Or feel free to substitute another word (or two) that start with B.S.

Dispatched to a call for a motorcycle versus car accident. As a general rule of thumb, the smart money bets on the car to win. Physics and all that dictates that the object with the most mass will win. Velocity of course mediates that, but the soft tissue riding on top of the motorcycle is still bound to lose either way. By how much is a matter of what he or she hits, protective gear (helmets are good), and sheer dumb luck. Sometimes the motor cycle rider will walk away with minor injuries when logic and the afore mentioned laws of physics tell you that the should be. Of course sometimes the rider will die when the impact seems relatively minor. While mechanism may give you some good rules of thumb for assessing for potential injuries, mechanism is not definitive by any definition of the word.

Back to our patient, or rather our patient’s motorcycle and the car it hit. Looking at the back of the car, which is where the motorcycle impacted, the damage looked impressive. Impressive to a body man, that is. My first thought when I looked at the back of the car was “Crumple zone”. A crumple zone is the term used for parts of cars that are designed to collapse and thus absorb energy from the collision. The entire reason for having them is to trade sheet metal (and plastic) for a reduction in injury. A crumpled fender or trunk lid has absorbed a lot of energey which would otherwise be transmitted to the patient. Motorcycles don’t have crumple zones because their body work is minimal. They also don’t have seat belts, bumpers, or airbags. As a result only the luckiest of riders escape all injuries in accidents. The #1 killer of motorcyle riders is head injury. Protect the noggin and the patient will stand a good chance of living, even if they have serious injuries to the torso. No guarantee, but it improves the odds. The better the helmet, the more protection is provides, which makes sense. No helmet means no protection and then the rider is depeding on pure luck. Good luck with that, as the saying goes.

Back to our patient. Who was conscious, had a pretty good recollection of what happened, was able to give us a complete medical history, and cooperate with the exam. Vital signs were good, and other than some cuts, bruises, and maybe a fractured wrist, he was pretty much uninjured. That’s luck of the good kind.

Mechanism, by itself, without a thorough examination, would dictate (in some systems) that this patient be given a full ALS work up. Which is why using mechanism alone is silly. Should this patient go to a trauma center? Very possibly, since there might be occult injuries that will only show up later. Should this patient go to a trauma center by ALS ambulance? A tougher question, with a lot of variables. The chief amongst them is the travel time to a trauma center or other capable hospital. If the patient has no airway issues, the trauma center is within a shortish distance, and the EMTs are capable, there doesn’t seem to be any real reason to travel by ALS ambulance.

Certainly mechanism alone should not be a criteria for anything. Mechanism with physical findings suggestive or indicative of serious injury are a different story. Or even a finding of serious injury without a mechanism for that matter.

A case in point. 30 or so years back I had an acquaintance who wanted to be a police officer. Specifically, he wanted to be a motorcycle officer. He had that part down, the motorcycle that is. He rode one whenever the weather permitted. In fact he rode a Harley Davidson, which as you probably know is a big motorcycle. One day he was stopped at a traffic light and somehow lost his balance. He and his HD fell over and one end of the handle bar dug into his flank. As luck (bad luck) would have it the end dug into his flank right over one of his kidneys. Which promptly started bleeding, which required a trip to the hospital, and removal of the injured kidney. A stupid accident caused him to end up in the operating room, the loss of his kidney, and thus disqualification from becoming a police officer. Remember what I said about luck and how it works both ways? Here’s an example of bad luck and a serious injury with no mechanism to suggest it.

It’s the examination of the patient that counts, not the amount of damage or “mechanism”.

Which is something that a lot of EMTs and all too many paramedics can’t seem to understand.

Happy Medic said it in response to Ambulance Driver,

The real argument is whether paying a Firefighter/Paramedic $25/hr to sit around eating ice cream while the single role medic sits on post making $8 is a good idea.  I don’t know for sure, but the only reason they make $8 is because the company knows they can keep you in the seat.  If enough of you left, they’d have to raise the salary to stay in business.

One nail, hit on head. I’ve said this before and I no doubt will say it again. There is no shortage of paramedics. What there is, is a shortage of paramedics who are willing to work for the low pay, high call volume, crappy or non existent benefits, sitting in an ambulance for 8-10-12 or more hours, not able to even go to the bathroom without asking for permission, lowest common denominator medicine, that is EMS in much of the country. It’s arguably worse in the private sector, but you have to look no further than NYC to know that the public sector treats much of it’s EMS work force like crap.

Until that changes, until EMT and paramedic educational training programs are little more than diploma mills, until EMS defines itself as at least a trade if not a profession, then nothing will improve.

I’m not sure why AD thinks that 75% of the people in EMS are overpaid, I certainly don’t see them. My service pays better than the average, by far, and yet I don’t know that we are overpaid. I’d guess, knowing him as I do, that he’s seen too many lazy medics who do just enough to get by. No doubt they exist, because they exist in every field of endeavor. Happy Medic no doubt knows fire fighters who do just enough to skate by, I know that there are police officers who do exactly that. I’ve seen doctors who do that too. Many lawyers are cringing as they read this because they know that it’s not how they operate. Still, in every field, those are the fortunately rare exceptions.

Most of the EMTs and paramedics I know work their asses off. What’s odd is that I know a lot of people who left higher paying jobs to become EMTs or paramedics because there was something in their previous careers that just didn’t make them happy.

Either way, for whatever reason, most EMS jobs pay far less than they should. It’s been that way since I started in EMS and I expect it to be that way long after I’ve gone.

If you’re in EMS and want to know why, look in the mirror.

We were sent for an “External Hemorrhage” which is usually either a dialysis shunt rupture or a varicose vein rupture. 99% of the time the bleed is controlled by the BLS guys before we get there and we’re cancelled.

Not this time, though. CAD update was “bleeding from neck”. WTF?

BLS crew arrives and gives no update. We’re waiting for the cancellation that never comes.

As we walked towards the house the BLS crew update is,  “Bring a scoop stretcher up with you.”

Oh-oh.

We grabbed our gear and the scoop and trudged up the stairs into the house. A guy standing in the front hall said,  “Go up stairs, turn left, go up the next set of stairs, turn right and go down the hall. Hmm, it’s a two story house, which means that we’re going to the attic. Which has a small apartment added on with an equally small stairway of course. Narrow and with a right angle about half way down. If this patient weighs more than about 100 pounds, it’s not going to be fun getting him down.

Question #1. Why do very sick people always gravitate to the top floor? Question #2.  Is it that they know they’re dying and figure that by going to the top floor they’ll be closer to heaven? If I ever figure that one out, my life will be complete. One of life’s imponderables I guess.

We got upstairs and found the BLS crew, FD, and of course the patient. Who is lying on the floor surrounded by blood. Lot’s of bright red blood with lots of clots. I’m guesstimating about 500 cc’s of blood. Damn. He weighed about 11o pounds more or less. At least we had that going for us.

“Does he have a pressure?”

“Yeah, about 90/p.”

Splendid. Which as I’ve mentioned before is what my mother used to say when things were anything but.

“Well, let’s get him on the scoop and get down to the ambulance.”

The BLS crew had the bleeding controlled with direct pressure and a dressing.

While we were securing the patient to the scoop, we got the story. 60ish year old manwith cancer of everything. Shunt in his neck, feeding tube, IV port in his chest, suprapubic urinary catheter. Oh, and a tracheostomy. I have to mention that because it becomes crucial later on. Full code, of course. No mention of DNR or hospice. I wonder what idiot at the hospital forgot to have that conversation.

We moved the patient downstairs and out of the house. On the front porch my partner asks me if we are going to our ambulance or the BLS one. I look at the BLS ambulance which is right in front of the house and then down the street half a block past the fire truck to our ambulance.

“Their ambulance.”

This turned out to be a very wise decision, as you’ll soon see.

The patient was conscious, he was alert, he was following commands. He was also a train wreck, but a manageable one we figured. Once we got the past the part where he had a terminal illness, he was doing OK.

Our plan was to get him in the ambulance, do the necessary monitoring, start an IV if possible and transport to his hospital of choice.

Off we went to the hospital and I prepped what I thought was a decent vein for the IV. My partner got on the med radio to call the patient’s hospital of choice and that’s when the shit show commenced.

First the radio wasn’t transmitting. While my partner was trouble shooting that, whatever process had caused the patient to start bleeding externally now caused the patient to bleed internally into his tracheostomy. (Later opinion from the hospital was that the cancer had eroded the innominate artery.) Which he declared to us by coughing blood up out of his stoma and all over the ambulance. And my partner. Note that that was the BLS truck. It must have been my wily old paramedic spidey sense that told me to go to the BLS ambulance.

Fuck!

My partner grabbed a suction catheter and started suctioning bright red bubbly blood out of the airway.

Then, just in case we hadn’t got the point that the call was going to hell, blood started to come out of his mouth and nose too.

The Shit Show had just been upgraded to a Goat Screw.

I grabbed the portable suction while I yelled to the EMT driving that we needed to divert to the closest facility, which was only about three minutes away. Uncontrollable bleeding + unmanageable airway = Closest hospital.

Through all of this the patient remained conscious, breathing, and aware of the fact that he was dying right in front of us.

I don’t think I’ll ever forget the look in his eyes. Mine probably had a very similar look and I know that my partner’s did as well. It’s pretty awful to watch someone dying helplessly.

My partner tried the med radio again with no luck.

I called dispatch on my portable radio and told the dispatcher to call the hospital on the phone and tell them we were bringing in a patient bleeding from his trach with an uncontrollable airway.

The patient coughed up more blood, covering my partner again. I, being the experienced provider that I am, didn’t get a drop on me. Comes with experience, I guess.

We got to the hospital in short order and transferred the patient over to the staff. Per usual for this joint, they didn’t have the full code team waiting for us because per usual they didn’t believe that we were telling the truth.

As soon as they got a look at the patient and pooped their drawers, much overhead paging of the resuscitation team started.

We cleaned up and watched for a while as the patient did his best to die and the hospital staff did their best to keep him from dying. He was in cardiac arrest for a while, but they got him back. They managed to intubate him, which we never even attempted to do being so busy just trying to keep him from drowning in his own blood. It helps to have doctors, nurses, Xray techs, respiratory techs, and lots of equipment. And plenty of working room of course.

I have no doubt that the patient finally beat them in the end and died.

Poor bastard.

UPATE: From a FB commenter,

Stephen Husak I call bullcrap story. You say he was in full code but yet when you were carrying him out of the house he was concious and alert and following commands while you were deciding ambulances. Then he was back in full code when you diverted.

The person who corrected you had it right, buddy. In all my years in EMS, I’ve never seen a “partial” cardiac arrest. Cardiac arrest is the term that I use for cardiac arrest. Nurseys use “code” for cardiac arrest, because they don’t know better.

Another UPDATE: Apparently the term “Full Code” is causing some confusion. Around here, and I’ve heard the term used in other parts of the country as well, “Full Code” means that the patient or their family, wants all resuscitative measures taken, no matter how futile. It has nothing to do with whether the patient is in cardiac arrest or not. I’ve always thought the term “Full cardiac arrest” was silly because, as I note above, I’ve never seen a patient in “Partial cardiac arrest”. Nor has anyone ever been able to explain to me what a “partial” cardiac arrest might be.

I won’t spend time explaining who Rube Goldberg was. If you don’t know, you can easily find out from the Internet. Once you understand that, you’ll understand why I chose the post title that I did.

Boulder Fire to test smaller vehicles for medical calls

Medical calls, not fires, account for more than half of all calls to which Boulder Fire-Rescue crews respond, and the number of medical calls increased 17 percent from 2006 to 2011.

Boulder’s fire department is looking at adding smaller vehicles for paramedics to respond to many of those calls without sending a fire engine or — when engines aren’t available — a ladder truck. A pilot program will test the idea at Fire Station No. 1, at 2441 13th St., across the street from Casey Middle School, starting in January.

So, the FD is going to buy new vehicles to respond to medical calls instead of sending big fire trucks to medical calls.

Oh, and they’re greening Boulder while they are at it,

One idea in the revised master plan for improving response to medical calls is to put smaller vehicles, most likely flex-fuel or hybrid sport utility vehicles, that could carry two people to medical calls instead of three in a fire engine.

I’m all for efficiency,

Information from the pilot program will be analyzed to determine if it saves money in fuel and wear-and-tear on the larger fire department vehicles and to see if it allows the department to be more efficient in how it responds to medical calls and fires.

Seems like a round about way to improve EMS response times. I have another idea. How about having AMR provide MORE ambulances? Radical huh?

One of the sleight of hand tricks used to improve EMS response times is to stop the response time clock when the first responders arrive, not when the ambulance arrives. That takes some of the pressure of of the ambulance service and sometimes allows them to claim faster response times than they actually have. I can’t say if that’s what goes on in Boulder, but it’s not unheard of. It’s also a form of cost shifting, which allows the ambulance service to use tax payer funded equipment to bolster their response time numbers. Of course the ambulance service, which provides the transport, also gets to keep all of the money and pays nothing to the municipality for the (free) use of their equipment and staff. Not that the fire service will complain, because responding to EMS calls, even if all they do is give the “Stare of life”, preserves jobs and budgets.

Just more fun and games with EMS, I guess. Which is supposed to be about timely and good patient care, but mostly seems to be a numbers game lately.

In investigating many types of crimes, the police have an adage,

“Follow the money.”

Money is a grat motivator, it motivates some people to work hard, some to commit crimes, others to compromise their principles.

Rogue Medic has been riding his “Epinephrine is Bad” hobby horse lately. He’s been citing studies from the 1990s to prove that we shouldn’t be giving Epinephrine to cardiac arrest patients. He suggests, or maybe demands, studies of Epinephrine to guide us into the future. Sounds good, in theory at least.

Epinephrine has been around for a long time, much longer than he or I have been in EMS. It’s also cheap and plentiful. It’s also naturally occuring in the human body so logic, if not science, say that giving it to a heart that has stopped should help. Maybe it does, maybe it doesn’t.

That’s where the adage I quoted at the top of this post comes into play.

No one is going to fund a study of Epinephrine because almost nobody stands to benefit from it. Well, except for the manufacturers of Vasopressin. Who would love a study that shows that Epinephrine is harmful, while Vasopressin isn’t.

Chances are that neither one will help, because as one of his commenters pointed out, patients in Asystole are probably beyond help absent specific circumstances.

Of course it’s hard to prove that Epinephrine causes death because patients in cardiac arrest are by definition dead. Sometimes we get (and they) get lucky and we can bring them back to life, but for the most part they stay dead, even those in Ventricular Fibrillation.

Since hypoxia is proven to be bad for the brain, I’m not going to hold my breath waiting for the multi-center, large number of patients, study that RM so desires.

Lost in the STEMI case I posted about yesterday was a weird case from the day before. I don’t have any strips, but I do have a tale of weirdness.

Braving the HIPAA gods I’m even going to post a picture of the patient for you.

I’ll give you the short story, although I’m not sure you’ll believe me.

Dispatched about 30 minutes before the end of the shift to a call less than a mile away. “Difficulty Breathing” as are about 50% of our calls. It’s so common to be a meaningless call type. Whatever, we’ll sort it out when we get there. The BLS crew assigned to the call with us left just before us and then turned the wrong way. Not sure what was up with that, but we turned the right way, drove down a street, crossed another street, drove down another street, took a right turn and were on scene. Neither the BLS crew nor the FD were to be seen. OK, not a big deal.

We grabbed our gear and walked into the house to find the patient sitting in a kitchen chair. He wasn’t having much difficulty breathing, but he wasn’t doing a whole lot of it either. The daughter told a tale of a doctor coming to administer oral Methadone to the patient, leaving, and then the patient passing out. The story made zero sense to us as neither of us had ever heard of a doctor making house calls to administer Methadone. Or much else for that matter. There are a couple of home health services that send doctors out, but not that early in the morning and they don’t administer Methadone.

We sort of skipped that part and asked for a list of medications. Which of course produced the obligatory plastic bag of medications which I took a quick look at.

Of course the mention of Methadone seemed to be a clinical clue, as did the pinpoint pupils and sort of breathing, so we produced a prefilled of Narcan and gave 1mg IM.

So much for the clinical clue. Instead of the expected waking up to a groggy state and the inevitable “Wha happen?”, the patient sort of woke up and started sneezing. And seizing.

It was my turn to ask “Wha happen?” and my partner was just as confused. Then the patient thought it would be amusing to start decorticate posturing on one side only. While still sneezing. We got a quick blood pressure which was something like 260/140. The train was now fully off the tracks and heading for the wall of the station.

No sense in sitting there looking dumb, it was time to move the patient. The BLS crew had showed up while this was going on and we got the patient into the chair and ready for the carry out. At least he wasn’t a big guy.

A family member helpfully pointed out that the patient seemed to be seizing.

Yeah, we got that part.

I took a second to look a the big bag ‘o meds and noted that he had one of each class of antihypertensive meds that can be prescribed in the US. Plus a bunch of renal medications.

“Is he on dialysis?”

“No, but they are getting him ready for it.”

Splendid, as my mother used to say when things were anything but.

Once in the ambulance we put the monitor on the patient and got a rhythm strip, pulse oximetry, and ETCO2 readings. And another blood pressure. Everything was now pointing to some sort of neurological problem, probably an intercranial hemorrhage. Patients are just full of surprises some times.

The debate that ensued was around whether we should intubate or not. I was in the not category and my partner was in the maybe category. Suctioning the airway produced a good bite reflex, so we decided to monitor and transport.

I started an IV while my partner alerted the hospital and gave them as much of the story as we had figured out and alerted them to muster their troops to General Quarters.

Which they did.

We got the patient into the resuscitation room and my partner gave his report. The team swarmed around the patient and started to treat him. They wanted to get his BP down, get his airway secured, and get him into the CT scanner post haste.

I was glad that we hadn’t intubated because the ER staff had to make multiple attempts after they sedated and paralyzed the patient. The resident couldn’t do it and the attending physician had to make multiple attempts.

The neurosurgeon came in and looked at the patient. She agreed with us that it was most likely a head bleed, but where and how severe wouldn’t be known until after the head CT. Well where wouldn’t be known, how bad was pretty obvious.

We left about the time the patient went off to CT and probably the Operating Room afterwards. Not that I think that will do much good, because I think the brain train has left the station.

Through the wall.

Dave, guru of EMSBlogs tells me that readers like posts with lots of ECG strips. Being a ratings whore as I am, I’ve been trying to find lots of nice strips and interesting calls to go with them. The problem is that we often spend most of our shift chasing the output of the Fictions Writers of America, I mean highly trained call takers. Who have given up their dart board of triage and now often just randomly enter stuff to make our lives more interesting.

Still, like the proverbial blind hog, every once in a while they do find an acorn. To paraphrase David Frye in I Am The President, “Well, you can’t lose them all.”

Back to our story.

Dispatched in the wee hours of the morning for a women in her mid 50s with chest pain. We get a fair number of calls like this and most of the time it turns out to be nothing like what we were told. Besides, as I’ve said before women generally don’t present with typical chest pain symptoms. I’m a highly trained EMS professional so I know what I’m talking about, trust me.

We’re dispatched, the fire is dispatched, a BLS ambulance is dispatched. The BLS ambulance is right around the corner, literally, from the call and beats the fire in. Pretty good response time and by rights we should get an update, but more and more that’s happening less and less. In fact the only update we get is to come in via a particular street. Which we do and pull up behind the BLS rig. The fire engine is cruising off down the street and we wave as they pass by. Generally that’s a good sign because it means that no CPR is being done. Or maybe just that the allure of EMS has worn off for most of the fire fighters who actually work on apparatus. What ever.

We grab our life saving equipment and head upstairs (it’s always upstairs) and find the BLS crew treating the patient. Who looked very ill indeed. The patient’s lack of English made the details vague, but even I understood “Dolor en el pecho”, “Ai, Ai, Ai”, and “Hospital por favor”. The EMTs reported that the patient had vomited when they first got there, which was why she was on a nasal cannula and not a mask. Not that I’m a big fan of masks, but OK. “I can’t get a radial pulse or blood pressure.”. My partner was skeptical of this, which for some reason he always is. “She’s got a radial pulse.” he opined. “Not on this side.”, I countered, “Nor a brachial.” We decided that lying the patient on her couch just might be a good idea. Lying her down didn’t help her pain, but it did produce a blood pressure. Of 80.

I should mention that the patient had a very unhealthy pallor, cool skin, and was diaphoretic. Day three of EMT school back when EMTs still learned such things, this was taught to me as cardiogenic shock. Of course there were other possibilities, but they weren’t plausibilities.

Now that we had the BLS part of the call pretty much in hand we decided that maybe some ALS type activity was in order. The patient wasn’t really all that enthusiastic because she just wanted to go to the hospital. All well and good, because we wanted her to go to, the only difference being we’d really like to have her get their alive. Much better for the stats, you know.

We attached the monitor leads and powered up the machine and were rewarded with this visage.

Oooo. Not good. Keep in mind that this is a “rhythm strip” and often the diagnostic mode 12 lead shows different, usually less ST segment elevation. Sure, it does, Pollyanna, sure it does.

So, on went the chest leads for the full diagnostic ECG.

You’ll notice that the ever helpful interpretation says definitive things like “Abnormal ECG Unconfirmed” and “ACUTE MI SUSPECTED” and helpfully suggests that we consider injury or infarct. Thanks for using your highly trained computer algorithm to tell me that. Why even most residents could figure that one out. Somehow I have feeling that lawyers were involved in that decision.

Using my finest medical terminology I said, “Holy crap.”, and handed the strip to my partner. He said pretty much the same thing, only being more erudite than I it came out as, “I better call the hospital right now and give them plenty of notice.” If we transmitted ECGs, they would probably have said “Holy crap.”

My partner went out into the hallway to call the hospital while I started the IV. Since the patients lungs were clear the plan was fluid resuscitation, followed by Fentanyl for the pain if we could get enough blood pressure. Once the IV was in place, the patient went on to our ever versatile scoop stretcher, was strapped thereto, and then brought down the stairs head first.

Down in the ambulance things didn’t seem to have improved, so we redid her BP, which was now 90. Good enough for some Fentanyl, so she got 50mcg, which didn’t seem to help her.

Off we started for the nearest cath lab equipped hospital, hoping that their on call staff was coming in to treat this patient.

Time for another 12 lead ECG. You’ll note that these aren’t in exact order. We had a lot of trouble getting the electrodes to stick to her slimy (really) skin so we had to do a lot of ECGs to get useable ones.

Not a great tracing, but it certainly is quite graphic.

The Fentanyl wasn’t helping the pain, but it was making the patient sleepy. Which is an odd combination, but there you have it. Her color continued to get crappier, which I wasn’t sure was possible. Here O2 sat started to drop, and her ETCO2 was below 20. Shit. Double shit. On went a non rebreather, which improved her numbers if not her color.

Now that we had time to actually breath and think, a 12 lead with a V4R seemed like a really good idea. It wouldn’t really do much other than scare us more, but it was a good idea.

The more I look at these strips in the light of day and some sleep, the more verklempt I get. As worried as I was that the patient was going to die right in front of us, I’m now amazed that she didn’t. Holy crap, was this lady sick or what?

My partner didn’t think that V4R looked bad, but I pointed out that it was a craptastic quality print out and even through that V4R looked bad. So, we did it again and he was amazed (as he perpetually is) that I was right. He should know by now not to doubt me. After all I’m a trained professional and have been doing this for several years more than he has. OK, it was a lucky hunch.

Here is another, better quality, tracing.

Better quality maybe, but not more reassuring at all. In fact, it looks worse. That thing that looks like a PVC isn’t, it’s an aberrantly conducted sinus beat. Wonderful, just f**king wonderful. Did I mention that I really thought that this lady might die on us?

Her blood pressure was good enough that we could give more Fentanyl. She might as well be comfortable. I wished that I was comfortable, but I was almost as diaphoretic as the patient.

It seemed like the EMT driving us had forgotten to start the engine and was pushing the ambulance to the hospital, but I’m pretty sure that she was actually driving. It just seemed to take a long time to get to the hospital.

We arrived in due course and she was rolled into a resuscitation room where the staff swarmed around her and started to prep her for the cath lab. Which of course wasn’t ready because the staff had to come in from home and get everything warmed up and ready.

In time she went off for her adventure in the cardiac cath lab and we went off to bail out a BLS crew that didn’t seem to understand that the post surgery patient that they were dispatched was displaying normal side effects from his Percocet and Oxycodone medications and really didn’t need ALS. Which is why we didn’t hang around the hospital to find out what happened in the cath lab. Not that the findings would be all that surprising to us. What I really wanted to know was if the patient lived through the night.

I have my doubts, but I can hope.