the flight, because flights mean money and continued existence (and jobs) for him or her. In private companies, that money comes in the form of billing the patient (and a helo flight is VERY expensive). In public, like where I'm at, that comes in the form of state and federal monies, which are given based on this case, usage of the service. So, because of the lack of confidence of the medic, and a poor report to the doctor (which does not paint an accurate picture of the patient) and a doctor afraid of 'zebras' and the extra money it will cost the hospital if the patient really IS a trauma who needs to be at a trauma center and has to be flown by private HEMS, a helo is dispatched, extra flight hours are put on the helo, taking it out of service faster, and in general, risk is run to everyone.

Equal to the lack of confidence, (and perhaps, and indirect result of lack of confidence) is the 'what if' scenario. 'What if' the patient has serious trauma injuries that are being masked by EtOH? 'What if' the patient really is hurt and deteriorates while we're taking them to the lower level trauma center? Constantly looking for the stampeding hordes of zebras doesn't make you a better provider. I've heard of doctor's with this same problem. I blame the lawyers and policy makers for making every medical provider from EMT up to surgeon uber-paranoid about lawsuits for 'what if' situations, so we over-treat in the hopes that the zebra will be caught. In the meantime, all those extra costs (or risks) are being passed down to the patient and public. But in reality, is this really totally the fault of the lawyers and policy makers? Why are some providers comfortable in treating patients as they present and others want to do everything under the sun 'just in case?'

In my opinion, it comes down to confidence. Confidence in assessments, abilities, and documentation. If you are confident in your ability to assess and treat, and then document EXACTLY what you did, the times you did it and why (not always needed, but it helps), then there should be no reason for you to call for a higher level provider unless it is truly needed. If you can back up what you did, why worry? Sure, something may slip by. But I was always taught that if you are acting within your scope of practice, and with the best interests of the patient in mind, and you document why you did what you did, then you should be covered.

Sadly, for so many, this is no longer so. Perhaps I just haven't gotten bit by the lawsuit bug yet, or been trampled enough by zebras to have this worry. Hopefully I never will.

Friday, October 17, 2008


I've been credited with initiating several partners with this term. I'm not quite sure how or where, since I don't recall first using it, but there you are. And I do tend to forget what I've said when I'm transporting a patient at 3am. Heck, one partner even said I used it over the radio when calling into County that we were enroute. Again, not something I recall.

At any rate, it's no secret around my dept that I have a deep and utter loathing for people who use the ambulance for their own personal taxi. Granted, there are exceptions to this, and I'm ok with that, and I've been told that other EMT's admire me for my 'outward' politeness to these system abusers (though my partners know full well what is going through my head at the time). I know many other EMT's and medics feel this way, and in fact, had an instructor in my EMT-I class who has been in trouble for taking a 'patient' (and I use the term lightly) to the hospital by telling the person to get in the back, and then getting back into the front seat himself, and dropping the person at the doors to the waiting room.

NOTE: I DO NOT condone this action. I did find it funny as hell when he related it to the class, and I wish to hell I had the cojones to do it, but I fear for my certification.

Here are some instances in which I have had the urge to tell the person calling an EMERGENCY VEHICLE for taxi-transport to F**K OFF!!!!

-the guy who has a history of kidney stones, thinks he's getting it again, and has abdominal pain of 3/10. Lives on a road that barely exists and is full of potholes. Has the energy to pack a suitcase, and wait for us at the end of the driveway, and then walk back up the driveway to the house to call 911 back and complain we aren't there yet, because we are lost. Upon putting his keys into his suitcase, I notice 2 car keys on the ring, and saw at least one car in the driveway when I was playing bellhop and loading up his suitcase into the ambo. Total time: 20 minutes getting to his house. 5 minute drive (no flashy lights or sirens because it's 2am) to the hospital, 15 minutes to put guy in triage and wait to give report to the nurse because the ED is full, 15 minutes back to the station.

-the mother who called 911 because her (old enough to know better) son was jumping on the bed and when the mattress slipped off, he cut his foot on the springs. Granted, the slice was deep, and probably painful, though the kid was remarkably calm, and definately needed stitches. Call comes in around 6pm, just as dinner is getting on the table. Upon arrival to the scene, there were so many cars in the driveway (and on the grass, and in the road) that we had to park one house away and walk everything in. Upon being told by the Lt riding charge that Jr needs stitches and a tetanus shot, but mom (or any one of the 15 adults standing around) can take him herself once we bandage the foot up (because arriving on the big white box with lights that aren't flashing doesn't mean you have to be seen immediately), mom states (and I quote) "Oh that's ok. Jr has never ridden in an ambulance, and thinks it would be neat, so we'll let you take him. I'll have someone follow in a car." Because clearly it is a priveledge for us to take your old-enough-to-know-better son and yourself to the hospital, just to take you to the waiting room (because both the adult ED and the peds ED are full) and listen to you complain that the wait will be too long.

-the 20-something year old woman who was complaining of lower back and flank pain on one side. Had no desire to go to the hospital, just wanted to know if she had a kidney infection. I almost hugged my Lt when he told her (with a straight face) that the ambulance's portable x-ray machine was broken and she would have to either go to the hospital or to her PCP. She didn't get it.

-if you cut yourself, and pass out at the sight of your own blood, and then call 911, don't get mad at me when I ask where the cut it. If I can't see it, it probably doesn't warrent a trip to the ED. Now, while I am not made sick at the sight of blood (my own, or anyone else's), I can understand that cutting yourself with a sharp knife is very painful and that some people have that reaction. I really am trying to be understanding and put your mind at ease. Your vitals are all fine, and the headache you feel is probably left over from the adrenaline rush which caused you to get all weak and wobbly anyway, and most likely is NOT from bumping your head on the cabinet as you slid to the floor. Oh, and having your wife constantly question me isn't helping...Man up, dude.

-Note to nursing home staff. I know it's hard to work in a nursing home, and I know the pay is crap. I know you have to pass a ridiculous amount of tests and audits and that you get treated like criminals every time a patient dies. Trust me, I've worked there....I know. But here's a few things I'd like you to think about....Just because the doc told you to ship the patient out to the ED because you woke him up at 2am because patient A has a cough doesn't mean you have to call 911. There are transport services around that can do the same job. The only difference between them and me is that I come in 5 minutes, after putting my own and other's lives in danger by running hot, and I don't charge a fee, unlike the transport service, that, depending on call volume, may get there in an hour or so, and will charge you.

Also, calling for the 'unconscious person' because you checked on them at 8 when you cleaned up their dinner tray and then didn't check on them again until midnight shift change won't go over well with me OR the medics when it turns out the patient was merely sleeping, and took out their hearing aides. Looking at me wide-eyed with astonishment when I was able to magically wake them up won't win you any points either. Obviously the patient is stone-deaf, and can't hear you whispering for them to wake up at the doorway.

As I said before, I've worked in nursing homes and such. I know the nurse to CNA ratio is low, and patient to carer ratio is extremely high. However, I made it a point to know my patients (and I was in a rehab place, so it was quick turn-around) so that if 911 did have to be called, I would know what was going on with them. Calling me for anything and having the CNA meet me, and tell me they don't know what's wrong with the patient is not helping you, me and most of all the patient. This is especially true for when you call me for a fall. If the patient falls, and you suspect something is wrong, PLEASE do not pick them up and put them back in bed, and then wait till the next shift comes in so that they have to call. Make them comfy on the floor and call and wait. I hate hearing the patient ask me not to hurt them again when I have to move them. It breaks my heart, and since it's been hypothesized that I don't have much a heart anyway, that is no mean feat.

And while I have several other beefs (especially with nursing homes), my last one is this. Many people go to a nursing home because they cannot be cared for at home. The vast majority of the time, these people are just waiting to die. Sorry to be blunt, but that's how it is. If I am old and sick, the LAST thing I want is to be moved from my bed and my belongings and sent to a cold, impersonal hospital to die. I have a DNR-B for a reason, and that reason is that I WANT TO DIE PEACEFULLY!!! I don't want to die with the sounds of a hospital ED being the last things I hear. So calling an ambulance for the 99 year old person with end-stage lung cancer and Alzhiemer's Disease who has a DNR-B, and at midnight shift change had a blood pressure of 50/10, a heart rate of 20, and a respiratory rate of 4-6 (and it's now 0130 because you HAD to finish shift change rounds) is probably not the best practice. Yes, I know you get investigated by the state every time a patient dies on grounds, but really? And yes, the doc told you to ship them out, (which I hate, because the patient is NOT a package to be 'shipped') but when you wake a doctor up at 1am and tell him the patient's vitals and not much else, what else do you think he's going to say? I really dislike transporting what is essentially a corpse to the hospital because you don't feel like doing the paperwork.

Being named the 'Angel of Death' by the ED nurses because 6 out of 10 patients I transported over a 2 day period (all of them nursing home patients with a DNR-B) took their last breath as I moved them over to the hospital bed doesn't make me much happier with you, by the way.

Perhaps this nursing home rant should be it's own post. I think it will be. But the next post I think will be one in which I discuss the times I don't mind being a cab-ulance. Those times include little old ladies or anyone who can't drive themselves for something that they otherwise would have.

Thursday, October 16, 2008

You always remember your first...

I took EMT-B class in NorthEastern PA (yes, it deserves being capitalized) during my sophomore year of college, between 1997 and '98.. I had wanted to ride an ambulance since I first started seeing them on the sidelines of the high school football games, while I was playing drums in the band. How cool, to be in those orange jumpsuits, driving around town lights and sirens to save people's lives!

I already had plans to go to medical school after college and then working in an ER or as a trauma surgeon (hey...I had dreams...), so when the opportunity came to take an EMT class, I figured, why not? By becoming an EMT and working car wreck scenes and heart attacks, I learn if I can hack the pressure and stress that comes with working in emergency situations, right?

So I took EMT class, and excelled, I'd like to think. My instructors made sure we could think our way out of a problem, because honestly, the way EMS was in PA at that time, you may very well find yourself on a trip to the trauma center an hour away with one medic in the back with you and the driver in the front. There was no helo on every corner, and the local Level II trauma center only took people with their particular insurance. And if you wanted to go to a specific hospital, you better either call when you're on the doorstep, or call before leaving scene, because the doc taking your call could very well refuse your patient, sending you to another hospital. We didn't do a lot of rendevous with the medics, because they were hospital based in a delta truck (van) and we had to respond to the station and then get to the scene, because the ambulances were housed in the city council building, along with the fire dept and the police, and the local jail. There was a room upstairs with the computers to do your reports and a couple of couches, but you weren't allowed to sleep there. Therefore, there was a lot of being woken up in the middle of hte night and calling in to dispatch and driving to the station to get the ambulance out. Dispatch, who was contacted by the county (who received the 911 calls) would tone out whatever was needed. You got 3 tone outs, 2 minutes apart, before mutual aid was activated. If you called in as the aide, or EMT, you would head to the station, but if they didn't raise a driver, it would go to mutual aid and you just drove across town at 3am for nothing. I can't say that I got a lot of experience there, but I learned a lot from the medics who beat us to the scene and treated the patients while they waited for transport. Our dept didn't have a lot of money, so I learned to improvise a lot of things, and I learned that if shit goes downhill, you can't freak out. You have to suck it up and deal and learn from what is going on so you don't let it happen again. A partner of mine had to once ride with a 300lb pt in the back of the secondary ambo, with a stretcher that wouldn't go down all the way and therefore wouldn't fit in the brackets. The patient was critical, and for once they had beaten the medics to the scene and set up a rendevous. I remember him relaying the story to me, him a new EMT on his second call, terrified that the medic would open the back and see him holding the broken stretcher against the brackets with his feet and have kittens. You can say that I learned early in my career the importance of 'Improvise, Adapt and Overcome.'

I got my certification in January of 1998. In NEPA, winters tend to be a bit rough, and one night, about 2 weeks after getting my card in the mail, our tones dropped for an injured child after sledding. It had been snowing and sleeting all day, and we hadn't had classes. So my partner and I piled into his truck and headed over to the station. We made it just as the ambo was pulling out and jumped on. We got on scene, and the medics, rescue chief, assistant rescue chief, and half the dept had already gotten there (lots of people responded in the POV's from home if they heard the ambo had a crew). We got there just in time to help put the backboard on the Reeves and slip and slide down the icey road to the ambo.

Everyone piled on. The rescue chief, the paramedic, myself, and my partner. A firefighter drove, and the patient's little brother sat in the front seat. The patient was a tall kid, somewhere in his early teens (I can't remember his exact age), who had been sledding down the street at night with his brother. The parents were out, maybe shopping, maybe working, I don't remember. The patient hit a tree after jumping the curb, and had been found by the first people on scene under a car.

I don't remember much about the trip to the hospital, or the patient's treatment. I remember that he didn't have a mark on him, save for a stripe of grease on his forehead, obviously from sliding under the car. I remember being given trauma shears by the medic and being told to cut his pants. I remember that it was a long-assed ride, with the on-spot chains down, slowly driving up the highway in the snow, the emergency lights reflecting off the flakes. I remember that we couldn't call for a helo because of the weather.

The most memorable thing though, was this. The rescue chief, also a medic, called the closest hospital, General Hospital, to give report. The doctor on the other end of the radio, after learning that the patient was a minor and the parents had not been contacted yet, refused the patient, instructing us to take him to We'll Take Anyone Hospital. Neither one was a trauma center, but the local level II trauma center didn't like to be bothered at night with patients who didn't have the right insurance. WTAH was 20 minutes up a major interstate on a good day. Tonight was not a good day.

Cursing a blue streak, the rescue chief told the driver to head for the highway. 45 minutes later, we were at the hospital. I don't remember much more than what I've written, perhaps because while cleaning up the ambo I slipped while going out the side door and fell, hitting my head on the floor. Don't know if I had a concussion, but I certainly had a headache for the ride back. And I do remember that 2 days later the news reported that the patient had died of a closed head injury.

Being in Maryland now, I tell that story, and people are incredulous. Perhaps I got some details wrong, being a newly minted EMT with ZERO experience with the hospitals and doctors and things of that nature. But I do remember having a box on the back of our run forms where the patient had to put their insurance info, or sign if they didn't have any. And I do remember the hospital, specifically General Hospital, being VERY interested in which box was signed. And I distinctly remember the rescue chief cursing the doctor at GH as we drove slowly to WTAH, impuning his degree and the questionable tactics of allowing a hospital to turf what could be a critical patient to a hospital father away on a horrid night to be out driving because insurance coverage couldn't be confirmed.

Whether the law in PA had changed by then to allow uninsured people payment options or not, I don't know. I didn't know much about the law in PA at that time. But when I tell that story to my EMT students, they don't believe it. Not the part about the hospital turfing the patient, or the part where the next closest hospital was more than 10 minutes away.

Wednesday, October 15, 2008


I'm starting this blog because I didn't want to continue on the Antarctica blog, keeping that one rather special for my Ice time.

But I have so many calls crammed into my head that I need to get them out. So while I'm recovering from surgery and waiting to be cleared to ride again, I figured I'd empty out my brain of 10 years of EMS calls. The good, the bad, and the ugly.